Dr.Reddy,

I think so that the most probable diagnose for this case is the cancer of the gallbladder which can be CA19.9 negative, not speaking about normal liver functional tests, and should be treated as such. The gallbladder cancers are extremely heterogenetic both from pathohistologic and immunohistochemical points of view (would you see J.Albores-Saavedra's classification of the GBCancer, please).

Would you kindly share pictures of this gallbladder obtained so we could discuss them here additionally?

Yours truly,

Andrey

If you suspect a neuroendocrine neoplasm check serum chromogranin and order an Octreoscan. I also think that the most probable diagnosis is gallbladder  adenocarcinoma.

Yours truly 

Alfonso.

It is not possible to differentiate preoperatively betweengallbladder adenocarcinoma and a gallbladder NET withimaging techniques. Ultrasound examination of the abdomenusually reveals a well-defined mass with a heterogeneousechogenicity in the gallbladder fossa, usually confirmed bycontrast-enhanced computed tomography scan.67The sensiti-vity of ultrasonography in the identification of GBC isB44%.68If, however, the lesion has infiltrated the liver orthere is lymph node metastasis, the diagnostic accuracy isgreater. The endoscopic ultrasonographic (EUS) appearanceof GBC is of a hypoechoic mass with or without gallbladderwall calcification.69Both transabdominal ultrasound andEUS enable fine needle aspiration (FNA) of the primarytumor, lymph nodes, or liver for cytology and improve thediagnostic sensitivity from 74 to 90% as compared to trans-abdominal ultrasonography alone.70Magnetic resonancecholangiopancreatography (MRCP) or endoscopic retro-grade cholangiopancreatography (ERCP) may provide someadditional information in regard to the extent of theencroachment of the lesion on the extrahepatic biliary tree.In addition to imaging the tumor and the ducts by ultrasoundor ERCP, computerized axial tomography (CT) (Fig. 2) isnecessary to define the extent of loco-regional disease anddetermine the T stage.71Since most NETs exhibit over-expression of somatostatin receptors, somatostatin analoguescintigraphy (SRS) is effective in identifying such tumors.72Positron Emission Tomography (PET) detects accumulationof radiolabeled biological substances such as 18F-fluorodeox-yglucose (FDG) in tumor tissue. More NET specific PETtracers include the use of radiolabeled somatostatin analogs.Combinations of PET with CT or MRI imaging systems areespecially effective as they generally have a particularly highsensitivity (>90%) for detection of NET.73–75From thesemodalities 6-[fluoride-18]fluoro-levodopa [(18)F-DOPA PET]improved tumor localization compared with conventionalimaging and 18F-TOCA PET improved the diagnosticaccuracy for the detection of metastases.73–75The role ofthese modalities in the detection of GB-NETs, however,remains to be evaluated. If a gallbladder tumor presentsalong with a very large hepatic mass and/or extensivelymphadenopathy at diagnosis, a NET should be considered.However, similar presentation is also common for otherneoplasms including advanced GB-adenocarcinomas, cho-langiocarcinoma, hepatocellular carcinoma, or hepatic meta-stasis involving the gallbladder.61Extensive lymph nodeenlargement is also seen with gallbladder lymphoma.

Neuroendocrine Tumors of the Gallbladder An Evaluation and Reassessment of Management Strategy. Available from: https://www.researchgate.net/publication/43073669_Neuroendocrine_Tumors_of_the_Gallbladder_An_Evaluation_and_Reassessment_of_Management_Strategy [accessed Nov 6, 2016].

Article Neuroendocrine Tumors of the Gallbladder An Evaluation and R...

Prof Julio,

Thankyou very much for such adetailed informative answer.I do expect many of our RG colleagues will go through it,