Presentation
Abdominal pain, bilirubin of 20.
Patient Data
Cholelithiasis, with multiple high density foci in the distal CBD consistent with choledocholithiasis.
While difficult to appreciate, a large gastric polyp at the gastric antrum is seen.
Cholelithiasis present within the lumen of the gallbladder. CBD measures 8 mm the porta hepatis. Multiple calculi present within the distal CBD, the largest calculus measures 9 mm. Pancreatic duct is normal in caliber. Small volume adenomyomatosis at the fundus of the gallbladder. No focal liver lesion. Signal within the liver is within normal limits. Spleen, adrenals and visualized bowel are within normal limits. Bilateral renal cysts.
Impression:
- Multiple calculi present within the distal CBD. Cholelithiasis within the gallbladder.
- Additional finding of a polypoid mass lesion within the antrum of the stomach measuring 5.4 x 2.8 x 2.9 cm. Signal within the adjacent muscularis propria is preserved with no MR evidence of extramural extension. No adjacent lymphadenopathy.
Stones seen in the distal CBD.
Case Discussion
Patient proceeded to biopsy of the gastric mass.
CLINICAL NOTES: Gastric mass - cancer - antrum ?primary vs secondary. Also second lesion @ upper lesser curve.
MACROSCOPIC DESCRIPTION: 1. "Lesser curve Bx": Three pieces of tissue 1-3mm. A1. 2. "Gastric pyloric mass": Numerous pieces of tissue 1-4mm. A1.
MICROSCOPIC DESCRIPTION: 1. The biopsy of glandular mucosa with muscularis mucosae shows glands and villi lined by markedly atypical columnar cells and foci of incomplete intestinal metaplasia. Desmoplastic stroma is not identified and the muscularis mucosae appears intact. 2. The biopsy of glandular mucosa with muscularis mucosae shows villi and glands lined by markedly atypical columnar cells focally within desmoplastic stroma. There is areas of acute inflammatory exudate. Scattered goblet cells are present within the epithelium.
DIAGNOSIS: 1. Lesser curve biopsy: Intramucosal carcinoma. 2. Gastric pyloric mass: Invasive adenocarcinoma. SUPPLEMENTARY REPORT Immunohistochemistry shows tumor cells stain positive with CK20 and CDX2. focal positive with CK7. Negative PSA, PSAP and TTF-1. Features in keeping with a gastrointestinal origin. Primary stomach or metastatases from colon are most likely possibilities.