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Right upper quadrant ultrasound. (A, B) A mildly distended gallbladder is visible containing two well-defined soft tissue masses within the gallbladder lumen, measuring 4.7 × 2.8 × 2.5 cm and 3.4 × 1.4 × 2.2 cm, respectively.
Source publication
Malignant melanoma is an aggressive neural crest cell-derived neoplasm with a propensity for metastasis to almost any organ. Gastrointestinal metastasis may manifest as gallbladder polyps. We report a case of metastatic malignant melanoma diagnosed in an 81-year-old male after cholecystectomy performed for acute cholecystitis. Cholecystectomy remai...
Context in source publication
Context 1
... soft tissue attenuation in the fundus of the gallbladder, mild extrahepatic biliary dilation and a common bile duct dilated to 10 mm (Fig. 1). Two wellcircumscribed rounded filling defects within the gallbladder lumen, measuring 4.7 × 2.8 × 2.5 cm and 3.4 × 1.4 × 2.2 cm without distal shadowing, were visualized on right upper quadrant ultrasound (Fig. 2). CA 19-9 was negative (6.0 U/l). Magnetic resonance (MR) imaging was unable to be safely performed due to a metal ...
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Citations
... If so, it usually presents with abdominal pain [6, 8, 11, 12, 17, 18, 20-23, 26-28, 33, 37-42, 46, 48, 49, 51, 53, 59-91]. Other observed symptoms are nausea and vomiting [8,73,75,78,79,84,86,91,92], jaundice [81,83], fever [79,83,89], tarry stools [11,19,36,93], hematemesis [19], hematobilia [93], and weight loss [5,6,16,22,51,84,84]. Physical examination usually is unremarkable. The most common finding is tenderness in the upper right quadrant of the abdomen. ...
... There are no characteristic laboratory findings in GBM. Anemia [10,27,36,93], leukocytosis [8,18,28,33,39,41,62,71,73,83,86,94], elevated erythrocyte sedimentation rate (ESR) [24], elevated bilirubin [8,44,46,83,89], and elevated liver enzymes [8,12,46,51,59,63,70,75,83,84,86,89] were reported. Also the presence of occult blood in stool sample may be found in cases with haematobilia or coexistence of intestinal metastases [27]. ...
... There are no characteristic laboratory findings in GBM. Anemia [10,27,36,93], leukocytosis [8,18,28,33,39,41,62,71,73,83,86,94], elevated erythrocyte sedimentation rate (ESR) [24], elevated bilirubin [8,44,46,83,89], and elevated liver enzymes [8,12,46,51,59,63,70,75,83,84,86,89] were reported. Also the presence of occult blood in stool sample may be found in cases with haematobilia or coexistence of intestinal metastases [27]. ...
Background:
The Valsalva Maneuver (VM) is the first-line treatment for paroxysmal supraventricular tachycardia, but a recent, novel, and efficient tool to restore sinus rhythm has been described, i.e., the Reverse Valsalva (RV). This study aims to compare changes in cardiovascular hemodynamics and autonomic system activity (ANS) based on heart rate variability (HRV) analysis during both maneuvers.
Methods:
Fifteen healthy participants performed the VM and RV maneuvers three times in a sitting position for durations of 15 s and 10 s, respectively. Blood pressure (BP) and heart rate (HR) were continuously monitored before, during and after the tests. Autonomic system activity was evaluated using frequency-domain analysis of HRV.
Results:
The decrease in HR from baseline to the lowest values, expressed as a ratio, was similar during both maneuvers (0.81 during the RV vs. 0.79 during the VM, p = 0.27). However, the final lowest HR in response to the RV was higher than that in response to the VM, 70/min vs. 59/min (p <0.001). The activation of the autonomic nervous system during the most bradycardic phase of the RV (phase II) and VM (phase IV) showed that the total power of HRV was less prominent during the RV than during the VM (p <0.012), with similar levels of parasympathetic activation.
Conclusions:
Our results showed less HR slowdown during the RV than during the VM. The changes in HRV parameters during both procedures in particular phases of the RV and VM suggest that the autonomic nervous system is activated alternately, so these tests can be used complementarily in a clinical setting with different results.
... Even if the surgical approach was different ( had a laparoscopic procedure, and 1 had an endoscopic surgery that was converted to an open procedure), it is worth mentioning that, unlike for our patient, all surgeries were carefully planned and performed with oncological precautions. Of note, only 3 of the 11 favorable postoperative outcome patients had adjuvant immunotherapy [13,15,17]. Pivotal randomized control trials have shown that adjuvant immunotherapy could significantly increase recurrence-free survival in resected stage IV melanoma patients [9,10], possibly improving these already favorable outcomes post gallbladder resection. ...
Cutaneous melanoma can metastasize to almost any organ, including in-transit metastases, lymph nodes, liver, lungs, brain, and bones. Spread to the gastrointestinal tract is less common and generally concerns the small bowel, colon, and stomach. Gallbladder involvement is rarer, and only few cases describe it as the sole site of metastasis upon diagnosis. Melanoma metastases to the gallbladder are usually detected on staging or surveillance imaging, as patients usually show few or no symptoms. In resectable stage IV melanoma patients, complete surgical resection appears to improve the prognosis. However, due to the rarity of isolated gallbladder metastasis of melanoma, there are no guidelines regarding the optimal surgical approach (endoscopic or open cholecystectomy). Here, we report the case of isolated gallbladder melanoma metastasis found after laparoscopic cholecystectomy performed in a 46-year-old female patient with no known history of cancer presenting with acute cholecystitis symptoms. Six weeks after surgery, the patient developed trocar site recurrence. This case highlights the importance of a planned and open surgery for resectable melanoma metastases rather than a laparoscopic approach.
... If so, it usually presents with abdominal pain [6, 8, 11, 12, 17, 18, 20-23, 26-28, 33, 37-42, 46, 48, 49, 51, 53, 59-91]. Other observed symptoms are nausea and vomiting [8,73,75,78,79,84,86,91,92], jaundice [81,83], fever [79,83,89], tarry stools [11,19,36,93], hematemesis [19], hematobilia [93], and weight loss [5,6,16,22,51,84,84]. Physical examination usually is unremarkable. The most common finding is tenderness in the upper right quadrant of the abdomen. ...
... There are no characteristic laboratory findings in GBM. Anemia [10,27,36,93], leukocytosis [8,18,28,33,39,41,62,71,73,83,86,94], elevated erythrocyte sedimentation rate (ESR) [24], elevated bilirubin [8,44,46,83,89], and elevated liver enzymes [8,12,46,51,59,63,70,75,83,84,86,89] were reported. Also the presence of occult blood in stool sample may be found in cases with haematobilia or coexistence of intestinal metastases [27]. ...
... There are no characteristic laboratory findings in GBM. Anemia [10,27,36,93], leukocytosis [8,18,28,33,39,41,62,71,73,83,86,94], elevated erythrocyte sedimentation rate (ESR) [24], elevated bilirubin [8,44,46,83,89], and elevated liver enzymes [8,12,46,51,59,63,70,75,83,84,86,89] were reported. Also the presence of occult blood in stool sample may be found in cases with haematobilia or coexistence of intestinal metastases [27]. ...
Melanoma is a highly malignant neoplasm with the most typical primary locations in the skin and eyeball and rarely reported in the other organs, including the gallbladder. More commonly metastases of melanoma of various primary sites to the gallbladder are observed. However, generally melanoma of the gallbladder is a rare entity with only 217 cases reported in the literature up to date. The paper summarizes knowledge on epidemiology, symptoms, laboratory and imaging findings, morphology, treatment options, and outcome of patients with both primary and metastatic melanoma to the gallbladder.
... Gallbladder metastasis may be clinically asymptomatic or present as acute cholecystitis, and is often diagnosed after cholecystectomy or abdominal ultrasound performed for other reasons, accordingly [9,10]. Apparently, due to their asymptomatic course, we are not aware of the real prevalence of gallbladder metastases: autopsy reports show that the prevalence of gallbladder metastases ranges between 15 and 20%, with melanoma alone as the most common metastatic malignancy of the gallbladder (50-67%) [4,11]. Instead, primary malignant melanoma of the gallbladder is extremely rare, with only a few case reports published in the literature [12], being a diagnosis of exclusion when no prior diagnosis of melanoma has been identified. ...
... In 1999, some clinicians reported 19 cases of melanoma of the gallbladder registered since 1970, with only 3 of them being isolated metastasis of gallbladder [13]. Since then, quite a few cases have been reported in the literature [4,9,11,[13][14][15][16][17][18][19][20][21][22]. Most of them report the same macroscopic and clinical evidence that we encountered in our patient: a polypoid lesion of the mucosa in a patient with acute cholecystitis-like symptoms. ...
Although malignant melanoma (MM) most frequently tends to metastasize to the regional lymph nodes, liver, lung and brain, several unusual sites of metastasis have been described in the literature. Among these, the metastatic involvement of gallbladder or uterus represents an exceptional event, usually associated with diffuse metastatic disease or observed as an autopsy finding. In this paper, we present two unusual cases of isolated MM metastasis to these anatomic sites, arising in a 71-year-old man and a 54-year-old woman, for whom no information on previous malignancies was known at the time of the histological examination. The clinico-pathologic features are described, emphasizing that MM metastasis must be included in the differential diagnosis when dealing with patients with a previous diagnosis of MM and onset of a novel mass/lesion even at unusual sites.
... Malignant melanoma is a very aggressive type of skin cancer. It arises from the melanocytes in the epidermis, uvea, meninges, and intestinal tract [5]. Malignant melanoma often metastasizes to the skin, lungs, liver, and brain [2]. ...
Introduction and importance
Malignant melanoma is one of the most aggressive unpredictable tumors that can metastasize to any organ. Metastases from cutaneous melanoma to the gallbladder are exceedingly rare. Most patients with gallbladder metastases from malignant melanoma are usually asymptomatic; therefore, its diagnosis can be a real challenge.
Case presentation
We report a case of a 71-year-old woman with a past history of cutaneous melanoma, who clinically presented with signs and symptoms of acute cholecystitis. Ultrasound investigation of the gallbladder revealed intraluminal polyp. Gross inspection of the excised gallbladder showed a polypoid lesion in the fundus. Microscopically, the H&E-stained sections revealed nests of malignant cells, occasionally with pigmented cytoplasm. The diagnosis of metastatic melanoma was reported, and supported by the results of the immunohistochemical stains.
Clinical discussion
Malignant melanoma is a very aggressive type of skin cancer. It arises from the melanocytes in the epidermis, uvea, meninges, and intestinal tract. Worldwide, only 40 cases of metastatic melanoma to the gallbladder were documented. Moreover, reviewing the English-language literature showed that primary melanoma is an extraordinary event and was described in about 28 cases. Clinically, metastases from cutaneous melanoma to the gallbladder are usually asymptomatic.
Conclusion
We report a metastatic malignant melanoma to the gallbladder presented as a polypoid lesion and clinically manifested as acute cholecystitis.
... This tumour can virtually metastasize to any organ of the body even years after diagnosis and it is characterized by various morphologic patterns that can mimic any type of neoplastic disease ranging from benign to malignant ones [13]. Metastasis usually spread via lymphatic system draining in the areas around the primary melanoma and via blood stream to distant sites, such as skin and soft tissues, lung, liver, brain and gastrointestinal tract [2,14]. Isolated metastasis of gallbladder are barely described, and mostly present in a widespread metastatic disease. ...
Introduction
Melanoma is one of the most aggressive and one of the fastest growing types of cancer. The occurrence of a malignant melanoma in the gastrointestinal tract, either primary or metastatic, is a rare event. Metastatis from cutaneous malignant melanoma to the gallbladder are a highly uncommon finding, usually associated with diffuse metastatic disease and observed during autopsy. The event of a solitary metastasis of malignant melanoma to gallbladder is barely reported.
Case report
We report a case of a 35-year old Caucasian woman with isolated metastasis of gallbladder from cutaneous primary malignant melanoma managed with laparoscopic cholecystectomy.
Discussion
Gallbladder metastasis as a first site of recurrence represents a rare condition for all cancers. Since the occurrence of an isolated gallbladder metastasis of cutaneous melanoma is an uncommon circumstance, no therapeutic guidelines have yet been proposed. Nevertheless cholecystectomy appears to be the standard of care for the treatment of this unusual condition, especially when symptomatic and for palliative purpose. The surgical approach is still debated, with no unanimous consent between mini-invasive surgery and open technique.
Conclusion
In our case, we decided to carry out a three-port laparoscopic cholecystectomy, preferring a mini-invasive approach considering the good performance status of our patient and her young age.
Rationale
Melanoma is one of a common cutaneous malignancy. Currently, metastatic malignant melanoma is difficult to be diagnosed through imaging examinations. Furthermore, the incidence of metastatic melanoma affecting the gallbladder and ureter is exceptionally rare.
Patient concerns
A 54-year-old female was admitted to the hospital with a half-month history of left lower back pain. Correlative examination revealed an occupying lesion in the mid-left ureter and the neck of the gallbladder.
Diagnoses
The patient was initially diagnosed with gallbladder cancer and left ureteral carcinoma based on imaging. Following 2 operations, immunohistochemical staining confirmed the presence of metastatic melanoma involving both the gallbladder and ureter.
Intervention
After multidisciplinary consultation and obtaining consent from the patient and her family, the patient underwent left radical nephroureterectomy, radical cholecystectomy, laparoscopic partial hepatectomy (Hep IV, Hep V), and lymph node dissection of hepatoduodenal ligament.
Outcomes
One month after treatment, the patient imaging showed no disease progression, and at 6 months of follow-up, the patient was still alive.
Lessons
It is difficult to distinguish metastatic melanoma from carcinoma in situ by imaging. In addition, metastatic malignant melanoma lacks specific clinical manifestations and is prone to misdiagnosis, which emphasizes the highly aggressive nature of malignant melanoma.
Background
Primary and secondary gallbladder melanomas are rare, and only 58 cases have been reported in scientific literature to date. This paper aimed to explore the role of minimally invasive surgery in the management of gallbladder metastatic melanomas.
Case
Herein, we present the case of a 68-year-old man with metastatic gallbladder melanoma who was treated with laparoscopic cholecystectomy. Our case management was then compared with that of other cases reported in the literature.
Conclusion
Currently, metastatic melanomas can be considered as a potentially curable disease. Palliation of symptoms and fast recovery following minimally invasive procedures could be beneficial for these patients. Particularly, laparoscopic procedures appear to prolong the survival of gallbladder melanoma patients.
