Article 1_25_23 | GBMNGeorgian Biomedical News

CASE REPORT

A Rare Incident of Metastatic Melanoma in the Gallbladder: A Case Report

Shalva Giuashvili1,ID, Tamaz Chkhikvadze2, Kakha Dangadze2, Tatiana Mermanishvili2,ID, Giorgi Lapanashvili-Dartsimelia1, Mirza Mikava3

Received: 3 May 2025; Accepted: 5 Jun 2025; Available online: 11 Jun 2025

ABSTRACT

Melanoma is the most serious type of skin cancer, developing from cells known as melanocytes. It is more aggressive, with a higher tendency to grow locally and metastasize to distant areas. Melanoma has the potential to spread to various sites, including subcutaneous tissue, lymph nodes, lungs, liver, bones, and brain. Metastatic involvement of the gallbladder is sporadic, and in living patients, this condition is rarely documented because it often presents without symptoms. While early-stage melanoma has a high cure rate when detected and treated promptly, advanced melanoma presents significant challenges due to its propensity for metastasis and resistance to traditional therapies. The primary treatment is surgical resection with clear margins, and adjuvant therapies may be used to lower the risk of recurrence. Chemotherapy is less commonly used for melanoma due to its limited effectiveness. In recent years, the emergence of novel therapies, such as immune checkpoint inhibitors and targeted therapies, has revolutionized the management of metastatic melanoma.

Keywords: Melanoma; laparoscopic extended cholecystectomy.

DOI: 10.52340/GBMN.2025.01.01.114

INTRODUCTION

Metastatic melanoma of the gallbladder is exceptionally uncommon and is associated with a very poor prognosis.1 It is primarily described in the literature through a limited number of case reports, and there is no clear consensus on its management. Most patients with gallbladder metastases are asymptomatic, and these metastases are typically detected during surveillance or staging imaging. Somatic mutations or deletions in the BRAF and CDKN2A genes, located on Chromosomes 9p21, 7q, 10q, 1p, 12q, 6p, 3, 11q, 14q, 8q, and 223 play a key role in the pathogenesis.2,3 Metastasis to the gastrointestinal (GI) tract occurs in approximately 2-4% of melanoma cases, with the small intestine being the most commonly affected site (35-67%), followed by the colon (9-15%) and the stomach (5-7%).4 Acute cholecystitis is the most common symptomatic presentation of gallbladder metastases, which typically occur via the bloodborne spread, resulting in tumor deposits on the gallbladder's outer layer. These deposits can develop into fast-growing polypoid masses. The polypoid nature of these metastases means they are elevated above the surface and can obstruct bile flow, potentially leading to symptoms similar to those of primary gallbladder diseases.5 The occurrence of metastasis in the gallbladder is unusual. Here, we describe a 65-year-old male patient with a history of melanoma. He presented with a history of malignant melanoma, which was resected two years ago. Furthermore, we provide a review of our case and discuss the best surgical management options.

CASE

A 65-year-old male with a previous diagnosis of malignant melanoma presented to our clinic with abdominal pain localized to the right upper quadrant. The patient had been diagnosed with melanoma two years prior in Turkey, where he underwent surgical excision with bilateral axillary lymph node dissection, followed by 12 sessions of immunotherapy and five sessions of radiotherapy. Unfortunately, the patient was unable to provide documentation of his prior treatment and was considered stable in terms of oncologic status.

During follow-up imaging in Turkey, a polypoid lesion in the gallbladder was identified. PET and MRI scans, along with a liver biopsy, revealed no hepatic malignancy or evidence of metastasis. The patient was referred to our clinic for elective surgical management involving gallbladder removal.

An abdominal MRI revealed a moderately filled gallbladder with an irregular mucosal area at the base. A T2 hypointense, diffusion-restricted, and contrast-enhancing polypoid lesion measuring 1.8 cm with minimal wall thickening was observed. Regional lymphadenopathy was detected. Biopsy of the gallbladder lesion was deferred due to the risk of gallbladder perforation and peritonitis. Despite the absence of biopsy results, laparoscopic extended cholecystectomy with en-bloc resection of the adjacent liver tissue and hepatoduodenal lymphadenectomy was recommended.

The patient underwent laparoscopic extended cholecystectomy. Intraoperatively, extensive adhesions were noted under the liver, with the gallbladder adherent to the hepatoduodenal ligament and transverse colon. Intramural tumor growth was evident at the gallbladder base, with a prominent, round surface mass. An enlarged lymph node was identified at the hepaticoduodenal ligament. The liver appeared mildly enlarged and steatotic, with no visible metastatic damage.

The gallbladder was mobilized along with pericholecystic adipose tissue with liver resection (resection of 1 cm of the gallbladder parenchyma). The artery and cystic duct were ligated, and lymphadenectomy of the hepaticoduodenal ligament was performed. Liver resection was executed laparoscopically with HEM-o-Lok clips and a LigaSure device, achieving hemostasis using bipolar coagulation.

Gross examination revealed a polypoid lesion at the gallbladder base. Histopathological analysis showed a population of pleomorphic, pigmented, anaplastic cells with diffuse infiltrative growth extending into the lamina propria (Fig.1), muscular (Fig.2), and perimuscular (Fig.3) layers. Evidence of necrosis, lymphoid infiltration, vascular invasion (Fig.4), and metastatic involvement of regional lymph nodes (Fig.5) was documented.

A month post-surgery, immunohistochemical analysis was performed.

FIGURE 1. Lamina propria

FIGURE 2. Muscular layer

FIGURE 3. Perimuscular layer

FIGURE 4. Necrosis, lymphoid infiltration, vascular invasion

FIGURE 5. Metastatic lesions of the hepatoduodenal junction lymph nodes

DISCUSSION

The challenge was that, despite the patient's known history of metastatic melanoma, imaging studies, including PET, MRI, and CT scans, revealed only a single polypoid lesion in the gallbladder, with no other detectable signs of oncological disease. The liver biopsy returned a negative result, and due to the risk of compromising the integrity of the gallbladder, a biopsy of the lesion was not feasible. The critical decision and dilemma were whether to perform a simple laparoscopic cholecystectomy or a laparoscopic extended cholecystectomy with atypical liver resection and lymphadenectomy. Based on the liver biopsy results, the patient's medical history, and the size of the lesion (1.8 cm), the decision was made to proceed with a laparoscopic extended cholecystectomy. The gallbladder was resected laparoscopically along with a 1-cm margin of the liver, and lymph nodes from the hepatoduodenal ligament were dissected and carefully removed by oncological principles. The appropriateness of this approach was confirmed postoperatively through morphological and immunohistochemical studies.

CONCLUSIONS

In our case, a rare metastasis of melanoma was found in the gallbladder. Morphological diagnosis of metastasis melanoma of the gallbladder is not possible before the removal of the organ. Considering the patient's oncological history and the presence of a large polypoid lesion (1.8 cm) in the gallbladder, an extended laparoscopic cholecystectomy is recommended.

AUTHOR AFFILIATION

1 Faculty of Medicine, Tbilisi State University (TSU), Tbilisi, Georgia

2 Department of Surgery, Aleksandre Aladashvili Clinic, Tbilisi, Georgia

3 East-West University (EWUNI), Tbilisi, Georgia

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ISSN (Online): 2720-8796