Xanthogranulomatous cholecystitis masquerading as malignancy with liver metastasis

Abstract

Xanthogranulomatous cholecystitis masquerading as malignancy with liver metastasisa ns_5150 946..947 Case noteA 52-year-old diabetic woman was admitted to our hospital with a history of intermittent pain in her right upper abdomen, radiating to the back for 5 years. There was no history of jaundice, anorexia or weight loss. Her physical examination was unremarkable except that a firm non-tender liver was palpable about 2 cm below the right coastal margin in midclavicular line. Routine biochemical parameters were within normal limits. Abdominal ultrasonography showed gall bladder stones with loss of interphase between gall bladder and segment V of liver showing evidence of contiguous metastasis. Contrast enhanced computed tomography (CECT) of abdomen and gall bladder showed irregular circumferential wall thickening with evidence of metastasis into segment IV and V and a separate nodule with a small hypoattenuated area in segment V of the liver (Fig. 1). It also showed few small lymph nodes in peripancreatic regions. Fine needle aspiration (FNAC) from the lesion was inconclusive with no evidence of dysplasia. As her imaging findings were strongly suggestive of malignancy, she was taken up for surgery. Gall bladder mass was densely adherent to and invading the liver bed with a single nodule about 3 cm distant from the gall bladder (Fig. 2). There were no obvious nodes in the area, however, the hepatoduodenal ligament tissues were a bit densely adherent. Assuming malignancy, extended cholecystectomy with wedge resection of about 5 cm from liver bed including the mass was done along with clearing of hepatoduodenal ligament tissue. Patient had an uneventful post-operative period.Histological examination showed acute on chronic xanthogranulomatous cholecystitis (XGC) with cholelithiasis. The liver bed showed collection of foamy histiocytes and lymphocytes forming nodules in liver, with no evidence of malignancy. DiscussionXGC is an uncommon inflammatory lesion of gall bladder characterized by marked proliferative fibrosis with infiltration of macrophages and foamy cells involving gall bladder walls. 1 The clinical presentation is similar to cholecystitis with imaging studies and per-operative findings may also sometimes mislead as gall bladder carcinoma. 2 XGC represents about 0.7 to 13.2% of cholecystectomies 3 and affects men and women equally. 1 Its aetiology is uncertain but current opinion favours acute inflammation of gall bladder due to calculous outflow obstruction. 3 Bile enters into the stroma of gall bladder wall through the ruptured Rokitansky-Aschoff sinuses or mucosal ulcerations secondary to presence of gallstones. The extravasated bile in stroma causes an inflammatory reaction with accumulation of histiocytes which engulf the insoluble cholesterol and bile lipids to form xanthoma cells. Microabscesses can form in gall bladder wall eventually resulting in xanthogranulomata. A fibrous reaction follows resulting in scarring. 3 Macroscopically, XGC is characterized by formation of multiple yellowish nodules ...

Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer: Can It Be Diagnosed Preoperatively?

“…Analogous to the results of a Chinese study, our data suggests that the presence of abdominal pain, acute cholecystitis, choledocholithiasis, and cholelithiasis may portend a diagnosis of XGC [6]. The role of tumour markers remains unresolved, with some studies showing no significant correlations with diagnosis [2, 3, 5, 6]. In our study, raised levels of tumour markers correlated well with the incidence of GBC and could be used in the differentiation of XGC from GBC.…”

“…Its incidence ranges from 0.7 to 10% [1–3]. XGC exhibits similar imaging and intraoperative findings as those of gallbladder cancer (GBC), leading to its frequent misdiagnosis [2–5]. Imaging does shed some light on this conundrum preoperatively, but diagnosis is often a postoperative histological surprise [6–12].…”

Xanthogranulomatous cholecystitis: a rare gallbladder pathology from a single-center perspective

“…XGC is an increasingly recognized rare variant of chronic cholecystitis characterized by severe proliferative fibrosis and accumulation of lipid-laden macrophages in areas of destructive inflammation [ 3 9 ]. While the former mimics chronic cholecystitis, mass-forming XGC is difficult to differentiate from gallbladder cancer [ 4 7 ].…”

“…Xanthogranulomatosis is an idiopathic, rare process in which lipid-laden histiocytes are deposited at various locations in the body. Xanthogranulomatous inflammation occurs in various organs such as skin, kidney, retroperitoneum, intracranium, gastrointestinal tract, genital organs, and gallbladder [ 3 4 ]. XGC is an unusual form of chronic cholecystitis that may simulate malignancy radiologically and pathologically [ 5 ].…”

“…Preoperative diagnosis of XGC is often difficult, and an intraoperative frozen section examination may be required in selected cases to distinguish it from malignancy. The clinical presentation resembles acute or chronic cholecystitis, and encountering difficulties in cholecystectomy is not uncommon [ 4 7 ]. In such cases, an open approach is frequently adopted due to suspicion of cancer or anticipation of significant difficulty and higher conversion to open cholecystectomy rate [ 3 7 ].…”