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CASE REPORT
Year : 2015  |  Volume : 42  |  Issue : 1  |  Page : 31-33

Solitary brain metastasis as an initial manifestation of gall bladder carcinoma


Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India

Date of Web Publication16-Jan-2015

Correspondence Address:
Akhil Kapoor
Department of Radiation Oncology, Room No. 73, PG Boys Hostel, PBM Hospital Campus, Bikaner, Rajasthan - 334 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.149479

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  Abstract 

Gallbladder cancer is a common malignancy in Northern India, and it accounts for 2-4% of all malignant gastrointestinal tumors. It is an aggressive tumor with early dissemination to liver and lymph nodes and associated with poor prognosis. Systemic metastases from gall bladder carcinoma (Ca) frequently occur; however, metastatic involvement of the central nervous system is rare and late manifestation and remains an ominous sign. Initial presentation of gall bladder Ca with brain metastasis is rare. We report a case of 65-year-old women who initially presented with a solitary brain metastasis from an adenocarcinoma of the gallbladder, which was diagnosed incidentally when the patient presented with headache, vomiting, and right temporal region swelling. Palliative chemotherapy and cranial radiotherapy were prescribed. She is symptom-free from 3 months after the completion of the treatment.

Keywords: Brain metastasis, gall bladder carcinoma, prognosis


How to cite this article:
Harsh KK, Kapoor A, Singhal MK, Narayan S, Kumari P, Kumari S. Solitary brain metastasis as an initial manifestation of gall bladder carcinoma. J Sci Soc 2015;42:31-3

How to cite this URL:
Harsh KK, Kapoor A, Singhal MK, Narayan S, Kumari P, Kumari S. Solitary brain metastasis as an initial manifestation of gall bladder carcinoma. J Sci Soc [serial online] 2015 [cited 2022 Aug 17];42:31-3. Available from: https://www.jscisociety.com/text.asp?2015/42/1/31/149479


  Introduction Top


Carcinoma (CA) of the gallbladder is the most common biliary tract malignancy and the fifth most common gastrointestinal cancer after esophageal, gastric, colon and rectal cancer. [1] It accounts for 3% of all the gastrointestinal tumors. The Indian Council of Medical Research Cancer Registry has recorded an incidence of 4.5 and 10.1/100,000 males and females, respectively in the northern parts of India. The 5-year survival in most of the large series to <5% with a median survival is <6 months. [2] In general, it is an aggressive tumor with early dissemination to lymph nodes and liver. Systemic metastasis from gall bladder cancer frequently occurs, but involvement of central nervous system (CNS) is rare. In the literature, only 12 cases of central nervous system (CNS metastases from gall bladder Ca have been reported. [3] At the time of the first diagnosis, 25% of the gall bladder tumors are localized to the gall bladder wall, 35% have local nodal involvement, and 40% have distant metastasis.

We report a case of Ca gall bladder with solitary brain metastasis with abdominal lymphadenopathy.


  Case report Top


A 65-year-old women presented with headache and vomiting from 2 months and swelling in right temporal region, which was continuously increasing in size over the past 1-month. On taking detailed history, it was revealed the initial symptoms included only morning headache and occasional projectile vomiting. Later, there was the development of a swelling in the skull region. On examination, she had the tender, firm to hard, 6 cm × 5 cm swelling in right temporal region. No palpable lump in neck, axilla, abdomen or inguinal region was identified. There was no significant past or family history. Routine laboratory investigations and Chest X-ray were normal. Contrast-enhanced computed tomography (CE-CT) of brain [Figure 1] showed a heterogeneously enhancing soft tissue density lesion of size 58 mm × 58 mm × 52 mm in right temporal region with destruction of squamous part of right temporal bone. Fine-needle aspiration cytology (FNAC) of the swelling demonstrated metastatic adenocarcinoma [Figure 2]. Further investigations to find out primary site were undertaken. The patient had already undergone colonoscopy and upper gastrointestinal tract endoscopy in a private hospital, which were normal. Mammography failed to reveal any lesion in either of the breasts. CE-CT of abdomen and pelvis showed a mass of 7.4 cm × 4.4 cm in the gallbladder fossa, with adjacent liver infiltration causing mild bilobar intrahepatic biliary radical dilatation with periportal and peripancreatic lymphadenopathy with mild ascites [Figure 3]. CE-CT of chest and bone scan was normal.
Figure 1: Contract enhanced computed tomography-scan of brain showing heterogeneously enhancing soft tissue density lesion of size 58 mm × 58 mm × 52 mm is seen in right temporal region with destruction of squamous part of right temporal bone

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Figure 2: Photomicrograph of brain tumor specimen showing metastatic adenocarcinoma, with increased mitotic activity and some of tumor cells containing mucin (a) (H and E, ×10), (b) (H and E, ×40)

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Figure 3: Contrast computed tomography scan of the abdomen showing a heterogeneous gallbladder fossa mass invading the right hepatic lobe and enlarged periportal and peripancreatic lymph nodes

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Fine-needle aspiration cytology of gallbladder mass showed adenocarcinoma. Immunohistochemical stains showed that most of the tumor cells were carcinoembryonic antigen (CEA) positive and several of them contained mucin, consistent with a mucin-producing adenocarcinoma [Figure 4]. The CEA level was 185 mg/ml and CA-19.9 was 142.2 IU/ml while CA-15.3, CA-125 and alpha-fetoprotein were all within the normal limits. Thus, a final diagnosis of Ca gall bladder with solitary brain metastasis with abdominal lymphadenopathy was made.
Figure 4: Photomicrograph of the gall bladder tumor specimen showing adenocarcinoma, with increased mitotic activity and some of tumor cells containing mucin (a) (H and E, ×10, (b) (H and E, ×40)

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  Discussion Top


Primary Ca of the gallbladder is the most common biliary tree malignancy and most of them only present at an advanced stage of the disease. Hence, the prognosis remains poor with curative resection rates between 10% and 30%. Surgery is the only definitive cure and even in advanced Ca, best palliation is debulking surgery. The average survival for patients with distant metastasis at the time of initial presentation is only 1-3 months. Distant metastasis to the CNS from gall bladder cancer rarely occurs. Interestingly, among these cases, [4],[5],[6] there is so far only one case reported by Takano et al. in 1991 [6] that has solitary brain metastasis from gall bladder Ca completely removed 4 months after the operation for the primary tumor. Other anatomical sites of CNS metastases were the meninges and venous sinuses, without intracerebral or intracerebellar metastases.

The median survival of patients with CNS metastasis is 3-12 months and is not necessarily compromised by the CNS lesions, if the diagnosis is established, and therapy promptly instituted. [7] Patients with solitary brain metastasis from gall bladder Ca can achieve a better outcome and longer survival after removal of a brain metastasis if there is no other metastasis. In the case of Takano et al. [6] the 68-year-old female patient led a normal life 4-year later. In the presence of multiple metastases elsewhere, the prognosis becomes poor. [8] The 5-year survival rate is a dismal 1-12%. [5],[9] In our case, the patient was diagnosed at a late stage when she presented with solitary right temporal brain metastasis with skull bone erosion and multiple abdominal lymphadenopathy metastasis. Since the patient gave history of morning headache and projectile vomiting developing prior to bony tenderness and swelling in the scalp, it was presumed that the patient was having cerebral metastasis with bone destruction instead of bone metastasis with destruction of bone and cerebral compression.

The patient had undergone invasive investigations like colonoscopy and endoscopy at a peripheral hospital. These were done without undertaking noninvasive tests like contrast CT scan of abdomen and FNAC from the lesion. This is a lesson learned from the case that FNAC should be undertaken first to guide further investigations for searching the primary and noninvasive tests should be preferred whenever possible.


  Conclusions Top


Although rare, brain metastasis should be considered as an important differential diagnosis is solitary intracranial tumor, and a high index of suspicion should always be exercised for better approach and treatment planning.


  Acknowledgments Top


The authors would like to thank the consultants in the Department of Oncology Dr. A Sharma, Dr. H. S. Kumar, Dr. N. Sharma, Dr. R. Bothra and Dr. S. L. Jakhar.

 
  References Top

1.
Tayo JR, Al-Abdulkarim H, Al-Rayess M. Brain metastasis as an initial manifestation of a gallbladder carcinoma. Neurosciences (Riyadh) 2005;10:235-7.  Back to cited text no. 1
    
2.
Lobo L, Prasad K, Satoskar RR. Carcinoma of the gall bladder. J Clin Diagn Res 2012;6:692-5.  Back to cited text no. 2
    
3.
Takeuchi T, Ogawa H, Kasahara E, Sakurada M, Satoh S. A diffuse metastatic leptomeningeal carcinomatosis from gallbladder cancer: Case report. No Shinkei Geka. 1991;19:1091-5.  Back to cited text no. 3
    
4.
Kawamata T, Kawamura H, Kubo O, Sasahara A, Yamazato M, Hori T. Central nervous system metastasis from gallbladder carcinoma mimicking a meningioma. Case illustration. J Neurosurg 1999;91:1059.  Back to cited text no. 4
    
5.
Smith WD, Sinar J, Carey M. Sagittal sinus thrombosis and occult malignancy. J Neurol Neurosurg Psychiatry 1983;46:187-8.  Back to cited text no. 5
    
6.
Takano S, Yoshii Y, Owada T, Shirai S, Nose T. Central nervous system metastasis from gallbladder carcinoma - Case report. Neurol Med Chir (Tokyo) 1991;31:782-6.  Back to cited text no. 6
    
7.
Lokich JJ. The management of cerebral metastasis. JAMA 1975;234:748-51.  Back to cited text no. 7
    
8.
Spinale RC, Meeker JF. Carcinoma of the gallbladder. J Am Osteopath Assoc 1989;89:625-9.  Back to cited text no. 8
    
9.
Perpetuo MD, Valdivieso M, Heilbrun LK, Nelson RS, Connor T, Bodey GP. Natural history study of gallbladder cancer: A review of 36 years experience at M. D. Anderson Hospital and Tumor Institute. Cancer 1978;42:330-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Case report
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