Metastatic Mucin-Producing Adenocarcinoma

Abstract

Introduction: Gallbladder adenocarcinoma is a rare, aggressive, and lethal malignancy affecting 7,000 individuals annually. Case Report: We present a case of 58-yr-old female, with a family history of colon cancer at age 50, with worsening abdominal pain beginning 2 weeks ago and worsening over the last 2 days. She stated that the abdominal pain began in the RUQ and began spreading to the LUQ. Associated symptoms included nausea and vomiting. She admitted to a negative FOBT with her PCP, 1 week prior to presentation. Physical exam was notable for RUQ tenderness to palpation. On admission, she was noted to have mild leukocytosis of 12.9, elevated ALK Phos of 766, AST of 117, and ALT 95. An US of the RUQ showed multiple gallstones and extra-hepatic CBD measurement of 6 mm along with liver masses of mixed echogenicity. CT showed thickened gallbladder wall and a large gallstone. The patient was started on antibiotics and referred to surgery. During the procedure, the patient was noted to have a choleduodenal fistula and the gallbladder was noted to be too friable for traction. The procedure was converted to open, gallbladder was removed, and the fistula was repaired. Intraoperative frozen section was negative for neoplasia. Further pathology/staining showed an infiltrating, poorly differentiated mucin-producing adenocarcinoma originating from the gallbladder. Subsequently, patient underwent CT guided biopsy of the liver masses and was found to have metastatic gallbladder adenocarcinoma of the liver. Hematology/oncology was consulted and a chemo port was surgically placed. EGD and colonoscopy were negative. The patient was discharged for outpatient for chemotherapy. Discussion: Gallbladder adenocarcinoma is a rare diagnosis. Predisposing factors include older age, female gender, and gallstones. Due to vague symptomatology, presentation is generally at advanced stages with a 5-year survival rate of less than 5%. Metastasis to adjacent organs, such as liver, along with biliary obstruction is also noted at diagnosis. Stage of the disease at diagnosis alters treatment options. Non-radical surgery alone may be recommended at stage 0, I, and II. Advanced disease may be offered radical surgery. Metastasis may be limited in therapeutic options altogether. Conclusion: Diagnosis of gallbladder carcinoma is often delayed due to vague presenting symptoms. If diagnosed early, curative surgery may be offered. However, late diagnosis leads to poor survival prognosis.