Xanthogranulomatous Inflammatory Strictures of Extrahepatic Biliary Tract: Presentation and Surgical Management

Background Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures. Methods A review of a prospectively maintained database for XGC was performed. Results Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection—CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy. Conclusion Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.     

A case of xanthogranulomatous cholecystitis suspected to be adenocarcinoma based on the intraoperative peritoneal washing cytology

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. XGC remains difficult to distinguish from gallbladder cancer radiologically and macroscopically.

PRESENTATION OF CASE

A 63-year-old female was referred to our hospital because of a gallbladder tumor. Abdominal CT and MRI revealed a thickened gallbladder that had an obscure border with the transverse colon. FDG-PET showed a high uptake of FDG in the gallbladder. Therefore, under the preoperative diagnosis of an advanced gallbladder cancer with invasion to the transverse colon, a laparotomy was performed. Because adenocarcinoma was suspected based on the intraoperative peritoneal washing cytology (IPWC), cholecystectomy and partial transverse colectomy were performed instead of radial surgery. However, the case was proven to be XGC with no malignant cells after the operation.

DISCUSSION

In patients with gallbladder cancer who underwent surgery in our institute from 2000 to 2009, the prognosis after the operation of patients with only positive IPWC tended to be better than that of patients with definitive peritoneal disseminated nodules. It is true that in some cases, it is difficult to differentiate XGC from gallbladder carcinoma pre- and intra-operatively.

CONCLUSION

Surgical procedures should be selected based on the facts that there are long-term survivors with gallbladder cancer diagnosed with positive IPWC, and that some patients with XGC are initially diagnosed to have carcinoma by IPWC, as was seen in our case.     

Organ-specific concept and controversy for premalignant lesions and carcinogenesis of gallbladder cancer

An analysis of premalignant lesions, risk factors and models of carcinogenesis of gallbladder cancer (GBC) involves the concept of organ specificity. In GBC, the dysplasia-carcinoma sequence and metaplasia-dysplasia-carcinoma sequence are considered to be more important models of carcinogenesis than the adenoma-carcinoma sequence. Cholecystectomy is recommended for gallbladder polyps ≥1.0 cm, and all pre-invasive adenomas and papillary neoplasms ≥1.0 cm are defined as intracholecystic papillary-tubular neoplasms (ICPTNs). Although adenomyomatosis (ADM) and xanthogranulomatous cholecystitis (XGC) are controversial lesions, a knowledge of their clinicopathological features would help clinicians to manage gallbladder lesions associated with ADM or XCG.     

Clitoral metastasis from transitional cell carcinoma of the renal pelvis: CT and MRI findings

Metastatic tumors of the clitoris are extremely rare. We report a case of clitoral metastasis in a 75-year-old woman who was treated for transitional cell carcinoma of renal pelvis 2 years ago. The computed tomography and magnetic resonance imaging findings are presented with a short review of the literature. To the best of our knowledge, clitoral metastasis originating from transitional cell carcinoma of the renal pelvis has not been reported in the English language literature.     

Surgical resection of splenic metastasis from the adenosquamous gallbladder carcinoma: A case report

IntroductionSplenic metastasis of gallbladder carcinoma is extremely rare. Specific anatomical, histological, and functional properties of spleen are believed to be responsible for the rarity of solitary splenic metastasis.Presentation of caseWe present the case of a 62-year-old female who developed metachronous splenic metastasis of adenosquamous carcinoma of the gallbladder. We performed central bisegmentectomy of the liver for gallbladder carcinoma. The patient subsequently presented 3 months later with isolated splenic metastasis and liver metastasis. Splenectomy and partial hepatectomy was performed at this time. Histological examination confirmed metastatic adenosquamous carcinoma of the gallbladder. No signs of recurrence were observed at 3 months after the second surgery.DiscussionAlthough splenectomy provides a potential means of radical treatment in patients with isolated splenic metastases, it should be performed with caution as splenic metastatic lesions may represent the initial clinical manifestation of systemic metastases at multiple sites. In this case, radical surgery was performed following the confirmation of no new unresectable metastatic lesions or systemic dissemination.ConclusionThis is the first report on the adenosquamous splenic metastasis from the gallbladder carcinoma. Curative resection may be the treatment of choice for prolonging survival in patients with the splenic metastasis of gallbladder carcinoma.     

Rare tumors of the gallbladder: Clear cell carcinoma

IntroductionGallbladder cancer is a rare tumor in the gastrointestinal tract has poor prognosis, low survival and is difficult to diagnose. The most common type of gallbladder cancer is adenocarcinoma, and the incidence of clear cell carcinoma is low. Mostly, it is difficult to determine whether the isolated tumor is a primary tumor in the gallbladder or a metastatic tumor from another region. Before accepting a clear cell carcinoma as a primary gallbladder tumor, the kidneys and other possible secondary focuses are clinically considered in terms of metastases.Presentation of caseHere, we present a rarely seen case of gallbladder clear cell carcinoma, which was diagnosed by pathological examination after the surgery.DiscussionPrior to establishing that clear cell carcinoma is a primary gallbladder cancer, it is appropriate to clinically investigate possible secondary focuses, in particular the kidneys in terms of metastasis.ConclusionOur goal in presenting this case was to emphasize the importance of taking an accurate medical history in patients with clear cell carcinoma, a rarely seen gallbladder cancer.     

Precancerous conditions of gallbladder carcinoma: overview of histopathologic characteristics and molecular genetic findings

Two distinct epithelial lesions (dysplasia and adenoma) and one high-risk condition (anomalous pancreatico-biliary ductal junction; APBDJ) are currently recognized as premalignant stages of gallbladder carcinogenesis. In addition to clinicopathologic observations, recent molecular genetic studies have provided further insight into the pathogenesis and biological behavior of these precursor lesions. In this review, we concentrate on describing the histopathologic and clinicopathologic background and recent molecular genetic findings for each of these putative precursor lesions. Received: June 3, 2000 / Accepted: August 8, 2000     

The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature

Introduction and importanceA gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus.Case presentationIn this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery.Clinical discussionWe review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus.ConclusionThrough this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management.     

胆囊腺肌瘤病的CT与MRI诊断价值

目的 探讨胆囊腺肌增生症的CT和MRI表现特点,提高诊断正确性.方法 回顾性分析我院2011年8月至2014年3月34例经病理检查证实的胆囊腺肌瘤病(adenomyomatosis of gallbl-adder,GBA)患者的CT和MRI资料.结果 本组行CT检查34例,其中术前确诊为GBA 25例,诊断为慢性胆囊炎5例,漏诊4例;行MRI检查20例,其中术前确诊为GBA 17例,诊断为慢性胆囊炎3例.CT及MRI平扫表现为胆囊壁弥漫性或局限性增厚,部分腔内、外面毛糙不整.增强表现为动脉期黏膜强化,门静脉期强化范围进展,延迟期持续强化,罗-阿氏窦腔内无强化.结论 CT与MRI对胆囊腺肌瘤病有较高的诊断价值,而罗阿氏窦的显示可作为定性的主要诊断依据.     

Follow-up of acute osteomyelitis in children: the possible role of PET/CT in selected cases

Background

Magnetic resonance imaging (MRI) and/or scintigraphy are commonly used for follow-up in children after treatment of acute osteomyelitis. Regularly, post-treatment imaging reveals pathological findings even if serum inflammatory parameters and clinical presentation are normal. We analyzed combined positron emission tomography and multislice computed tomography (PET/CT) for this condition.

Methods

Six children received PET/CT after treatment of acute osteomyelitis. Post-treatment MRI had revealed suspicious residual and/or additional findings. All patients had physiological serum infection parameters and no clinical symptoms.

Results

Median patient age was 59.5 months (range, 48-156). No increased 18-Fluor-2-deoxy-D-glucose uptake was observed in 3 patients. In 3 patients, there was minimal activity at the site of infection, which, however, did not reach the presumed range of osteomyelitis. All children were taken off antibiotic medication. No clinical symptoms reoccurred in any of them, and repeatedly controlled serum infection parameters were all normal. Median follow-up was 33 months (range, 4-65).

Conclusions

The PET/CT was superior to MRI in distinguishing between infection and reparative activity within the musculoskeletal system in selected children after acute osteomyelitis. The termination of antibiotic treatment for children after acute osteomyelitis seems justified when laboratory parameters as well as clinical presentation are normal, and PET/CT scan is unsuspicious.     

The utility of FDG-PET/CT and other imaging techniques in the evaluation of IgG4-related disease

ObjectivesThis study aimed to evaluate the utility of imaging techniques, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), in immunoglobulin (IgG)4-related disease (IgG4-RD).MethodsWe reviewed eight IgG4-RD patients who were referred to our hospital between August 2006 and April 2012. All cases underwent FDG-PET/CT and brain magnetic resonance imaging (MRI) and endobronchial ultrasonography (EBUS) were also performed in five cases and one case, respectively.ResultsAlthough nearly all patients with IgG4-RD in this study were negative for CRP (mean 0.22 mg/dL), various organ involvement sites were detected by FDG-PET/CT. In the active phase in two autoimmune pancreatitis (AIP) cases, FDG-PET/CT showed longitudinal and heterogeneous FDG accumulation in the pancreas with FDG uptake in the hilar or mediastinal lymph nodes. Follow-up FDG-PET/CT after therapy in one case revealed that the abnormal FDG uptake in all affected lesions had completely disappeared. In two cases, brain MRI revealed asymptomatic hypertrophic pachymeningitis. In one case, EBUS imaging of mediastinal lymph node swelling was consistent with tortuous vessels with high Doppler signals and hyperechoic strands between lymph nodes.ConclusionsWhen FDG-PET/CT shows FDG accumulation, characteristic of IgG4-RD in organs, without evidence of an associated inflammatory reaction, a diagnosis of IgG4-RD can be made. Treatment effects can be assessed by the disappearance of FDG uptake. A routine brain MRI is useful for detecting asymptomatic hypertrophic pachymeningitis. EBUS may also be useful for differentiating among the etiologies of lymphadenopathy with characteristic sonographic imaging findings.     

表现为磨玻璃影的新型冠状病毒肺炎和早期肺肿瘤的CT影像学对比研究

目的回顾性分析以磨玻璃影(GGO)为表现的新型冠状病毒(2019-nCoV,SARS-CoV-2)肺炎(COVID-19)与早期肺肿瘤的CT影像学特点,以指导抗疫防治工作。方法回顾性纳入华中科技大学同济医学院附属同济医院2020年1月17日至2月13日收治的CT表现为GGO的COVID-19临床诊断71例患者,作为COVID-19组;以2017年9月至2019年5月收治的CT表现为GGO并行手术切除、术后病理证实为早期肺肿瘤患者80例作对照,为早期肺肿瘤组。分析两组患者性别、年龄、就诊症状(发热、咳嗽、乏力、肌痛、呼吸困难)、流行病学史、SARS-CoV-2核酸检测结果、肺肿瘤术后病理结果的临床特征及包括病灶数量、病灶位置、最大直径的CT影像特征。结果相比早期肺肿瘤组,COVID-19组具有特异性临床症状和流行病学史(P<0.001),而在高分辨率CT(high resolution CT,HRCT)上多表现为2个以上病灶(61例,85.92%,P<0.001),主要分布在双肺的外周1/2带(69例,97.18%,P<0.001),病灶形态多为最大径>1 cm的较大片状(65例,91.55%,P<0.001)。COVID-19组在病程初期与早期肺肿瘤组形态相似,但随着病程进展则出现融合实变,可能出现GGO样的COVID-19和早期肺肿瘤共存的现象。结论以GGO为表现的COVID-19与早期肺肿瘤在CT影像上具有既相似又独立的特征。充分了解两者的影像特点并结合患者病史、实验室检验和确诊金标准、短期复查CT协助评估,有利于实现应收尽收、减少交叉感染,打赢疫情防控阻击战。     

胰腺腺泡细胞癌的CT及MRI影像学分析

目的 分析胰腺腺泡细胞癌（ACC）的CT和MRI特征,提高对该病影像学表现的认识。方法 回顾性分析2007年1月至2016年1月在我院经手术病理或穿刺活检证实的7例ACC患者的CT及MRI影像学资料,其中3例行CT平扫及增强扫描,4例行MRI平扫及增强扫描,观察其影像学表现。结果 男4例,女3例,平均年龄51岁;7例均为单发,病灶位于胰体尾部5例,胰头2例;最大直径约2~13 cm,平均直径5.2 cm,边界较清楚;CT平扫为略低密度,病灶内见不规则更低密度区,未见明显钙化。MRI扫描示病灶T1WI上为混杂稍低信号、T2WI上为混杂稍高信号。CT、MRI增强扫描均见瘤内实性成分动脉期轻度强化,门脉期呈渐进性强化,强化程度低于正常胰腺组织。7例中1例肝转移,1例侵犯临近脾脏,2例显示胰管侵犯并扩张,3例出现腹膜后淋巴结转移。结论 胰腺腺泡细胞癌CT、MRI表现具有一定特征性。     

Computed tomography in cases of multiple sclerosis: Problems of differential diagnosis in cases with atypical findings

The value of computed tomography in the diagnosis of multiple sclerosis is undisputed. The examination is usually carried out as a routine part of the examination program.We report on the CT results of 112 patients with confirmed or suspected MS. Seventy-three patients were examined without, 39 with intravenous administration of a contrast medium. In 41% of the patients, isolated or multiple hypodense foci were found as a manifestation of a multilocular demyelinization process. In 17.8%, only cerebro-at-rophic changes were encountered. In 30.3% of the cases the CT showed normal results. In the group of patients examined with a contrast medium, a pathological contrast medium concentration was found in 30.7%.The differential diagnostic demarcation against other diseases of the CNS with similar CT findings and problems of differential diagnosis with MRI are discussed.     

Outcome of radical surgery for carcinoma of the gallbladder according to the tumor node metastasis and Japanese Society of Biliary Surgery stages

Primary carcinoma of the gallbladder is a progressive, lethal disease. Survival of patients with this neoplasm depends strictly on lymph node involvement and depth of tumor invasion. The aim of the study was to evaluate the results of our surgical series according to the tumor node metastasis and Japanese Society of Biliary Surgery classification systems. A retrospective analysis of our 15-year experience was performed. Of the 79 patients with gallbladder carcinoma observed at our institution between 1984 and 2001, a radical resection was carried out in 20 patients. Patients with stage I-II disease represent a minority of the cases of gallbladder carcinoma; the disease is localized in these patients, and surgical treatment provides the opportunity for good survival. Survival rates for patients with stage III-IV disease demonstrates that radical extended surgery offers the only chance for a relatively prolonged survival.     

Two cases of retained foreign bodies after cholecystectomy: Diagnosis by sonography,CT, angiography,and MRI

We encountered two cases of subphrenic abscesses around surgical sponges that had eeen left at cholecystectomy. These cases had been operated on either eight years or seven years earlier, respectively. These lesions resembled another diseases, especially, liver tumors. In order to make a differential diagnosis, various diagnostic procedures were carried out. Sonography showed a cystic mass with spongiform structures in one case. But in another case, no information of internal structures could be obtained because of the presence of a calcified wall. On CT, the lesions appeared as either round or elliptic masses that contained calcified foci in both cases. Angiography showed the extended and compressed branches of the hepatic artery. Spotty stains were also observed in one case. This appearance resembled a hepatic tumor. MR demonstrated both T1 and T2 elongated masses. The internal structures of the mass were clearly revealed by the improved version of the MR machine. MR proved to be extremely useful in making a differential diagnosis. It is, however, important to evaluate the findings of these imaging procedures synthetically and in association with a careful review of a patient's prior surgical history.