Gallbladder metastasis from renal cell carcinoma
Ultrasound Abdomen (selected gallbladder images)
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The gallbladder is distended by heterogeneous content which may comprehend small echogenic stones and biliary sludge. Within the region of the gallbladder neck, there is an amorphous hypoechoic mass that does not show clear vascularity on color Doppler. The gallbladder wall is thin and there are no pericholecystic fluid or stranding. The remainder of the liver and biliary tree is unremarkable (not shown).
CT Abdomen and pelvis (selected images)
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There is a lobulated exophytic mass inside the gallbladder neck without clearly extending beyond the gallbladder wall. It shows vivid arterial enhancement. A note is mate tp left nephrectomy. No other suspicious lesions identified.
MACROSCOPY: Labelled "Gallbladder": 130 x 52 mm. The serosal surface is smooth and grey/purple. The cyst wall is less than 1 mm thick. The mucosa is flattened and tan with less than 1 mm white flecks and a 3 mm white/pale tan polyp. The lumen contains thick, tenacious mucoid material containing occasional small calculi. The cystic duct node is not identified.
MICROSCOPY: Sections through the gallbladder wall show two intramural tumour deposits comprised of a population of epithelioid cells with round, hyperchromatic nuclei, small round nucleoli and moderate to abundant cleared cytoplasm arranged in sheets and nests about a fine calibre, capillary-sized vasculature. There is an accompanying lymphocytic infiltrate. One deposit lies within a shave section from the cystic duct resection margin. Tumour cells immunoreactive with antibodies against cytokeratins AE1/AE3 and PAX8 and are negative with antibodies against S100. Surrounding gallbladder parenchyma shows pyloric epithelial metaplasia, transmural chronic inflammation and adenomyosis.
CONCLUSION: Gallbladder: Two intramural deposits of metastatic clear cell renal cell carcinoma, one present in a shave section of the cystic duct resection margin, chronic cholecystitis and adenomyosis.
The patient WUQ pain was attributed to a distended gallbladder without convincing imaging features to suggest cholecystitis. The gallbladder neck shows a hypoechoic mass like lesion that appears to be obstructive. Further CT confirmed a hypervascular lobulated mass in the gallbladder neck and the hint for the right differentials is the surgical removal of the left kidney. This patient had a clear cell RCC 5 years ago. Common sites of RCC metastasis are bones, lungs, brain, liver, and adrenal glands 1.
The main differentials for this case are metastatic disease and primary gallbladder carcinoma. Given its hypervascularity, the lesion was favored to represent metastasis, as gallbladder malignancies do not commonly show this feature. Although melanoma is a known malignancy to metastasize everywhere and is the most frequent metastasis to the gallbladder 2, this patient had an RCC years ago, which is then the favored origin further confirmed histologically.
- 1. Maldazys JD, deKernion JB. Prognostic factors in metastatic renal carcinoma. (1986) The Journal of urology. 136 (2): 376-9. Pubmed
- 2. Sand M, Bechara FG, Kopp J, Krins N, Behringer D, Mann B. Gallbladder metastasis from renal cell carcinoma mimicking acute cholecystitis. (2009) European journal of medical research. 14: 90-2. Pubmed