Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET

Recently, several reports have demonstrated that fluorine-18 fluorodeoxyglucose positron emission tomography （FDG-PET） is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.

Xanthogranulomatous cholecystitis:a premalignant condition?

BACKGROUND:Xanthogranulomatous cholecystitis(XGC)is an uncommon variant of chronic cholecystitis,characterized by marked thickening of the gallbladder wall and dense local adhesions.It often mimics a gallbladder carcinoma(GBC), and may coexist with GBC,leading to a diagnostic dilemma. Furthermore,the premalignant nature of this entity is not known.This study was undertaken to assess the p53,PCNA and beta-catenin expression in XGC in comparison to GBC and chronic inflammation. METHODS:Sections from paraffin-embedded blocks of surgically resected specimens of GBC(69 cases),XGC(65), chronic cholecystitis(18)and control gallbladder(10)were stained with the monoclonal antibodies to p53 and PCNA, and a polyclonal antibody to beta-catenin.p53 expression was scored as the percentage of nuclei stained.PCNA expression was scored as the product of the percentage of nuclei stained and the intensity of the staining(1-3).A cut-off value of 80 for this score was taken as a positive result. Beta-catenin expression was scored as type of expression-membranous,cytoplasmic or nuclear staining. RESULTS:p53 mutation was positive in 52%of GBC cases and 3%of XGC,but was not expressed in chronic cholecystitis and control gallbladders.p53 expression was lower in XGC than in GBC(P<0.0001).PCNA expression was seen in 65%of GBC cases and 11%of XGC,but not in chronic cholecystitis and control gallbladders.PCNA expression was higher in GBC than XGC(P=0.0001),but there was no significant difference between the XGC,chronic cholecystitis and control gallbladder groups.Beta-catenin expression was positive in the GBC,XGC, chronic cholecystitis and control gallbladder groups.But the expression pattern in XGC,chronic cholecystitis and control gallbladders was homogenously membranous,whereas in GBC the membranous expression pattern was altered to cytoplasmic and nuclear.CONCLUSION:The expression of p53,PCNA and beta-catenin in XGC was significantly different from GBC and similar to chronic cholecystitis,thus indicating the inflammatory nature of XGC and may not support a premalignant nature of the lesion.

Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature

Xanthogranulomatous cholecystitis （XGC） is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. A 46 year-old woman was referred to our center for suspected gallbladder cancer involving the liver hilum, right liver lobe, right colonic flexure, and duodenum. Brushing cytology obtained by endoscopic retrograde cholangiography （ERC） showed high-grade dysplasia. The patient underwent an en-bloc resection of the mass, consisting of right Iobectomy, right hemicolectomy, and a partial duodenal resection. Pathological examination unexpectedly revealed an XGC. Only six cases of extended surgical resections for XGC with direct involvement of adjacent organs have been reported so far. In these cases, given the possible coexistence of XGC with carcinoma, malignancy cannot be excluded, even after cytology and intraoperative frozen section investigation. In conclusion, due to the poor prognosis of gallbladder carcinoma on one side and possible complications deriving from highly aggressive inflammatory invasion of surrounding organs on the other side, it seems these cases should be treated as malignant tumors until proven otherwise. Clinicians should include XGC among the possible differential diagnoses of masses in liver hilum.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer and causing obstructive cholestasis

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder that can mimic gallbladder carcinoma. METHODS: We present the case of a 35-year-old Hispanic male complaining of right upper quadrant pain and jaundice for 2 months prior to admission. He denied a history of fever, nausea/ vomiting, and weight loss. The past medical history was relevant only for diabetes. He had no previous history of jaundice or previous operations. RESULTS: CA19-9 was slightly elevated (52 U/mL). Abdominal ultrasonography showed an irregular thickening of the gallbladder wall and no gallstones were detected. CT scan also revealed an irregular thickening of the wall of the gallbladder body suggestive of malignancy. At laparotomy, the mass was adherent to the duodenum and colon, and although the frozen section biopsy was negative, the intraoperative findings were suggestive of malignancy, and the patient underwent left liver trisegmentectomy, resection of the common bile duct and Roux-en-Y hepaticojejunostomy. Pathological examination unexpectedly revealed XGC without malignancy. CONCLUSIONS: Preoperative and intraoperative differential diagnosis of XGC from gallbladder carcinoma remains a challenge when it is associated with inflammatory involvement of surrounding tissues. Since gallbladder carcinoma and XGC may coexist, radical resection is justified when malignancy cannot be completely ruled out.

Surgical treatment of xanthogranulomatous cholecystitis:experience in 33 cases

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe fibrosis and foam cells, and can be a cause of difficulty in cholecystectomy. Patients with XGC are frequently misdiagnosed intraoperatively as having carcinoma of the gallbladder and are treated with extensive excision. This study aimed at providing proper surgical treatment for patients with XGC. METHODS: The clinical data of 33 patients with XGC definitely diagnosed by pathological examination over a period of 10 years were analyzed retrospectively (mean age of onset, 60 years; male/female ratio, 1.5: 1). RESULTS: Preoperatively, the 33 patients were examined by abdominal B-ultrasonography while 20 of them were further examined by computed tomography (CT). Intraoperatively, XGC associated with cholecystolithiasis was found in 97.0% of the patients, thickening of the gallbladder wall in 90.9%, xanthogranulomatous tissue invading into other tissues in 87.9%, XGC associated with choledocholithiasis in 15.2%, and Mirizzi syndrome in 9.1%. In addition, a gallbladder fistula was observed in 4 patients. Open cholecystectomy was performed on 15 patients, partial cholecystectomy on 7, cholecystectomy and partial liver wedge resection on 5, and gallbladder cancer radical correction on 6. The intraoperative misdiagnosis rate was 24.2%. Frozen-section examination was carried out in 9 patients. Postoperative complications were observed in 5 patients. CONCLUSIONS: XGC is difficult to diagnose either preoperatively or intraoperatively and definite diagnosis depends exclusively on pathological examination. Firm adhesions of the gallbladder to neighboring organs and tissues are common and lead to difficulty in surgical treatments. The mode of operation depends on specific conditions in varying cases, and since frozen-section examination plays an important role in determining the nature of the lesions, intraoperative frozen-section examination should be carried out to differentiate XGC from carcinoma of the gallbladder.

Presentation and surgical management of xanthogranulomatous cholecystitis

Background:Xanthogranulomatous cholecystitis(XGC)is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management.In addition,distinguishing XGC from gallbladder cancer preoperatively is still a challenge.The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC.Data sources:The present systematic review was designed using the PRISMA and AMSTAR guidelines.We searched MEDLINE,Scopus,Clinicaltrials.gov,EMBASE,Cochrane Central Register of Controlled Trials(CENTRAL)and Google Scholar databases from inception until June 2020.Results:The laparoscopic cholecystectomy rate(34%)was almost equal to the open cholecystectomy rate(47%)for XGC.An important conversion rate(35%)was observed as well.The XGC cases treated by surgery were associated with low mortality(0.3%),limited intraoperative blood loss(58-270 m L),low complication rates(2%–6%),along with extended operative time(82.6–120 minutes for laparoscopic and 59.6–240 minutes for open cholecystectomy)and hospital stay(3–9 days after laparoscopic and 8.3–18 days after open cholecystectomy).Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome.In addition,complex surgical procedures,like wedge hepatic resections and bile duct excision were required during operations for XGC.Conclusions:XGC seemed to be a rare,benign inflammatory disease that presents similar features as gallbladder cancer.The mortality and complication rates of XGC were low,despite the complex surgical procedures that might be required in some cases.

Xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma: retrospective analysis of 10 cases

Objective: To investigate the reasons for misdiagnosing xanthogranulomatous cholecystitis (XGC) as gallbladder carcinoma, and to provide differential points between these two diseases. Methods: Thirty-three patients with the final diag- nosis of XGC in our hospital over a period of 10 years (1996–2005) were reviewed, among which 10 (6 males and 4 females) were misdiagnosed as having gallbladder carcinoma either preoperatively or intraoperatively. Results: 10 misdiagnosed cases were examined preoperatively by B-ultrasound (BUS) and computed tomography (CT). BUS and CT revealed 5 cases of gallbladder carcinoma and 1 of chronic cholecystitis; 2 cases were diagnosed as gallbladder carcinoma on BUS but chronic cholecystitis on CT; other 2 cases were diagnosed as chronic cholecystitis on BUS but as gallbladder carcinoma on CT. Intra- operatively, thickening of the gallbladder wall was found in all of the patients; xanthogranulomatous tissue was found invading into other tissues including gallbladder bed and omentum majus. Intraoperative frozen section investigation was performed on 1 patient revealing that no tumor cell was found. Open cholecystectomy + partial hepatic wedge resection were performed on 3 patients; cholecystectomy + partial hepatic wedge resection + regional lymphadenectomy in the liver duodenum ligament on 6 patients; cholecystectomy + cholecystoenterostomy + colocolic anastomosis after partial resection of transverse colon on 1 patient. Postoperative pathological findings revealed XGC in all these patients. Conclusion: XGC is an uncommon variant of chronic cholecystitis of which clinical and imaging presentations closely resemble gallbladder carcinoma. Thus differentiation is essential by means of intraoperative frozen section investigation to ensure optimal surgical treatment since XGC has its pathological distinctions, which are not that of a precancerous change.

Strategies for diagnosis of xanthogranulomatous cholecystitis masquerading as gallbladder cancer

Background Patients with xanthogranulomatous cholecystitis sometimes exhibit imaging and intraoperative findings that are similar to those of advanced gallbladder cancer,thus these patients are easily misdiagnosed.The present study aimed to investigate the characteristics of xanthogranulomatous cholecystitis masquerading as gallbladder cancer that could potentially aid in the correct diagnosis of this condition.Methods The clinical,serological,radiological and operative features of twelve patients with obviously wall-thickening or mass-forming xanthogranulomatous cholecystitis were retrospectively analyzed.Additionally,the patient preoperative features were compared to those of 36 patients with advanced gallbladder cancers.Results Twelve patients with xanthogranulomatous cholecystitis exhibited one to three episodes of acute cholecystitis within 0.5 to 7 months prior to admission to the hospital.Five of these patients exhibited concomitant choledocholithiasis,whereas no concomitant choledocholithiasis was identified in patients with advanced gallbladder cancer.The incidence of abdominal pain （x2=6.588,P=0.010）,acute cholecystitis （x2=29.176,P=0.000）,acute cholangitis （x2=6.349,P=0.012）,choledocholithiasis （x2=16.744,P=0.000）,carcinoembryonic antigen test （P=0.007）,CA125 （P=0.001）,and diffuse gallbladder wall thickening （x2=6.031,P=0.014）,continued mucosal line （x2=15.745,P=0.000）,homogeneous enhancement of mucosal line （x2=19.947,P=0.000）,submucosal hypoattenuated nodules or band （x2=18.607,P=0.000） in computed tomography demonstrated statistically significant differences between cases of xanthogranulomatous cholecystitis and gallbladder cancer.Furthermore,all the twelve patients with xanthogranulomatous cholecystitis exhibited at least one positive computed tomography imaging feature aside from past acute cholecystitis episode,and no patient with advanced gallbladder cancer simultaneously exhibited past acute cholecystitis episode and at least one positive computed tomography imaging feature.Conclusions The accurate preoperative diagnosis of xanthogranulomatous cholecystitis includes an integrated review of past acute cholecystitis episode,choledocholithiasis,and positive computed tomography imaging features.Besides,we present an algorithm for intraoperative diagnosis.

Xanthogranulomatous Cholecystitis and Misdiagnosis Analysis

INTRODUCTION Gastric sub-epithelial masses （SEMs） are relatively common findings when receiving gastric endoscopy. It is a mass, bulge, or impression visible. Computed tomography （CT） and magnetic resonance imaging can assist in making a diagnosis,

Imaging-based algorithmic approach to gallbladder wall thickening

Gallbladder(GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma(GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities(conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.