This 60-year-old lady presented with sudden onset of right sided abdominal pain to our ED. She underwent a CT scan which demonstrated multifocal deposits within the liver and a distended gallbladder with soft tissue mass.

Tumor markers: CA 19-9 5.9, AFP 70, CEA <1.0

The patient underwent a liver biopsy. Histopathology:

• Features consistent with poorly differentiated adenocarcinoma
• Gallbladder adenocarcinoma has no specific immunohistochemistry marker
• Ancillary studies in this case do not suggest any specific tumor type or origin
• Differentials include gallbladder adenocarcinoma, cholangiocarcinoma as well as metastatic adenocarcinoma

Imaging and biopsy findings consistent with metastatic gallbladder adenocarcinoma (stage IV disease).