SEER Training Modules
Case #5
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Physical Exam
06/02/XX
69-year-old male with increased liver enzymes. Recent ultrasound, CT of gallbladder at outside facility showed gallstones. On exam neck supple, chest clear. Abdomen soft and nontender without adenopathy.
X-Rays & Scans
05/27/XX
CXR negative for malignancy.
Scopes
05/27/XX
ERCP attempted, blocked by apparent gallstone.
06/30/XX
Diagnostic laparoscopy w/cholecystectomy and intraoperative cholangiogram. Excisional biopsy of peritoneal masses x 2.
Pathological Reports
06/30/XX
Cholecystectomy: 2.5 cm moderately differentiated adenocarcinoma invades through muscle wall into adjacent adipose tissue. Lymphatic space invasion present. Invasive carcinoma and high grade dysplasia present at apparent cystic duct margin and within < 1.0 mm of cauterized hepatic margin. Peritoneal biopsy: poorly differentiated adenocarcinoma compatible with gallbladder lesion.
Treatment
06/30/XX
Laparoscopic cholecystectomy.
08/01/XX
Started chemo: Gemzar.
