Mohammed Alsehli, MD, Seetha Lakshmanan, MD, Ali Akhtar, MD; Roger Williams Medical Center, Providence, RI
Introduction: Cholangiocarcinoma is an aggressive tumor involving epithelial cells of the bile duct. It accounts for 3-4% of all gastrointestinal malignancies and is typically diagnosed late. Bone is a common site of metastasis for prostate, breast and lung cancers. However, bone metastasis from cholangiocarcinoma is uncommon and carries very poor prognosis. We present a case of sclerotic bone metastasis from cholangiocarcinoma.
Methods: An 80-year-old male with 30-year-pack smoking history, diabetes, hypertension and gout, presented to the ED with worsening left shoulder pain for 5 weeks. His pain was initially mild and only on movement of left shoulder but recently became constant and unrelieved with painkillers. He also endorsed fatigue, loss of appetite and 10lbs weight loss in the past month. On examination, patient appeared distressed. His left shoulder was in semi-flexed position and kept close to his chest. He had limited motion due to pain. Initial labs showed WBC 15.8x109/L, hemoglobin 9.5g/dl, total bilirubin 0.3mg/dl with ALP of 265IU/L and normal renal function. Chest x-ray revealed a 2 cm lesion along the left border of the left scapula. CT head was negative, while CT chest and abdomen with contrast showed an inferior gallbladder wall mass inseparable from the liver concerning for direct invasion. There were also lucent lesions of left scapula, thoracolumbar spine and sternum concerning for osseous metastasis. Numerous subcentimeter bilateral metastatic pulmonary nodules and hepatic lesions were also seen. The patient underwent CT-guided biopsy of the left scapular mass which was consistent with metastatic well-differentiated adenocarcinoma. Our oncology team started him on chemoradiation which the patient tolerated but unfortunately, his disease progressed quickly causing severe biliary and duodenal obstruction. He was then transitioned to Hospice care and eventually passed away. Discussion: Although the prevalence of cholangiocarcinoma appears to be low in the United States, it is prudent to consider them as the possible primary site of malignancy even in the absence of overt gastrointestinal symptoms. A high-volume tertiary center studied 340 cases of cholangiocarcinoma and reported only 7 patients (2%) with skeletal metastasis. The vertebra was the most common site of skeletal metastasis shown in 5 patients, followed by pelvic bones in 2 patients, while sternum and skull were present in 1 patient each. Metastasis to the scapulae has never been reported in the literature.
Disclosures: Mohammed Alsehli indicated no relevant financial relationships. Seetha Lakshmanan indicated no relevant financial relationships. Ali Akhtar indicated no relevant financial relationships.