Sanjay Singh, Puneet Gupta, Rahul Khanna and Ajay K Khanna

Varanasi, India

Simultaneous breast and ovarian metastasis from gallbladder carcinoma

Sanjay Singh, Puneet Gupta, Rahul Khanna and Ajay K Khanna

Varanasi, India

BACKGROUND:Gallbladder carcinoma is a common malignancy in the Indian subcontinent. It commonly metastasizes through lymphatics, direct invasion, and hematogenous spread. A common extra-abdominal site of metastasis is the lungs. Simultaneous metastasis to breast and ovary is extremely rare.

METHOD:This report describes an unusual case of carcinoma gallbladder metastasizing to the breast and ovary at the same time.

RESULTS:A 45-year-old woman came to us with complaints of flatulent dyspepsia associated with weight loss and anorexia. Ultrasound of the abdomen revealed hepatomegaly with thick-walled gallbladder with multiple stones and a mass at the fundus, but normal uterus and ovary. Contrast-enhanced computer tomography of the abdomen showed a gallbladder mass infiltrating the liver parenchyma. The patient underwent radical cholecystectomy. Histopathological examination revealed a poorly-differentiated adenocarcinoma with margins free from tumor infiltration. One month after surgery she developed a breast lump. Ultrasound of the abdomen for metastatic workup revealed an ovary mass. Simple mastectomy and salphingo-opherectomy were performed, and histopathological examination revealed a metastatic adenocarcinoma. The patient is now on chemotherapy with gemcitabin.

CONCLUSION:This is an unusual case of carcinoma of the gallbladder with metastasis to the breast and ovary, which has not been documented before.

(Hepatobiliary Pancreat Dis Int 2010; 9: 553-554)

gallbladder carcinoma; breast metastasis; ovary metastasis

Introduction

Cancer of the gallbladder, a common malignancy in the Indian subcontinent, is predominantly seen in elderly women, with poor prognosis. Ninety percent of carcinomas of the gallbladder are adenocarcinomas and metastasize through the lymphatics, venous drainage, and direct invasion into the liver parenchyma. When diagnosed, about 25% of gallbladder carcinomas are localized at the wall of the gallbladder, 35% have nodal involvement or extension into the adjacent liver, and approximately 40% have distant metastasis. The common site of distant metastasis is to the lungs and rarely to the bowel, cervix, kidney, thyroid, hernia sac, and heart. Breast metastasis from carcinoma of the gallbladder is unknown.[1]Breast carcinoma may metastasize to the gallbladder, but gallbladder carcinoma metastasizing to the breast is extremely rare.

Case report

A 45-year-old married woman presented with pain in the right upper abdomen, flatulent dyspepsia, and loss of appetite and weight for 4 months. On examination of the abdomen, a hard globular gallbladder lump of 3×4×4 cm and hepatomegaly were found. The patient was jaundiced. Hematological parameters, renal function, and liver function tests were within normal limits. Ultrasound of the abdomen showed a thick-walled gallbladder with multiple stones and a mass at the fundus. The uterus and both ovaries were normal. Contrast-enhanced computer tomography of the abdomen showed cholethiasis with a gallbladder mass infiltrating the adjacent liver parenchyma. The patient was subjected to radical cholecystectomy with resection of segments IVb and V (Fig. A). Exploration revealed a mass in the gallbladder infiltrating into liver segments IVb and V with multiple stones. Nodes were not involved. The common bile duct and duodenum were normal. Histopathological study revealed a poorly differentiated adenocarcinoma of the gallbladder with infiltration into the liver; the cutmargins of the liver were free from tumor infiltration.

Fig. A: Gallbladder specimen showing growth and multiple stones; B: Patient developed left breast lump following a radical cholecystectomy; C: Specimen of the ovarian tumor.

One month later, the patient complained of a lump in the upper inner quadrant of the left breast, 4×3 cm shown by clinical examination. Axillary and supraclavicular lymph nodes were not palpable (Fig. B). Fine needle aspiration cytology from the lump revealed adenocarcinoma cells. The patient was advised to undergo a lumpectomy but she refused and came back 3 months later. At this time, the lump had increased to 10×5 cm along with an ovary mass that was clinically palpable. Ultrasound of the abdomen revealed a left ovary mass, while the gallbladder area was clear. Hematological results, liver function, and renal function and chest X-ray findings were normal. The patient underwent simple mastectomy and salpingo-oopherectomy (Fig. C). Histopathological study of tissues from the breast and ovary revealed a poorly differentiated adenocarcinoma, probably metastasized from the gallbladder. The patient was maintained on gemcitabine and is under follow-up.

Discussion

Metastasis from gallbladder carcinoma is usually through lymphatic to hepatogastric lymph nodes, through veins to the liver, by hematogenous spread to various distant organs, and transcoelomic spread. The incidence of metastasis from various organs to the breast is only 0.5% to 0.6%, among which metastasis from gallbladder carcinoma is extremely rare. Though there are several case reports of breast carcinoma metastasizing to the gallbladder,[2-5]the reverse is extremely rare. Probably, there is only one case report on metastasis from gallbladder carcinoma to the breast along with multiple subcutaneous metastases,[1]but our patient had isolated breast metastasis along with ovary metastasis. Metastasis to the ovary in the form of Krukenburg tumor is a common feature of intra-abdominal malignancy, but metastasis of cancer of the gallbladder and bile duct to the ovary is unusual. Metastasis to the ovary is either by transcoelomic, lymphatic, or hematogenous spread. Metastasis to the breast from the gallbladder is probably by the hematogenous route. In conclusion, this is a very rare case of gallbladder carcinoma with simultaneous metastasis to be breast and ovary. There should be high suspicion of metastasis in patients with a breast lump who are known to have gallbladder carcinoma.

Funding:None.

Ethical approval:Not needed.

Contributors:SS wrote the first draft of this commentary. All authors contributed to the intellectual context and approved the final version. KAK is the guarantor.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

1 Garg PK, Khurana N, Hadke NS. Subcutaneous and breast metastasis from asymptomatic gallbladder carcinoma. Hepatobiliary Pancreat Dis Int 2009;8:209-211.

2 Beaver BL, Denning DA, Minton JP. Metastatic breast carcinoma of the gallbladder. J Surg Oncol 1986;31:240-242.

3 Shah RJ, Koehler A, Long JD. Bile peritonitis secondary to breast cancer metastatic to the gallbladder. Am J Gastroenterol 2000;95:1379-1381.

4 Calafat P, de Diller AB, Sanchez C. Breast carcinoma metastasis in ileum-colon and gallbladder simulating inflammatory diseases. Rev Fac Cien Med Univ Nac Cordoba 1999;56:123-127.

5 Doval DC, Bhatia K, Pavithran K, Sharma JB, Vaid AK, Hazarika D. Breast carcinoma with metastasis to the gallbladder: an unusual case report with a short review of literature. Hepatobiliary Pancreat Dis Int 2006;5:305-307.

September 13, 2009

Accepted after revision December 1, 2009

Author Affiliations: Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India (Singh S, Gupta P, Khanna R and Khanna AK)

Ajay K Khanna, Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India (Fax: 91-542-2367568; Email: akkhanna@gmail.com)

? 2010, Hepatobiliary Pancreat Dis Int. All rights reserved.