We report the case of a 68-year-old man who consulted for two to three weeks of polydipsia, anorexia, diaphoresis and weight loss in January 2015 without fever.
Computed tomography (CT) was requested, which showed parietal thickening of the gallbladder, informed as suspected pathological focus of adenomyosis versus biliary mud, without other findings.
Controls were lost, consulting the Emergency Department of Clínica Santa Maria in October 2015 for abdominal pain of three days duration, located in the upper right quadrant of the abdomen, associated with nausea.
On physical examination: positive Murphy's sign did not present jaundice.
An abdominal ultrasound compatible with acute sepsis had been performed in another center, so it was decided to perform an immediate surgical management by means of a laparoscopic cholecystectomy, which was performed without sentinel node biopsy.
Deferred biopsy of the surgical specimen showed CCAS in the body and vesicular fundus (5.8 x 3.6 cm), with intact transmural to the serosa, negative surgical edge, without signs of lymph node involvement.
In the pavilion I didn't visualize locoregional, hepatic or peritoneal compromise, sought directed.
Immunohistochemistry for C-ERB-B2 was negative, corresponding to T3N0Mx.
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F18-FDG PET/CT was requested to complete staging, which showed multiple lytic bone lesions with increased marked glucose metabolism (hypermetabolic) compatible with previous CT findings.
Not all hypermetabolic lesions have anatomical translation.
The diagnosis was made on the basis of pathology report. Neither surgery nor PET CT showed locoregional or hepatic lymph node involvement. A bone biopsy was performed to confirm the histology of these lesions and rule out other tumoral origin.
A CT-guided percutaneous biopsy of a hypermetabolic lytic lesion of the left iliac bone was performed, which was compatible with CAS ineffective.
Immunohistochemistry was consistent with the primary vesicular tumor.
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Chemotherapy with gemcitabine and prolactin was initiated.
At 4 months of diagnosis and due to increased bone pain, a bone scintigraphy was performed, which showed multiple osteolytic metastases and bone defects in axial skeleton and more extensive than in initial skeleton, showing multiple metastases.
The patient died within a few months of follow-up.
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We had the consent of the Ethics Committee of Clínica Santa Maria and the informed consent of the patient.
