Image of the Month—Quiz Case

A 63-year-old man had a history of stage IV metastatic melanoma arising from the back and subsequently metastatic to the cervical nodes, brain, and stomach. Metastatic lesions were managed with chemobiotherapy, interleukin 2, gamma-knife radiotherapy, and partial gastrectomy, rendering the patient free of disease for 8 years. Surveillance staging revealed lesions on his gallbladder with increased signal on positron emission tomography. Computed tomography demonstrated abnormal frondlike gallbladder wall nodularity with eccentric masses within the gallbladder lumen (Figure 1). The patient remained asymptomatic at this time. At cholecystectomy, the gallbladder was distended but had no external abnormalities. However, diffuse superficial mucosal nodularity was observed. More than 85% of the gallbladder mucosal surface was covered with more than 100 tan to black irregularly shaped polypoid lesions that ranged from 0.2 to 1.5 cm in diameter (Figure 2). Areas of grossly unaffected gallbladder mucosa were tan and velvety. The patient tolerated the procedure and recovered without incident.

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Figure 1. Computed tomographic scan of the abdomen demonstrating multiple intraluminal masses (arrow) arising from the gallbladder wall.

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Figure 2. Gross specimen of the gallbladder, weighing 124.9 g and measuring 13.0 × 6.4 × 4.1 cm. No specific lesions or ulcerations were seen on the serosal surface. The gallbladder contained more than 50 small black multifaceted stones, varying from 0.1 to 0.2 cm in diameter. More than 85% of the gallbladder mucosal surface was covered with approximately 100 tan to black irregularly shaped polypoid lesions ranging from 0.2 to 1.5 cm in diameter. To convert inches to centimeters, multiply by 2.54.

A. Cholelithiasis

B. Metastatic melanoma to the gallbladder

C. Primary adenocarcinoma

D. Gallbladder polyps

Answer