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2010, Volume 26, Number 2, Page(s) 162-164
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DOI: 10.5146/tjpath.2010.01016 |
Signet Ring Cell Carcinoma of the Gallbladder with Skin Metastasis: A Case Report |
Erdal KARAGÜLLE1, Emin TÜRK1, Halil KIYICI2, Elif KARADELİ3, Gökhan MORAY1 |
1Departments of General Surgery, Başkent University, Faculty of Medicine, ANKARA, TURKEY
2Departments of Pathology, Başkent University, Faculty of Medicine, ANKARA, TURKEY
3Departments of Radiology, Başkent University, Faculty of Medicine, ANKARA, TURKEY |
Keywords: Gallbladder neoplasms, Signet ring cell carcinoma, Skin nodule, Metastasis |
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The aim of this case report is to attract the attention of related
clinicians to similar cases because of their rarity. We believe this case
and other similar cases in the literature could initiate studies that may
explain the pathways of metastasis.
A 50-year-old female patient underwent laparoscopic cholecystectomy
because of symptomatic cholelithiasis. Postoperative pathologic
examination of the specimen led to a diagnosis of signet ring carcinoma
in the wall of gallbladder. After this incidental diagnosis, this patient
underwent a second operation, which was a radical cholecystectomy.
After pathological examination of the second operation material, we
decided to call this patient for periodic controls, as the tumor was
graded as stage I. A cutaneous lesion 33 months after the second
operation was diagnosed as metastasis of signet ring cell carcinoma.
Signet ring carcinoma of the gallbladder is a rarely seen malignancy.
Cutaneous metastasis of this rare malignancy is also quite rare. There
are only a few reports of cutaneous metastasis of signet ring carcinoma
of the gallbladder. It is necessary to explain the reasons of this unusual
metastasis with further studies. |
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Gallbladder carcinoma is rare and is seen with gallbladder
stones in about 90% of the cases 1. It has an aggressive
course except for early cases found incidentally during
cholecystectomy for cholelithiasis. Signet ring cell carcinoma
is a rare form of mucinous adenocarcinoma and has a worse
prognosis. Skin metastasis of signet ring cell carcinoma is
rare and there are only a few reported cases 2,3. |
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Abstract
Introduction
Case Presentation
Disscussion
References
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A 50-year-old female presented at the out patients department
with dyspectic complaints. Her history was unremarkable
except for hypertension. Physical examination
revealed right upper quadrant abdominal tenderness only.
Routine biochemistry tests and full blood count were normal.
Upper abdominal ultrasonography revealed multiple stones
in the gallbladder lumen with the largest 2 cm in diameter.
Upper gastrointestinal system endoscopy showed alkaline reflux gastritis. Laparoscopic cholecystectomy was planned
with a diagnosis of symptomatic cholelithiasis. During
surgery, the gallbladder was found to be firm, thick and
edematous. Malignancy was not suspected and the surgery
was finished laparoscopically. Pathological examination of
the gallbladder revealed malignant neoplastic infiltration as
single cells and small cell groups along the complete wall of
the gallbladder including the surgical margin, in addition
to the stones in the gallbladder lumen. The tumor cells
were denser in the areas close to the mucosal surface and
became sparse further away. Cytoplasmic mucin was found
in some of the cells with an eccentric nucleus (signet ring
cell carcinoma) with mucin histochemistry (Figure 1). The
colonoscopy, and thoracic and abdominal CT that followed
were normal. The patient was reoperated to perform radical
cholecystectomy. The trocar insertion site in the subxiphoid
region where the gallbladder had been removed from the abdomen was excised to include the skin-subcutaneous
tissue-fascia and peritoneum. The cystic stump was excised
and sent for frozen section and no tumor was found on the
distal part. The radical cholecystectomy was then completed.
The patient was discharged uneventfully on the 7th postoperative
day. Pathological investigation of the specimen
showed signet ring cell carcinoma infiltration in the cystic
canal stump although there was no tumor in the surgical
margin. Reactive changes were seen in sections of the skin,
subcutaneous tissue, peritoneum and falciform ligament.
No metastasis was found in the 3 lymph nodes dissected
from the paraduodenal and paracholedochal regions. The
patient was referred to Oncology and followed-up with
no treatment recommendiation. The patient underwent
routine follow-up with no signs or symptoms but presented
at the outpatients department 33 months after the surgery
with a 2x2 cm mass on the skin over the left scapula. The
mass was excised under local anesthesia. Pathological investigation
of this mass revealed signet ring cell carcinoma
and clean surgical margins (Figure 2). Positron emission
tomography was performed and revealed a 2 cm area in the
bony tissue of the occipital region that was consistent with
metastasis. Chemotherapy was decided on and the patient
underwent 12 cycles. Shoulder magnetic resonance imaging
was performed for shoulder pain and showed findings consistent
with metastasis. Bone scintigraphy also showed widespread
metastases and radiotherapy was initiated. The
patient currently continues to receive treatment on the 40th
month following the surgery.
Click Here to Zoom |
Figure 1: Signet ring cell carcinoma infiltration of gallbladder
wall (H&E, x400). |
Click Here to Zoom |
Figure 2: Signet ring cell carcinoma infiltration of dermal tissue
(the dermis) (H&E, x100). |
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Abstract
Introduction
Case Presentation
Disscussion
References
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Signet ring cell carcinoma is a rare type of mucinous
adenocarcinoma and has a poor prognosis 4. When a
diagnosis of gallbladder cancer is made, usually 50% of
cases have local regional spread or regional lymph node
metastasis. Lymphatic spread is to the hepatic artery and
celiac axis or portal system 4. The rate of skin metastasis
from intraabdominal malignancies is 1 to 9% 5. Skin
metastasis of signet ring cell carcinoma is rare. There are
few well-documented cases in the literature 2,3. The 5-
year survival for gallbladder cancer is less than 5% despite
aggressive treatment 4. Our case was Grade I (T1N0M0).
The expected 5-year survival for grade I patients is reported
as 75 to 100% 6,7. The treatment for early grade incidental
cancers is a matter of debate. Some authors provide long
survival periods following cholecystectomy, saying this
surgery is sufficient without a need for reoperation while
others feel reoperation and radical cholecystectomy are the
only way to obtain cure 8-10.
Skin tumors of signet ring cell morphology may be
metastatic or primary. The skin metastases of signet ring cell
carcinomas usually originate from the stomach, pancreas,
colon, rectum, breast, prostate, gallbladder and bladder that
are the most common mucin-secreting adenocarcinomas.
If the signet ring cell carcinoma of the skin is primary,
such cases have been reported with primary signet cell
ring carcinoma of the skin, squamous cell carcinoma, basal
cell carcinoma, signet ring cell lymphoma, trichilemmal
carcinoma and malignant melanoma3,11. Although the
skin metastasis of signet ring cell carcinoma usually appears
as a nodule and a plaque with central necrosis, herpetiform
lesions have also been reported recently12. Excess mucin
is collected in signet ring cell carcinomas as there are no
normal secretion or excretion mechanisms. The nucleus is
compressed in one part of the cell and looks like a crescent,
giving rise to the signet ring name. The mucinous content
looks clear with routine stains while it stains positive with
Periodic acid-Schiff, negative with diastase and positive with
mucicarmen11. Immunohistochemical investigation may
help differentiate the origin of signet ring cell carcinoma.
Cytokeratin 7 is positive in tumors of gallbladder, hepatic
canal and pancreatic canal origin. Cytokeratin 20 is positive
in gastric/intestinal mucosa or gallbladder and skin primary
signet ring cell carcinoma13. Skin metastases of signet ring
cell carcinomas are mostly seen in regions rich in apocrine
glands and this is attributed to the collection and growth of
metastatic signet ring cells in areas with regional stromal
support. This stromal support is emphasized in recurrent
and metastatic disease in recent reports14.
We presented a case that had undergone elective laparoscopic
cholecystectomy for cholelithiasis and was incidentally
diagnosed with grade I gallbladder cancer in this case report.
A skin metastasis, which is not an expected metastasis site
for signet ring cell gallbladder carcinoma, appeared during
the patient's follow-up. It is difficult to explain the skin
metastasis 33 months and the bone metastasis 38 months
after the surgical treatment without intraabdominal organ
involvement. It is necessary to explain these metastases at
unusual sites of these tumors with new studies. |
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Abstract
Introduction
Case Presentation
Discussion
References
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Top
Abstract
Introduction
Case Presentation
Discussion
References
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