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Gastrointest Cancer Res. 2009 Nov-Dec; 3(6): 252–253.
PMCID: PMC3000073

Isolated Scapular Metastasis in a Patient With Carcinoma of the Gallbladder

Carcinoma of the gallbladder is considered a disease with a grim prognosis, due primarily to frequent locoregional recurrence after surgery and poor disease-specific survival and overall survival. It is a particularly common malignancy among women in North India. 1 Primary gallbladder cancer usually spreads by direct invasion and via the lymphatics. The incidence of the latter varies from 35%–75%. 2 Distant metastasis is usually due to hematogenous spread. Anminski, in an excellent review of data in the world literature published in 1949, observed that gallbladder carcinoma has been reported to metastasize to virtually every organ in the body,3 a finding that has been corroborated by other authors.4,5 The spread to various distant organs, though vascular in etiology, probably occurs in the late stages of the disease via the systemic and retroperitoneal veins and, until recently, was thought to be of little or no surgical significance. Hence, evaluation for distant metastasis is not routinely considered if the disease remains locoregionally confined. We report a case of otherwise resectable gallbladder carcinoma that presented with painful osseous metastasis.

CASE REPORT

A 40-year-old woman presented with a history of dyspeptic symptoms and dull, aching, chronic back pain for 1 year. She also had a history of significant anorexia and weight loss. Physical examination revealed a fixed, hard, 8 × 7 cm mass in the region of the left scapula (Figure 1). Breast and thyroid examinations were unremarkable. Abdominal examination revealed a hard palpable gall bladder. Abdominal imaging with ultrasound and magnetic resonance imaging (MRI) revealed a mass in the fundus and body of the gallbladder with cholelithiasis. Radiographs revealed a lytic lesion in the left scapula (Figure 2). A technetium-99 (99mTc) radiolabelled bone scan revealed intense uptake of isotope in the left suprascapular area (Figure 3). Fine needle aspiration cytology from the suprascapular lesion revealed adenocarcinoma (Figure 4).

Figure 1.
Mass visible in the left scapular area.
Figure 2.
Radiograph showing a lytic lesion in the left scapula.
Figure 3.
Technetium-99 labelled bone scan showing intense uptake of radiocolloid in the left suprascapular area.
Figure 4.
Fine needle aspiration cytology smear from scapular mass showing fragments from an adenocarcinoma comprising a crowded cluster of tumor cells with vesicular nuclei, irregular nuclear margins, and prominent nucleoli. (May Grunwald Giemsa × 400) ...

In view of the disseminated nature of her disease, the patient was offered the option of chemoradiotherapy. She declined and was subsequently lost to follow-up.

DISCUSSION

It is unusual for patients with otherwise resectable carcinoma of the gallbladder to present with painful osseous metastasis. Radiography and bone scan was suggestive of the nature of the lesion, but diagnosis of metastasis was confirmed by aspiration cytology from the mass. A review of the literature revealed that cases of extra-abdominal metastasis of gallbladder carcinoma to bone,6 skin,7 central nervous system,8 and heart9 have been reported in cases of unresectable disease. Metastasis to the scapula associated with resectable carcinoma gallbladder, however, is reported for the first time.

CONCLUSION

Carcinoma of the gallbladder is often associated with a dismal prognosis owing to increased propensity for metastasis via multiple routes. Early hematogenous spread can occur via retroperitoneal veins and render it incurable.

Acknowledgments

We acknowledge the support of the Departments of Nuclear Medicine, Radiology & Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi.

REFERENCES

1. Misra A, Misra S, Chaturvedi A, et al. Orbital metastasis from gallbladder carcinoma. Brit J Radiol. 2002;75:72–73. [PubMed]
2. Fahim RB, McDonald JR, Richards JC, et al. Carcinoma of the gallbladder: a study of its modes of spread. Ann Surg. 1962;156:114–124. [PubMed]
3. Anminski TC. Primary carcinoma of the gallbladder: a collective review with the addition of twenty-five cases from the Grace Hospital, Detroit, Michigan. Cancer. 1949;2:379. [PubMed]
4. Kirshbaum JD, Kozoll DD. Carcinoma of the gallbladder and extrahepatic bile ducts: a clinical and pathological study of 117 cases in 13,330 necropsies. Surg Gynecol Obstet. 1941;73:740.
5. Tragerman LJ. Primary carcinoma of the gallbladder: review of 173 Cases. Calif Med. 1953;78:431. [PMC free article] [PubMed]
6. Misra S, Chaturvedi A, Misra NC. Carcinoma gallbladder presenting with skeletal metastases. Indian J Gastroenterol. 1997;16:74. [PubMed]
7. Bardaji M, Roset F, Puig A, et al. Cutaneous metastatic adenocarcinoma of gallbladder origin: report of a case and review of the literature. Hepatogastroenterology. 1998;45:930–931. [PubMed]
8. Kawamata T, Kawamura H, Kubo O, et al. Central nervous system metastasis from gallbladder carcinoma mimicking a meningioma. Case illustration. J Neurosurg. 1999;6:1059. [PubMed]
9. Suganuma M, Marugami Y, Sakurai Y, et al. Cardiac metastasis from squamous cell carcinoma of gallbladder. J Gastroenterol. 1997;6:852–856. [PubMed]

Articles from Gastrointestinal Cancer Research : GCR are provided here courtesy of International Society of Gastrointestinal Oncology