Primary gallbladder carcinoma presenting as advanced-stage ovarian cancer

Abstract

Primary gallbladder carcinomas are rare and the prognosisis very poor. The incidence is 1e2% of all gastro-intestinal(GI) tract cancers [1]. Information on ovarian metastasis ofprimary gallbladder cancer is limited [2e13], partly becauseprimary gallbladder cancers are rare, and partly becausemetastases from primary gallbladder cancer are mediatedthrough either lymphatic or hematogenous routes. Sinceprimary gallbladder cancers are mucinous tumors, there areproblems with the differential diagnosis if mucinous ovariancarcinomas are found. Furthermore, primary or secondaryovarian mucinous tumors may present similar clinical symp-toms, for example, non-specific GI symptoms or signs, andsimilar findings on imaging studies or tumor marker surveys.Before and during an operation, an accurate diagnosis some-times cannot be made [14]. Herein, we present a case ofsecondary ovarian mucinous cancer emanating from primarygallbladder mucinous carcinoma.An 84-year-old woman was sent to the emergency roombecause of diffuse abdominal pain and poor appetite. Clinicalexamination showed an acutely ill-looking woman withapparent peritoneal signs (diffuse tenderness and reboundingpain) associated with a lower abdominal mass. Ultrasoundshowed a 15-cm complex cystic mass in the right adnexa, butthe uterus and the left ovary were normal. Computed tomog-raphy further identified this 15-cm ill-defined right adnexalheterogeneous mass with diffuse peritoneal seeding andcarcinomatosis. Serum tumor markers, including CA 125, CA153, CA 199, and CEA were 327.3 U/mL, 29.0 U/mL, 218.0U/mL, and 85.8 ng/mL, respectively. The other hematologicaland biochemical tests were normal. Upper and lower gastro-intestinal tract evaluations were negative.Under the diagnosis of ovarian cancer, an exploratorylaparotomy was done. A complex cystic right ovarian masswith a mucinous component was found, as well as diffusecarcinomatosis involving the entire lower and upper abdom-inal cavity, including the omentum, in which the inflamedgallbladder was embedded. Frozen section of the removedovarian tumor favored the diagnosis of primary ovariancarcinoma, mucinous type. The patient underwent a subop-timal debulking surgery, including total hysterectomy, bilateralsalpingo-oophorectomy, omentectomy, and retroperitoneallymph node sampling, and multiple biopsies. The finalpathology was primary gallbladder mucinous carcinoma.Microscopic features showed hyperchromatic dysplasia ofthe mucinous glandular cells of the gallbladder; the mucinoustumor occupied the entire cavity of the gallbladder. The tumorhad invaded whole layers of the gallbladder, and penetrated tothe outside serosa and the attachment of the omentum. Othersections of the right ovary, appendix, omentum, abdominalwall, mesentery, and right pelvic lymph nodes all showedtumor metastases with floating mucinous tumor cells within anextensive mucin pool.Using the American Joint Committee on Cancer (AJCC)staging for gallbladder cancer, the final diagnosis was gall-bladder cancer stage IVB (pT4NxM1). However the patientdied of disease 48 days after the operation.This case report raised the following interesting issues.First, since 15% of ovarian cancers are secondary and 7e15%