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Laparoscopic cholecystectomy for melanoma metastatic to the gallbladder: is it an adequate surgical procedure? Report of a case and review of the literature.

Marone U, Caracò C, Losito S, Daponte A, Chiofalo MG, Mori S, Cerra R, Pezzullo L, Mozzillo N - World J Surg Oncol (2007)

Bottom Line: Metastatic melanoma to the gallbladder is extremely rare and it is associated with a very poor prognosis.Gallbladder metastasis represents a rare event as a first site of recurrence.It must be considered a possible expression of systemic disease also despite radiological absence of other metastatic lesions.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgical Oncology "B", National Cancer Institute of Naples, Italy. dott.marone@virgilio.it

ABSTRACT

Background: Only 2% to 4% of patients with melanoma will be diagnosed with gastrointestinal metastasis during the course of their disease. The most common sites of gastrointestinal metastases from melanoma include the small bowel (35%-67%), colon (9%-15%) and stomach (5%-7%), with a median survival of 6-10 months after surgery, and 18% survival at five years. Metastatic melanoma to the gallbladder is extremely rare and it is associated with a very poor prognosis.

Case presentation: We report a case of a 54-year old man presented to observation with diagnosis of 6.1 mm thick, Clark's level IV, ulcerated melanoma of the trunk, developing in the course of the disease metastatic involvement of the gallbladder as first site of recurrence, treated by laparoscopic cholecystectomy. To date only few cases of patients with metastatic melanoma of the gallbladder treated by this surgical procedure have been reported in literature.

Conclusion: Gallbladder metastasis represents a rare event as a first site of recurrence. It must be considered a possible expression of systemic disease also despite radiological absence of other metastatic lesions. Laparoscopic approach has a possible therapeutic role, but open surgery has also a concomitant diagnostic purpose because gives the possibility of manual exploration of abdominal cavity, useful particularly to reveal bowel metastatic lesions, not easily identifiable by preoperative imaging examinations.

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Neoplastic cells immunostained with anti-S-100 antibodies (× 400).
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Figure 3: Neoplastic cells immunostained with anti-S-100 antibodies (× 400).

Mentions: In May 2001 a 54-year-old man presented to observation with diagnosis of 6.1 mm thick, Clark's level IV, ulcerated cutaneous melanoma of the trunk. Preoperative staging with chest X-ray and abdominal ultrasound (US) did not reveal signs of systemic disease. He underwent wide local excision (WEX) and sentinel lymph node biopsy (SLNB). Preoperative lymphoscintigraphy showed uptake of the radiotracer in one node of the left axilla that was removed and resulted on finally pathology negative for metastatic melanoma. The patient was submitted to regular follow-up every three months with physical examination, chest X-ray, US and blood work, according to the Multicenter Selective Lymphadenectomy Trial [9]. In January 2002 hepatobiliary US detected the presence of intracholecystic nodule of 1.0 cm. Three months later the patient presented upper abdominal pain mimicking symptomatic cholecystolithiasis. Blood analysis values were normal. US examination showed an increasing in size to 2.0 cm of the intracholecystic nodular image (Figure 1). Computerised tomography (CT) confirmed the presence of a nodule in the lumen of the gallbladder measuring about 2.0 cm and a positron emission tomography (PET) revelead uptake in the gallbladder area without evidence of systemic uptake of the radiotracer. In May 2002 the patient underwent laparoscopic cholecystectomy. Intrabdominal exploration showed a normal gallbladder but with an enlarged blue coloured lymph node along the cystic duct, and the presence of a dark spot image of the diaphragmatic peritoneum. The gallbladder was removed together with the lymph node along the cystic duct and put into an endobag to avoid any contamination of the abdominal cavity and extracted. An excisional biopsy of the diaphragmatic peritoneal lesion concluded the surgical procedure. Macroscopic evaluation of the gallbladder showed one vegetant brown coloured polyp adherent to the mucosa, projected into the lumen, measuring about 3,5 cm in size, and a brown lymph node 1.5 cm in diameter. At histological examination, the mucosal (Figure 2) and muscular layers of the gallbladder were diffusely infiltrated by epithelioid and spindle heavely pigmentated cells; the epithelium was partially eroded and no junctional activity was evident; the cystic duct lymph node and the peritoneal node were both involved by metastatic cells from melanoma. Immunohistochemical staining of the removed tissues showed a strong positivity for S 100 protein, HMB 45 and MART-1 (Figure 3, 4, 5). Postoperative course was uneventful and the patient was discharged home on postoperative day two. No adjuvant chemotherapy was offered at this time by our oncologists. Two months later the patient presented clinical evidence of intestinal obstruction. CT revealed intussusception of two segments of the small bowel tract. At laparotomy resection of two portions of the involved small bowel by two stenosing metastases with contiguous involvement of the mesentery and of mesenteric lymph nodes was performed. Pathology confirmed the abdominal recurrence by metastatic melanoma. After surgery he recieved chemoimmunotherapy (fotemustine 100 mg/m2 and dacarbazine 900 mg/m2 intravenously every three weeks for a total of three cycles plus interferon alfa-2b 5 MU/m2 subcutaneously).


Laparoscopic cholecystectomy for melanoma metastatic to the gallbladder: is it an adequate surgical procedure? Report of a case and review of the literature.

Marone U, Caracò C, Losito S, Daponte A, Chiofalo MG, Mori S, Cerra R, Pezzullo L, Mozzillo N - World J Surg Oncol (2007)

Neoplastic cells immunostained with anti-S-100 antibodies (× 400).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2233626&req=5

Figure 3: Neoplastic cells immunostained with anti-S-100 antibodies (× 400).
Mentions: In May 2001 a 54-year-old man presented to observation with diagnosis of 6.1 mm thick, Clark's level IV, ulcerated cutaneous melanoma of the trunk. Preoperative staging with chest X-ray and abdominal ultrasound (US) did not reveal signs of systemic disease. He underwent wide local excision (WEX) and sentinel lymph node biopsy (SLNB). Preoperative lymphoscintigraphy showed uptake of the radiotracer in one node of the left axilla that was removed and resulted on finally pathology negative for metastatic melanoma. The patient was submitted to regular follow-up every three months with physical examination, chest X-ray, US and blood work, according to the Multicenter Selective Lymphadenectomy Trial [9]. In January 2002 hepatobiliary US detected the presence of intracholecystic nodule of 1.0 cm. Three months later the patient presented upper abdominal pain mimicking symptomatic cholecystolithiasis. Blood analysis values were normal. US examination showed an increasing in size to 2.0 cm of the intracholecystic nodular image (Figure 1). Computerised tomography (CT) confirmed the presence of a nodule in the lumen of the gallbladder measuring about 2.0 cm and a positron emission tomography (PET) revelead uptake in the gallbladder area without evidence of systemic uptake of the radiotracer. In May 2002 the patient underwent laparoscopic cholecystectomy. Intrabdominal exploration showed a normal gallbladder but with an enlarged blue coloured lymph node along the cystic duct, and the presence of a dark spot image of the diaphragmatic peritoneum. The gallbladder was removed together with the lymph node along the cystic duct and put into an endobag to avoid any contamination of the abdominal cavity and extracted. An excisional biopsy of the diaphragmatic peritoneal lesion concluded the surgical procedure. Macroscopic evaluation of the gallbladder showed one vegetant brown coloured polyp adherent to the mucosa, projected into the lumen, measuring about 3,5 cm in size, and a brown lymph node 1.5 cm in diameter. At histological examination, the mucosal (Figure 2) and muscular layers of the gallbladder were diffusely infiltrated by epithelioid and spindle heavely pigmentated cells; the epithelium was partially eroded and no junctional activity was evident; the cystic duct lymph node and the peritoneal node were both involved by metastatic cells from melanoma. Immunohistochemical staining of the removed tissues showed a strong positivity for S 100 protein, HMB 45 and MART-1 (Figure 3, 4, 5). Postoperative course was uneventful and the patient was discharged home on postoperative day two. No adjuvant chemotherapy was offered at this time by our oncologists. Two months later the patient presented clinical evidence of intestinal obstruction. CT revealed intussusception of two segments of the small bowel tract. At laparotomy resection of two portions of the involved small bowel by two stenosing metastases with contiguous involvement of the mesentery and of mesenteric lymph nodes was performed. Pathology confirmed the abdominal recurrence by metastatic melanoma. After surgery he recieved chemoimmunotherapy (fotemustine 100 mg/m2 and dacarbazine 900 mg/m2 intravenously every three weeks for a total of three cycles plus interferon alfa-2b 5 MU/m2 subcutaneously).

Bottom Line: Metastatic melanoma to the gallbladder is extremely rare and it is associated with a very poor prognosis.Gallbladder metastasis represents a rare event as a first site of recurrence.It must be considered a possible expression of systemic disease also despite radiological absence of other metastatic lesions.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgical Oncology "B", National Cancer Institute of Naples, Italy. dott.marone@virgilio.it

ABSTRACT

Background: Only 2% to 4% of patients with melanoma will be diagnosed with gastrointestinal metastasis during the course of their disease. The most common sites of gastrointestinal metastases from melanoma include the small bowel (35%-67%), colon (9%-15%) and stomach (5%-7%), with a median survival of 6-10 months after surgery, and 18% survival at five years. Metastatic melanoma to the gallbladder is extremely rare and it is associated with a very poor prognosis.

Case presentation: We report a case of a 54-year old man presented to observation with diagnosis of 6.1 mm thick, Clark's level IV, ulcerated melanoma of the trunk, developing in the course of the disease metastatic involvement of the gallbladder as first site of recurrence, treated by laparoscopic cholecystectomy. To date only few cases of patients with metastatic melanoma of the gallbladder treated by this surgical procedure have been reported in literature.

Conclusion: Gallbladder metastasis represents a rare event as a first site of recurrence. It must be considered a possible expression of systemic disease also despite radiological absence of other metastatic lesions. Laparoscopic approach has a possible therapeutic role, but open surgery has also a concomitant diagnostic purpose because gives the possibility of manual exploration of abdominal cavity, useful particularly to reveal bowel metastatic lesions, not easily identifiable by preoperative imaging examinations.

Show MeSH
Related in: MedlinePlus