Gall Bladder Carcinoma Presenting with Spinal Metastasis: A Rare Phenomenon
A 50-year-old lady presented to out-patient orthopedic clinic with pain in the neck since 3 months and weakness in her right upper limb of 2 months duration. The general physical examination was normal; she had tenderness over C4 and C5 vertebra with sensory and motor deficit (power 3/5) in right upper limb. A right upper quadrant abdominal lump was also discovered during the examination. The patient was put on a hard cervical collar and analgesics were advised. Orthopedicians planned a magnetic resonance imaging (MRI) scan of cervico-dorsal spine and a bone scan. An ultrasound scan of the abdomen was also done to evaluate the incidentally found abdominal lump.\nThe MRI scan showed altered marrow signal intensity in right half of C4 vertebra and posterior neural arch with paravertebral soft tissue thickening plugging the right C3/C4 neural foramen and encasing vertebral artery []. The bone scan showed an osteolytic lesion in right side of C4 vertebra with increased uptake over mid cervical vertebra. In addition, there was increased focal uptake on the left side of manubrium sterni. Ultrasound scan of the abdomen revealed a large ill-defined heterogeneous mass lesion in the area of gall bladder, which was infiltrating into adjacent liver; the gall bladder was not separately visible. A diagnosis of metastatic lesion in the sternum and C4 vertebra causing cord compression was made and a general surgeon's opinion was sought for the ultrasound findings.\nThe history was reviewed; she complained primarily of neck pain with weakness in her right upper limb of 3 months duration which was increasing progressively from 2 months. As we were biased by the ultrasound findings, some direct questions were asked to which she responded by stating some discomfort in her left upper abdomen from last 7 months and decreased appetite from last 4 months. There were no complaints on the right side of abdomen. She related her symptoms to ‘indigestion’. On re-examination, we found her to be of medium built with average nutrition. The general physical examination was essentially normal. Abdominal examination revealed mildly tender, irregular, and hard lump measuring 5 × 4 cm in her right upper abdomen, which was moving well with respiration with surrounding hepatomegaly. A clinical diagnosis of carcinoma of gall bladder was made and a contrast enhanced computed tomography (CECT) scan of abdomen was advised for staging. The CT scan showed a poorly differentiated heterogeneous mass lesion replacing gall bladder with extension into the segment 4 and 5 of liver []. For histological confirmation, an ultrasound (USG)-guided fine needle aspiration cytology (FNAC) was performed from the mass which showed well-differentiated adenocarcinoma of the gall bladder. The patient and her relatives were explained about the nature, stage and likely poor outcome of the disease. She was offered chemotherapy and local radiotherapy for the painful spinal lesion but she opted for ‘no treatment’, left the hospital, and was subsequently lost to follow-up.