Gallbladder mass in a sexagenarian

Abstract

CLINICAL PRESENTATION: (Dr. J. Metersky) A 69year-old white man was referred for management of a symptomatic ventral hernia, but during his preoperative evaluation he was found to have microhematuria. A subsequent computed tomographic (CT) intravenous pyelogram demonstrated an enhancing 3.8-cm mass originating in the gallbladder with apparent extension into the hepatic parenchyma (Fig. 1). In retrospect, the patient acknowledged a recent onset of mild, steady supraumbilical pain but denied nausea, vomiting, fever, or weight loss. There was no history of jaundice, itching, acholic stools, or dark urine. The patient’s medical history was positive for non–insulin dependent diabetes mellitus and moderate hypertension; his present medications included metformin, glyburide, and metoprolol. In addition, a recent urinary tract infection had been successfully treated with antibiotics. An umbilical hernia had been repaired 2 years previously. On examination, the patient was an alert, slightly obese man with a blood pressure of 134/88 and a regular pulse. His sclera were not icteric and his cardiorespiratory findings were normal. Abdominal palpation revealed a protuberant but soft abdomen without masses or organomegaly. There was slight deep tenderness localized to the supraumbilical area and associated with a small fascial defect in the site of the previous ventral herniorrhaphy. The genitourinary examination was normal, and the rectal examination revealed a symmetrically enlarged prostate but a negative fecal occult blood test. The laboratory evaluation returned a hematocrit of 46.8% with a white blood cell count of 8900 and normal blood urea nitrogen and creatinine. The total bilirubin was 0.4 mg/dl with an alkaline phosphatase of 100 units and normal hepatic enzymes. The serum carcinoembryonic antigen was 5.8. An abdominal ultrasound confirmed the presence of a cholecystic mass lesion and uncovered a single large gallstone (3.7 cm) in the infundibulum. No neoplastic involvement could be visualized in the portal vein or the duodenum. A CT-guided fine needle aspirate of the gallbladder mass returned a diagnosis of adenocarcinoma. An endoscopic ultrasound study showed no apparent extension of the tumor through the muscularis of the gallbladder and no involvement of the extrahepatic ductal system or duodenum (Fig. 2). GROUP DISCUSSION: (Dr. W. E. Strodel and faculty) It was generally agreed that cholecystectomy with major hepatic resection and regional lymphadenectomy would be required to achieve cure. Because of the CT scan findings suggesting extensive disease, it was suggested that a diagnostic/staging laparoscopy might help to avoid an unnecessary celiotomy.