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Cutaneous Metastasis as the First Manifestation in Gallbladder Adenocarcinoma
Apresentação do caso
A 74-year-old female, was referred to the surgery clinic for a painful, ulcerated cutaneous nodule on the umbilical region and a history of weight loss and innapetence, symptoms started eight months prior. On physical examination, there was also left inguinal lymphadenopathy. A biopsy from the nodule showed moderately differentiated adenocarcinoma and led to the hypothesis of an occult gastric carcinoma. These results were consistent with a Sister Mary Joseph's nodule. A computed tomography scan, apart from the previous findings, showed only a small hepatic nodule near the gallbladder, and upper gastrointestinal endoscopy was normal. The patient was brought to the operating room fifteen weeks later. On peritoneal cavity inventory, we found an unresectable hepatic lesion, strongly adhered to the gallbladder, stomach, and duodenum and extensively involving of other intra-abdominal organs. Cholecystectomy, right oophorectomy and resection of the umbilical nodule were performed. The abdominal wall was reconstructed with polypropylene mesh. The postoperative recovery progressed well and she was discharge home on the fourth day. She eventually returned to the emergency room presenting dehiscence of the surgical wound, tissue necrosis and mesh exposure. Another surgery was performed, and upon weekly follow-up, she maintained, satisfactory improvement of the wound. After six weeks the patient presented with an enteroatmospheric fistula. She was readmitted and treated with exclusive parenteral nutrition, wide-spectrum antibiotics, and symptomatic drugs. On the fourth week, after exhaustingly discussing the patient’s clinical condition with the family and multidisciplinary team, she was discharge home on oral and enteral feeds and died eight weeks later.
Gallbladder cancer is the sixth most common gastrointestinal tumor and has a small overall survival rate. In advanced cases, it commonly presents with liver, regional lymph nodes and peritoneum metastases. The incidence of cutaneous metastases in these tumors ranges from 0.7% to 9% of the cases, where only 10% are umbilical. In gallbladder cancer, this manifestation is especially rare. Sister Mary Joseph's nodule is usually associated with advanced metastasizing intra-abdominal cancer and generally indicates a poor prognosis. Therefore, early biopsy is paramount for accurate diagnose and early treatment.
In this case report we presented a rare early cutaneous manifestation of gallbladder cancer.
Gallbladder Cancer, Neoplasm Metastasis, Sister Mary Joseph's Nodule
NATHÁLIA GABRIELA SOARES MORATO, EDMILSON CELSO SANTOS, PEDRO HENRIQUE FARIA SILVA TROCOLI COUTO, JOÃO LUCAS DE CARVALHO GOMES, HENRIQUE ARAÚJO LIMA, DIOGO VIANA ABREU, VINÍCIUS NASCIMENTO FERREIRA, RONALDO BATISTA MELO JUNIOR, FERNANDA MELAZZO NASCIMENTO SANTOS, MARIA ELISA SOARES SILVEIRA CARDOSO