Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

Abstract

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum, provoked biliary dilatation and jaundice, and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder, extrahepatic bile duct, and hilar lymph nodes, as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases, the best option may be radical resection following oncological principles performed by expert surgeons, in order that postoperative complications may be minimized if not avoided altogether.

Machine learning-based diagnostic model for preoperative differentiation between xanthogranulomatous cholecystitis and gallbladder carcinoma: a multicenter retrospective cohort study

“…The preferred treatment modality for XGC is cholecystectomy. When hilar invasion, intrahepatic bile duct dilatation, vascular invasion, or other potentially invasive conditions are present, surgical intervention should extend beyond the gallbladder to include the resection of adjacent affected organs ( 12 ). Due to severe fibrosis and inflammation, undissected Callot’s triangle, unclear anatomy, life-threatening hemorrhage, and major bile duct injury, the frequency of conversion to open surgery in patients with XGC is higher than that in patients with other forms of cholecystitis.…”

Machine Learning-Based Radiological Features and Diagnostic Predictive Model of Xanthogranulomatous Cholecystitis

“…XGC was originally considered a malignant disease process; however, many studies have now confirmed its benign course ( 15 ), which is characterised by a focal or diffuse destructive inflammatory process, followed by significant macrophage and foam cell infiltrations and hyperplastic fibrosis. Concerning the pathogenesis of XGC, the most widely accepted theory is that the extravasation of bile through the ruptured Rokitansky-Aschoff sinus or increased internal pressure of the biliary tract causes small mucosal ulcers ( 16 ).…”

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: A diagnostic and therapeutic dilemma

“…Features more commonly associated with malignant pathology including mass lesion, hepatic invasion, and enlarged lymph nodes, may also be seen in XGC. While involvement of the biliary tree by the inflammatory process ("Xanthogranulomatous Choledochitis") may be present, intrahepatic biliary dilatation is often absent, as in these cases [14] . The role of percutaneous and endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) biopsy in the diagnostic workup of gallbladder lesions remain undefined.…”

“…Gallbladder cancer (GBC) may co-exist with XGC in up to 12% of cases and GBC may be missed due to sampling error when the two are present simultaneously. Also, opening a potentially cancerous gallbladder to examine the mucosa risks cutting across tumor and disseminating malignant disease [14] . Complete resection with negative margins (radical cholecystectomy) remains the only curative treatment for patients with GBC, if expertise is available.…”