Unusual and extremely rare sites of metastases in gallbladder carcinoma

Abstract

Gallbladder carcinoma is an aggressive neoplasm that is often diagnosed only in the later stages of the disease progression. Common sites of distant metastases of primary carcinoma gallbladder include lymph nodes, peritoneum and lung. Only a few cases of metastases to adrenal glands and kidneys have been reported in literature. Cutaneous and muscular metastases from gallbladder cancer are also unusual, and an extensive literature search revealed only a few cases to date. We present two such cases of gallbladder carcinoma which presented with metastases to these rare sites at the time of diagnosis which were detected by 18 fluorodeoxyglucose positron emission tomography/ computed tomography (18F FDG PET/CT). The first case is of a 45-year-old lady who presented to the general surgery department with complaints of abdominal pain, loss of appetite and nausea for 2 months. Conventional imaging with ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen showed asymmetric gallbladder wall thickening occupying the fundus and body with extensive regional lymphadenopathy. 18F FDG PET/CT revealed a metabolically active gallbladder mass with bilateral adrenal gland lesions with cutaneous, muscular and skeletal metastases. The second case is of a 35-year-old lady who complained of left upper quadrant abdominal pain and nausea for one month. Successive CECT and Magnetic Resonance Cholangiopancreatography (MRCP) studies made the radiological diagnosis of gallbladder neoplasm. Pre-operative 18F FDG PET/CT showed a metabolically active gallbladder mass with bilateral adrenal gland lesions, lymph node involvement and bilateral renal metastasis. The Third case was 75 years old male who had incidental carcinoma gall bladder on cholecystectomy and PETCT was done for staging, and it showed metabolically active liver SOL, Bilateral adrenal deposits with mediastinal abdominal, retroperitoneal and lymph nodes. The fourth case is a 55 year old female who was diagnosed as neck gall bladder wall thickening on ultrasonography on further evaluation PETCT was done which showed hypermetabolic gall bladder neck wall thickening along with bilateral adrenal lesion and abdominal, retroperitoneal and retro-crural and right supraclavicular lymph nodes. Adrenal and other metastasis detection on 18F FDG PET/CT led to a change in the management from curative surgery to palliative chemotherapy in all patients. Thus,18F FDG PET/CT is a valuable modality in such type of cases that aids decision making regarding staging, appropriate management and monitoring response to therapy.