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Inicio Acta Otorrinolaringológica Española Metastasis of Gallbladder Adenocarcinoma to the Skin of the External Auditory Ca...
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Vol. 69. Issue 2.
Pages 114-116 (March - April 2018)
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125
Vol. 69. Issue 2.
Pages 114-116 (March - April 2018)
Case study
DOI: 10.1016/j.otoeng.2017.01.015
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Metastasis of Gallbladder Adenocarcinoma to the Skin of the External Auditory Canal, a Case Report
Metástasis de adenocarcinoma de vesícula biliar a piel de conducto auditivo externo, a propósito de un caso
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125
Valery Nuñez Carrascoa,
Corresponding author
valerynunezmd@yahoo.com

Corresponding author.
, Jose Luis Serdio Ariasa, Juan Jose Artazkoz del Toroa, Leticia Melgar Vilaplanab
a Servicio de Otorrinolaringología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
b Servicio de Anatomía Patológica, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
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Clinical Case

A male patient aged 85 with a history of high blood pressure, diabetes type II, dyslipidaemia, benign hypertrophy of the prostate, and who due to clinical symptoms of biliary colic is a vector of percutaneous cholecystostomy. Laparoscopic cholesystecomy was performed on an elective basis with anatomopathologic result compatible with poorly differentiated (pT2) gallbladder adenocarcinoma. In a post-surgical CAT scan no pathological changes were appreciated but in another posterior scan (5 months later) a lymphadenopathy was noted in the hepatic hilum of tumour appearance, and treatment with chemotherapy was initiated.

The patient presented at the ENT surgery due to a probable otitis in the left external auditory canal, which did not respond well to standard treatment, and to which additionally there was bloody discharge from the ear (without otalgia) with an excrescent bleeding surface lesion at the roof of the left external auditory canal (EAC). Biopsy reported a poorly differentiated gallbladder adenocarcinoma compatible with metastasis of known primary gallbladder. The CAT scan (Fig. 1) reported a soft tissue tumour relating to the posterior superior wall of the middle third of the left EAC with no bone erosion. Removal of the tumour confirmed diagnosis and indicated the presence of bile pigment, as well as testing positive for immunohistochemistry with CK19 (Fig. 2). Subsequent clinical controls showed no evidence of recurrence in the left EAC.

Figure 1.

CAT scan with lump in the skin of the left EAC.

(0.18MB).
Figure 2.

(A) Tumour with H&E, 4×; (B) H&E, 40× with bile pigment in left ear.

(0.63MB).
Discussion

Gallbladder cancer is an uncommon disease, where extra abdominal metastases are rare but it has a high mortality rate.1,2

The GLOBOCAN 2012 report refers to the fact that Europe has an age-adjusted gallbladder cancer incidence rate which is similar to that of the U.S.A. (1.8 and 1.6 for every 100,000 inhabitants), and lower than that in Asia and Latin American (2.6 and 2.4 for every 100,000 inhabitants).

Women predominate, with a higher marked geographical pattern (Chile and India are some of the countries with the highest worldwide rates), with clear genetic susceptibility (higher incidence in the American Indian population), hormonal factors (linked to oestrogen), environmental factors (diet, poverty, infections) and to gallbladder lithiasis. The most common age of presentation is between 65 and 75 years. 95% are adenocarcinomas.2 Most metastases present in the liver and only 20% in different sites. The most common extra abdominal site of metastasis is the lung followed by the brain. Bone metastases are very rare.1,2

Metastasis of gallbladder adenocarcinoma to the skin has been described around surgical wounds but its distant spread to the skin is extremely rare, with an incidence which varies between 0.7% and 9%.3,4 It presents in advanced stages of the disease and is an indicator of a poor prognosis with a mean survival rate of 7.5 months.5 A review of the literature describes 8 cases of metastasis of gallbladder adenocarcinoma to the skin, and the areas include the upper lip, upper limb, pre-auricular region, scalp, neck and back, which shows us that the most common sites for metastasis are the neck, head and trunk.5 Confirmation of skin metastasis may present a challenge to healthcare.4

Metastases to the skin of the EAC are exceptionally rare and all the more so when it is the primary sign of a metastatic carcinoma. Only 12 cases have been described in the literature, with primary sites in the kidney (3 cases), oesophagus (2 cases), breast (2 cases), lung, liver, colon, rectum and prostate.6

With regard to symptoms presentation is in the form of polyps,7 small painless masses,8 which bleed.9

Ours is not a common case of gallbladder adenocarcinoma (male, European ascendency). Its presentation is atypical since the primary signs of clinical metastasis was in the skin of EAC, and with the patient being in a good general state of health the tumour was removed with no recurrence occurring to date.

Although metastasis to the skin of the EAC is extremely rare, clinicians, radiologists and pathologists should take it into consideration for differential diagnosis of tumours in the EAC.

As far as we are aware this is the first reported case in the literature detailing metastasis of gallbladder adenocarcinoma to the skin of the external auditory canal.

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgements

We would like to thank the Otorhinolaryngology and Pathological Anatomy Service of the University Hospital Nuestra Señora de la Candelaria.

References
[1]
S. Singh, R. Bhojwani, A. Singh, A. Bhatnagar, R.K. Saran, A.K. Agarwal.
Skeletal metastasis in gall bladder cancer.
[2]
K.M. Andia, G.A. Gederlini, R.C. Ferreccio.
Gallbladder cancer: trend and risk distribution in Chile [Article in Spanish].
Rev Med Chile, 134 (2006), pp. 565-574
[3]
R. Chopra, S. Chhabra, S.G. Samra, G.P. Thami, R.P. Punia, H. Mohan.
Cutaneous metastases of internal malignancies: a clinicopathologic study.
Indian J Dermatol Venereol Leprol, 76 (2010), pp. 125-131
[4]
R. Mukhia, S. Shrestha, K. Malla, V.K. Sharma.
Cutaneous metastases from carcinoma of gall bladder.
JNMA J Nepal Med Assoc, 48 (2009), pp. 318-320
[5]
S. Saeed, C.A. Keehn, M.B. Morgan.
Cutaneous metastasis: a clinical, pathological and immunohistochemical appraisal.
J Cutan Pathol, 31 (2004), pp. 419-430
[6]
I. Vasileiadis, S. Kapetanakis, D. Vasileiadis, A. Petousis, T. Karatzas.
External auditory canal mass as the first manifestation of a bronchogenic carcinoma: report of a rare case.
Ann Otol Rhinol Laryngol, 122 (2013), pp. 378-381
[7]
B.A. Baraka, B.J. Al Bahrani, S.S. Al Kharusi, I. Mehdi, A.M. Nada, N.H. Rahabi.
External auditory canal as an unusual site for metastasis of breast cancer: a case report.
Gulf J Oncol, 17 (2015), pp. 85-87
[8]
T. Terada.
Prostatic carcinoma whose initial manifestation was a tumor of external auditory canal.
Hum Pathol: Case Rep, 3 (2016), pp. 30-31
[9]
S. Sari, B. Battal, V. Akgun, M. Salih Deveci.
Metastasis of breast carcinoma to the external auditory canal: report of an unusual case and literature review.
J Belg Soc Radiol, 99 (2015), pp. 53-57

Please cite this article as: Nuñez Carrasco V, Serdio Arias JL, Artazkoz del Toro JJ, Melgar Vilaplana L. Metástasis de adenocarcinoma de vesícula biliar a piel de conducto auditivo externo, a propósito de un caso. Acta Otorrinolaringol Esp. 2018;69:114–116.

Copyright © 2017. Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello
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