Recurrent melanoma of the leg and polypoid lesions of the gallbladder—a management dilemma

Isolated limb perfusion (ILP) is a well-tolerated method of regional chemotherapy for melanoma, with response rates ranging from 40–80%, used to treat recurrences or metastases confined to the limb from which the original tumour was excised. We present the case of a 75-year-old woman with a third recurrence of melanoma of the left leg, referred for ILP, in whom staging investigations revealed two probable malignant polypoid lesions of the gallbladder (PLG). These were thought likely to represent metastatic melanoma. In view of the diagnostic difficulty, she underwent laparoscopic cholecystectomy together with left superficial femoral ILP. Multiple papillary adenomatosis, with dysplasia ranging from mild to severe, and with areas of invasive adenocarcinoma, were found on gallbladder histology. No previous case of this combination of tumours has been reported. This case provides evidence of an adenoma—carcinoma sequence, and to our knowledge no previous case has been reported with both carcinoma and the full range of dysplasia from mild to severe within the same gallbladder. The use of minimally invasive surgery allowed the ILP to be performed at the same operation. The pathology, natural history and place of laparoscopic surgery in the management of PLG is discussed.