CT images.

Other than the thickened fundus, is there any enlarged lymph node around?

How is the previous ERCP cholangiogram findings?

From your description, the pancreas seems not involved.

The clinical history presented makes malignancy the most important to rule out. This require discussion with patient for type of surgery to be performed, one off vs staged; laparoscopy vs open; on table frozen or not.

ERCP guided biopsy may also be considered, yet technical challenging.

If malignancy is not a concern, and patient is asymptomatic as you said, then we can observe.

Ist possibility of Ca gall bladder should be considered and if there are no distanct lesions like lymph nodes. Then you 1st performed HRCT chest;if it is normal then planned for open cholecystectomy. And during surgery frozen should be performed.

There are neither lymph node nor distant lesions.

Liaise with your pathologist for possibility of on table fresh frozen section service in the hospital, and then discuss with patient to compromise on the treatment approach.

Yes, of course. I am thinking in first perform staging laparoscopy followed a formal inferior central bisegmentectomy and portal lymphadenectomy with frozen section.

It seems a gallbladder cancer but can be a fundic adenomyomatosis. My fear is a overtreatment if this is a benign disease.

Dear Sergio, I faced this dilemma in few occasions. My recommendation is to perform a diagnostic laparoscopy. If no clear signs of malignancy are present, proceed with laparoscopic cholecystectomy, without intraoperative cholangiogram and do not cause any bile leakage. If gallbladder wall is thin, you may enter a few millimeters in the liver. Better some bleeding than bile cancer cells spilling. Protect around the hepatic hilum area with gazes. Remove the gallbladder inside a plastic retrieval bag and perform frozen section. If negative, finished the operation. If positive, you may complete the operation with hepatic hilar lymphadenectomy and removal of liver segments 5 and 4b. Discuss with the patient and family before the procedure and all possibilities that you may encounter and the surgical procedures that may follow.

This paper may help you decide the technique, open or minimally invasive. Good luck.

Totally Laparoscopic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer.

Machado MA, Makdissi FF, Surjan RC.

Ann Surg Oncol. 2015 Dec;22 Suppl 3:S336-9. doi: 10.1245/s10434-015-4650-9.

Don’t you think that PET-CT may add some new information in this case?

I think that PET-CT would not help in this case, the studies about PET-CT in gallbladder cancer are controversial. I dont know wheter PET-Ct can shine in adenomyomatosis generating more doubts.

If it is positive, then definitively cancer. Adenomyomatosis always negative on PET-CT

Nice idea Professor Marcel, but this patient have choosen up front surgery. We will go to start by laparoscopy. We will try to resect it by means this approach. Thank you for your comentaries.

We have performed a laparoscopy and have observed a locally advanced GBC. We have underwent a formal hilar lymphadenectomy where was observed no comprised lymphonodes (0/6) and finally we have done na open formal inferior central bisegmentectomy (SIVB+V) with free margins.

Great job. Congratulations. What was the final pathology? Do you think that the patient will need neoadjuvant treatment? If yes, what? chemotherapy or chemoradiation? With which drugs?

Just for the sake of discussion..

Nice professor. T3nomo . I have done a revision about adjuvant chemotherapy. It is indication for 》t2 or n+. Something such as capecitabine or gencitabine. I will decide in multidisciplinary revision. Thanks once!

hi, dear, good times

an asymptomatic patient needs to follow up visits.

Repeat Ct scan and Mri

Change life style

Nice comentaries Hazim.