Gallbladder Carcinoma Presenting with Manubrium Metastasis: A Rare Phenomenon

Abstract

Gallbladder carcinoma is the 5th most common malignancy of the gastrointestinal tract. Symptoms in the early stages are similar to other benign diseases and thus it is rarely diagnosed early. Distant metastasis to bone is uncommon with the most common sites of metastasis being regional lymph nodes, liver parenchyma, peritoneum, and lungs. A 78-year-old female with past medical history of hypertension, gastroesophageal reflux disease, and complete heart block with a dual chamber pacemaker presented with chest pain that developed after PO intake. The pain typically lasted for 30 minutes and was associated with increased belching, bloating, and mild constipation. Patient was a former smoker and had moderate alcohol use. Physical exam showed no jaundice, abdominal tenderness, or palpable masses. Labs showed AST 19 U/L, ALT 16 U/L, total bilirubin 0.7 mg/dL and elevated ALP at 123 U/L. Patient's recent cardiac stress test showed no ischemia. Abdominal ultrasound showed common bile duct dilatation at 1.5 cm and a hypoechoic mass-like area in the neck of the gallbladder suspicious for a gallbladder mass. Hepatobiliary (HIDA) scan revealed an abnormal function response to cholecystokinin (CCK) with an ejection fraction of 8.7%. General surgery was consulted and a diagnostic laparoscopic cholecystectomy was performed. A thickened gallbladder wall was found and pathology was sent, which resulted positive for poorly differentiated adenocarcinoma of the gallbladder. Computed tomography (CT) chest ordered for staging showed a 3 cm mass with bony destruction involving the left manubrium. Interventional radiology performed ultrasound-guided biopsy of the left manubrium, which revealed metastatic moderately differentiated adenocarcinoma with mucinous features. Positron emission tomography (PET) scan showed increased FDG uptake within the cervical and thoracic spine and sternum and hypermetabolic lymph nodes. Magnetic resonance cholangiopancreatography (MRCP) showed mild intra and extrahepatic biliary ductal dilation but no filling defects, strictures, or masses were identified in the biliary ductal tree. The patient ultimately refused further treatment, including chemotherapy, and was discharged with home hospice. Although rare, gallbladder carcinoma can present with chest pain secondary to bone metastasis. Further work-up should be considered in patients presenting with chest pain of unknown etiology and associated gastrointestinal symptoms.Figure 1Figure 2