黄色肉芽肿性胆囊炎和胆囊癌的鉴别诊断及治疗策略分析

Differential diagnoses and treatment strategies of xanthogranulomatous cholecystitis versus gallbladder cancer

目的探讨黄色肉芽肿性胆囊炎(xanthogranulomatous cholecystitis,XGC)的临床病理特征,及其与胆囊癌(gallbladder cancer,GBC)的鉴别诊断和治疗策略。方法回顾性分析同济大学附属同济医院近12年XGC病人及GBC病人的病例资料,分析各项指标和影像学检查结果,结合文献分析,寻找可能的术前诊断方式,并评估术式、术野选择对XGC病人预后的影响。结果纳入XGC病人65例、GBC病人44例。糖类抗原(CA)50和CA19-9(r=0.84)、CA19-9和CA242(r=0.72)的表达在XGC病人中具有强相关性,CA50和CA19-9(r=0.81)、CA50和CA242(r=0.64)、CA125和CA72-4(r=0.68)的表达在GBC病人中也有强相关性。而血清肿瘤标志物中的CA125(P=0.014)、CA72-4(P=0.005)、CA242(P<0.001)、癌胚抗原(P<0.001)在GBC组更高;增强CT检查发现胆囊壁内结节、壁内血流、周围脏器受累、囊壁增强不均一、肝胆界面模糊和增强后出现“快进快退”的表现是鉴别XGC和GBC的重要方式。腹腔镜胆囊切除术是XGC的首选治疗措施,但不必要的侵入性操作和手术范围的扩大会对XGC病人术后恢复产生不利影响。超声造影可在XGC的鉴别诊断中发挥作用,且较常规影像学检查具有更高的诊断效能。结论血清肿瘤标志物可协助XGC的诊断;综合各类影像学检查手段有助于XGC和GBC的鉴别,但手术仍是疑诊XGC的首选治疗措施,术后的病理学资料仍是确诊的唯一标准。

Objective To explore the clinicopathological features of xanthogranulomatous cholecystitis(XGC)and examine its differential diagnosis and treatment tactics from gallbladder carcinoma(GBC).Methods Clinical data were retrospectively reviewed for XGC and GBC patients over the past 12 years.The results of various parameters and imaging examinations were analyzed along with a literature search to seek possible preoperative diagnostic methods and evaluate the effects of operative approaches and field selections on the prognosis of XGC patients.Results The expressions of CA50 versus CA19-9(r=0.84)and CA19-9 versus CA242(r=0.72)were strongly correlated among XGC patients.And the expressions of CA50 versus CA19-9(r=0.81),CA50 versus CA242(r=0.64)and CA125 versus CA72-4(r=0.68)were strongly correlated in GBC patients.The expressions of CA125(P=0.014),CA72-4(P=0.005)and CA242(P<0.001)in blood tumor markers were strongly correlated in GBC patients.Carcinoembryonic antigen(CEA)was higher in GBC group(P<0.001).And enhanced computed tomography(CT)examination revealed intrabial nodules in gallbladder wall,blood flow,peripheral organ involvement,uneven enhancement of cyst wall,blurred hepatobiliary interface and"fast forward&rewind"after enhancement.Laparoscopic cholecystectomy remains a primary treatment for XGC.However,unnecessary invasive operation and expansion of operative scope had adverse effects on postoperative recovery of XGC patients.CEUS plays an important role in the differential diagnosis of XGC and offers a higher diagnostic efficiency than conventional imaging.Conclusion Plasma tumor markers are valuable in the diagnosis of XGC.A combination of various imaging examinations helps to distinguish between benign and malignant diseases.However,surgery is still a first option for suspected XGC and a definite diagnosis is dependent upon postoperative pathological examination.