Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature

Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature

Journal of the Egyptian National Cancer Institute (2016) xxx, xxx–xxx Cairo University Journal of the Egyptian National Cancer Institute www.elsevie...

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Journal of the Egyptian National Cancer Institute (2016) xxx, xxx–xxx

Cairo University

Journal of the Egyptian National Cancer Institute www.elsevier.com/locate/jnci www.sciencedirect.com

Case Report

Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature Damodara Kumaran a,*, Manikandan Anamalai a, Umesh Velu a, Aruna Nambirajan b, Pramod Kumar Julka a a b

Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Received 25 April 2016; accepted 7 June 2016

KEYWORDS Gall bladder carcinoma; Breast metastasis; Case series

Abstract Background: Gall bladder carcinoma is one of the most common cancers in India. Gall bladder cancer with metastasis to the breast is very rare. Herein we intend to report a case of carcinoma gall bladder with breast metastasis and a short review of the literature. Methods: This report describes an interesting and unusual case of gall bladder carcinoma presenting with breast metastasis. Case report: A 38-year lady presented with complaints of right abdominal pain. Bilateral breast examination showed 2  2 cm palpable lump in the upper outer quadrant of the left breast. Contrast-enhanced CT of the abdomen and pelvis showed circumferential thickening of gall bladder with the loss of fat plane with the adjacent liver parenchyma. Biopsy from the breast lump was reported as metastatic adenocarcinoma compatible with primary in the gall bladder. Whole body PET-CT showed gall bladder mass with abdominal and pelvic nodes with metastasis to liver, left breast, C7 vertebral body and left supra-clavicular node. She was diagnosed to have disseminated carcinoma gall bladder with liver, breast and supraclavicular nodal metastasis. She received palliative chemotherapy with gemcitabine and carboplatin and radiotherapy to C7 vertebra. After receiving 3 cycles of chemotherapy, chemotherapy was changed to the second line with single agent capecitabine. In spite of two lines of chemotherapy, she succumbed to disease progression and expired. Conclusion: There are limited examples of gall bladder adenocarcinoma with simultaneous metastasis to breast in the English literature. Our case showed an unusual dissemination of gall bladder cancer. Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Tel.: +91 9910111323. E-mail address: [email protected] (D. Kumaran). Peer review under responsibility of The National Cancer Institute, Cairo University. http://dx.doi.org/10.1016/j.jnci.2016.06.002 1110-0362 Ó 2016 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Kumaran D et al. Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature, J Egyptian Nat Cancer Inst (2016), http://dx.doi.org/10.1016/j.jnci.2016.06.002

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Figure 1 Metastatic adenocarcinoma favouring primary gall bladder origin. Sections show breast parenchyma infiltrated by a poorly differentiated adenocarcinoma (A, H&E, 100) composed of pleomorphic cells with intracytoplasmic mucin (B, H&E, 400). Tumour cells are immunopositive for cytokeratin-19 (C, IHC, 400).

Figure 2

PET-CT showing liver and retroperitoneal lymph nodal metastasis.

Introduction

Case report

Gall bladder carcinoma is one of the most common cancers in India with a higher incidence in the north and central India [1]. In one of the autopsy series, nearly 92% of gall bladder carcinoma results in distant metastasis, most common sites being liver, lung and brain [2]. The most common site of metastasis is liver and lymph nodes. Gall bladder cancer with metastasis to the breast is very rare. Till now only 3 cases have been reported [3]. Herein we intend to report a case of carcinoma gall bladder with breast metastasis. We also present a short review of the literature.

A 38 year lady from Delhi presented to our outpatient department with complaints of right abdominal pain of three months duration. The pain was spasmodic in nature, which was radiating to the posterior chest wall and right shoulder. She had no associated history of fever, vomiting and jaundice. She had a history of constipation and decreased appetite for the past three months. She was not having any comorbidities. She was moderately built and nourished. On clinical examination, she was having tenderness in the right hypochondriac region with no palpable mass. There was a 1  2 cm left

Please cite this article in press as: Kumaran D et al. Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature, J Egyptian Nat Cancer Inst (2016), http://dx.doi.org/10.1016/j.jnci.2016.06.002

Gall bladder Carcinoma with metastasis to breast

3 supraclavicular node. Bilateral breast examination showed 2  2 cm palpable lump in the upper outer quadrant of the left breast. Physical examination of the patient was within normal limits. Contrast enhanced CT of the abdomen and pelvis showed circumferential thickening of the gall bladder with a loss of fat plane with the adjacent liver parenchyma. Multiple hypodense lesions were noted in the liver with metastatic retroperitoneal nodes (Fig. 1). Fine needle aspiration from the supraclavicular node showed adenocarcinoma. Biopsy from the breast lump was reported as metastatic adenocarcinoma with CK-19 positivity, compatible with primary in the gall bladder (Fig. 2). Her CA19.9 was 3800. Whole body PET-CT showed gall bladder mass with abdominal and pelvic nodes with metastasis to liver, left breast, C7 vertebral body and left supraclavicular node (Fig. 3). She was diagnosed to have disseminated gall bladder carcinoma with liver, breast and supraclavicular nodal metastasis. She underwent coeliac plexus neurolysis following which her abdominal pain was decreased. She received palliative radiotherapy of 8 Gy in single fraction to C7 vertebra. She was then started on palliative chemotherapy with gemcitabine and carboplatin. After receiving 3 cycles of chemotherapy, there was a progression in the primary site with ascites. So she was changed to second line chemotherapy single agent Capecitabine. But she succumbed to disease progression and expired on 23rd August, 2015. Discussion

Figure 3

Table 1

PET CT showing left breast parenchymal metastasis.

Current epidemiological studies showed gall bladder carcinoma to be the sixth common cancer involving the gastrointestinal system [4]. Gall bladder cancer usually presents in the advanced stage and when diagnosed, about 25% are localized to the gall bladder, 35% have lymph nodal involvement or

Various case reports of breast metastasis.

S. No

Cases

Recurrence

Age

Survival post breast metastasis

Treatment offered

Duration- from primary diagnosis to metastasis

Author

1

Solitary breast metastasis Metastasis to skin, breast, lung Port site and breast metastasis Skin and B/L breast metastasis Port site and breast metastasis Local recurrence with breast metastasis Breast with ovarian metastasis

Yes

35 yrs

Not reported

24 months

Yes

74 yrs

6–7 months

Khangembam [11] Jeyaraj et al. [12]

Yes

35 yrs

No

42 yrs

Alive and disease free at 3 months of follow up 3 weeks

Wide local excision and exploratory laparotomy Surgery of the metastasis site and SBRT of lung nodules with 5FU and gemcitabine chemotherapy Wide excision of breast followed by local RT and 5FU based chemotherapy Nil

Yes

35 yrs

Not reported

Yes

50 yrs

Yes

45

2

3

4

5

6

7

6 months

46 months

Kallianpur [3]

3 weeks

Garg [13]

Wide local excision of scar and breast lump

12 months

Shukla [14]

5 months

Chemotherapy-gemcitabine and carboplatin

27 months

Malik [15]

Not reported [Alive on follow up]

Mastectomy with oopherectomy followed by Gemcitabine

5 months

Singh [5]

Please cite this article in press as: Kumaran D et al. Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature, J Egyptian Nat Cancer Inst (2016), http://dx.doi.org/10.1016/j.jnci.2016.06.002

4 extension into the liver, and approximately 40% have distant metastasis [5]. Advanced gall bladder carcinoma usually spreads through lymphatics or transcoelomic and hematogenous spread to various distant organs. The common site of distant metastasis is liver, abdominal lymph nodes, lungs and rarely to the bowel, cervix, kidney, thyroid, heart. The incidence of metastasis from various organs to the breast is rare and accounts only 0.5% to 0.6% [6]. Metastasis to the breast from gall bladder is very rare and only a few cases have been reported [3,7]. Metastasis to the breast from gall bladder cancer is probably by the hematogenous route. Unlike primary breast cancer, metastasis to the breast from various organs generally consists of firm, well-circumscribed, superficial, non calcified and multinodular masses with the overlying skin uninvolved. The most common clinical presentation was a solitary tumour (85%) with very rare (4%) diffuse involvement [8]. Upper outer quadrant was the most common location which was found in 62% of patients [9]. Mammography can provide additional information. They usually lack speculation, microcalcifications, architectural distortion and other skin changes. There is no consensus for the management of breast metastasis from gall bladder cancer due to its rarity. Studies havereported an average survival of 10–12 months with 100% mortality rate within 3 years [10]. The approach toward distant metastasis from gall bladder carcinoma is generally palliative. This case reports from literature as shown in table 1, shows the rarity of gall bladder carcinoma with breast metastasis. With no intervention, survival is less than a month. Gemcitabine based chemotherapy is the commonly used regimen. Limited metastasis showed better prognosis. Aggressive management with systemic chemotherapy and surgery or radiation therapy, overall survival can be extended by few months. In our case, she received palliative chemotherapy with gemcitabine and carboplatin and radiation therapy to the bone for pain relief. With the multi-modality approach, she survived for 6 months. So less toxic chemotherapy like gemcitabine with good quality of life is important. Conclusion There are limited examples of gall bladder adenocarcinoma with simultaneous metastasis to breast in the English literature. Our case showed an unusual dissemination of gall bladder cancer. However overall survival remains poor in metastatic gall bladder cancer.

D. Kumaran et al. References [1] Misra S, Chaturvedi A, Misra NC, Sharma ID. Carcinoma of the gallbladder. Lancet Oncol 2003;4:167–76. [2] Sons HU, Borchard F, Joel BS. Carcinoma of the gallbladder: autopsy findings in 287 cases and review of the literature. J Surg Oncol 1985;28:199–206. [3] Kallianpur AA, Shukla NK, Deo SV, Singh M, Subi TS, Kapali A. A rare case of gallbladder carcinoma metastases to the breast treated with curative intent. Trop Gastroenterol 2012;33:155–8. [4] Goodman K, Wagman R, Ho AY. Cancer of the Liver, Bile Duct, and Gall Bladder. In: Hoppe RT, Phillips TL, Roach M, editors. Leibel and Phillips Textbook of Radiation Oncology. Philadelphia: Elsevier Saunders; 2010. p. 820–41. [5] Singh S, Gupta P, Khanna R, Khanna AK. Simultaneous breast and ovarian metastasis from gallbladder carcinoma. Hepatob Pancreat Dis Int 2010;9:553–4. [6] Shah RJ, Koehler A, Long JD. Bile peritonitis secondary to breast cancer metastatic to the gallbladder. Am J Gastroenterol 2000;95:1379–81. [7] Beaver BL, Denning DA, Minton JP. Metastatic breast carcinoma of the gallbladder. J Surg Oncol 1986;31:240–2. [8] Kayikc¸ioglu F, Boran N, Ayhan A, Gu¨ler N. Inflammatory breast metastases of ovarian cancer: a case report. Gynecol Oncol 2001;83:613–6. [9] Moore D, Wilson DK, Hurteau J, Look KY, Stehman FB, Sutton GP. Gynecologic cancers metastatic to the breast. J Am Coll Surg 1998;187:178–81. [10] Ricardo AE, Feig BW, Ellis LM, Hunt KK, Curley SA, MacFadyen BV. Gallbladder cancer and trocar site recurrences. Am J Surg 1997;174:619–22, discussion 6232–3. [11] Khangembam BC, Sharma P, Naswa N, Sahoo MK, Kumar R. Solitary breast metastasis from recurrent gallbladder carcinoma simulating a second primary on 18F-FDG PET/CT. Clin Nucl Med 2013;38:e433–4. [12] Jeyaraj P, Sio TT, Iott MJ. An unusual case of isolated, serial metastases of gallbladder carcinoma involving the chest wall, axilla, breast and lung parenchyma. Rare Tumors 2013;11:e7. [13] Garg PK, Khurana N, Hadke NS. Subcutaneous and breast metastasis from asymptomatic gallbladder carcinoma. Hepatob Pancreat Dis Int 2009;8:209–11. [14] Shukla P, Roy S, Tiwari V, Mohanti BK. Unusual presentation of metastatic gall bladder cancer. J Cancer Res Ther 2014;10:397–8. [15] Malik AA, Wani ML, Wani SN, Malik RA, Malik TR. Breast metastasis from carcinoma of gall bladder. Int J Health Allied Sci 2013;2:35–6.

conflict of interest No conflict of interest to declare.

Please cite this article in press as: Kumaran D et al. Carcinoma of Gall bladder with distant metastasis to breast parenchyma. Report of a case and review of literature, J Egyptian Nat Cancer Inst (2016), http://dx.doi.org/10.1016/j.jnci.2016.06.002