Cutaneous Metastasis of Gallbladder Adenocarcinoma in a Patient with Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature
A 70-year-old male patient was admitted to an emergency unit in December 2009 due to stomachache, nausea, and vomiting, which had exacerbated during the previous 2 days. Cholecystectomy was performed due to cholecystitis. During the operation, it was observed that the patient had a 2 cm gallbladder stone and a tumoral mass originating from the gallbladder corpus with a 1~2 cm satellite lesion. During explorative surgery his liver and peritoneum were intact. Postoperative pathological examination showed a malignant epithelial tumor of the gallbladder; the patient was then referred to our department.\nThe pathological examination showed patchy epithelial dysplasia and ulcerated regions in the morphologically mostly solid tumor tissue, which formed a patchy gland structure. Immunohistochemical analysis showed diffuse staining with cytokeratin (CK)-7, CK-19, and CK-20, whereas they did not stain with synaptophysin or chromogranin, which was consistent with poorly differentiated primary gallbladder adenocarcinoma. The tumor had infiltrated the entire gallbladder wall and invaded the regional adipose tissue and liver (pT3). One extracted lymph node showed that adenocarcinoma metastasis was present (pN1) ().\nThe patient had a previous history of B-cell CLL (Rai stage 0/Binet stage A) and had been treated with oral chlorambucil 5 mg/d for the 5 years prior to his presentation to the emergency room on December 2009; the patient was treated concomitantly with oral metoprolol succinate 50 mg in day 1 p.o. and acetylsalicylic acid 150 mg in day 1 p.o. for hypertension and ischemic heart disease. The patient had no family history of cancer, tobacco or alcohol use. The patient's performance, blood pressure, and heart rate were 1 by Eastern Cooperative Oncology Group, 125/85 mmHg and rhythmic 92 bpm; respectively. There was no pathological finding on physical examination except for 1/6 systolic mesocardial murmur and a 1 cm non-tender, mobile and firm lymphadenomegaly (LAM) in the left axillary area. Laboratory data were hemoglobin 10.6 g/dl and hematocrite 30.4%. Other laboratories parameters were within normal range. His chest X-ray was within normal limits. His postoperative carcinoembriogenic antigen (CEA) level was 1.6 (normal range: 0~0.5 ng/ml) and carbohydrate cancer antigen (CA) 19.9 level was 6.6 U/ml (normal range: 0~37 U/ml); Baseline preoperative measurements were not performed.\nThoracic, neck, and abdominal computed tomography (CT) showed multiple bilateral axillary LAMs, of which the largest one was 1×1 cm in dimension and, a 1.2×1 cm right LAM at submandibulary area. The patient did not have distant metastases and was receiving 3 courses of cisplatin (40 mg/m2, D1) and concurrent adjuvant radiotherapy (a dose of 50 Gy) every 21 d.\nThe patient was referred to our surgical department, 7 months post-surgery due to a non-tender, rapidly growing (4~5 d) mass in the inter-scapular region. The lesion, which was 2 cm in diameter, was completely excised, and the patient was again referred to our department. The pathological examination showed a malignant epithelial tumor metastasis in cutaneous mass. Immunohistochemical analysis of the extracted inter-scapular lesion by the pathology department showed diffuse staining with CK-19 and focal staining with CK-7 and 20, and a positive staining pattern with CEA. The tumor cells in the skin exhibited similar morphological properties consistent with gallbladder adenocarcinoma metastasis ().\nThe patient had no negative pathologic finding except for a couple of 1×1 cm LAMs in the left axillary and submandibulary regions, along with hepatomegaly. Laboratory data were Hb 8.2 g/dl, Hct 29%, leukocyte count 5,400 mm3, serum lactate dehydrogenase 298 U/L (normal range: 125~243 U/L), gamma-glutamyl transpeptidase 278 U/L (normal range: 12~64 U/L). Other laboratories parameters were within normal limits. CEA and CA 19.9 levels were 2.9 ng/ml and 15.4 U/ml, respectively. There was no evidence of activation or blastic transformation of CLL in blood marrow aspiration and biopsy specimens. Abdominal CT showed multiple metastatic lesions, of which the largest was 3.3 cm and located in the 8th segment of the liver's right lobe. On October of 2010 the patient started to receive chemotherapy consisting of cisplatin (80 mg/m2 on d1), calcium folinate (200 mg/m2 on d1), and fluorouracil (1,000 mg/m2 on d1 and d2) with 15 d cycles. However during chemotherapy, new lesions -a 0.5 cm lesion with an accompanying 1 cm red nodular lesion on the scalp, a non-tender, mobile subcutaneous local right scapular lesion, and a 1.5 cm submandibular lesion were observed ().\nThe patient was admitted to the emergency department 16 days after starting chemotherapy due to mechanical jaundice and pancytopenia. Abdominal ultrasonography and CT showed that the number and size of liver metastases had increased. Percutaneous drainage could not be performed because the intrahepatic biliary branches were not dilated. The patient died due to hepatic failure on the fifth day of hospitalization and 11 months after surgery.