Xanthogranulomatous cholecystitis: the use of preoperative CT findings to differentiate it from gallbladder carcinoma

Background and aim

A retrospective analysis was performed on 32 patients with histologically confirmed xanthogranulomatous cholecystitis (XGC) and 21 patients with gallbladder carcinoma who underwent surgical treatment between 1998 and 2007.

Methods

All patients underwent preoperative CT scanning. The CT features analyzed were: the presence of intramural hypoattenuated nodules or bands, mucosal line, the patterns of wall thickening and enhancement, and the presence of stones in the gallbladder. The variables of the CT findings with XGC were analyzed using multivariate logistic regression analysis.

Results

Intramural hypoattenuated nodules were observed in 21 patients (65%) with XGC, but in only six patients (29%) with gallbladder carcinoma (P < 0.01). The mucosal line was observed in 27 patients (84%) with XGC and in only four patients (19%) with gallbladder carcinoma (P < 0.0001). Gallstones were noted in 24 patients (75%) with XGC and five patients (24%) with gallbladder carcinoma (P < 0.001). There was no significant difference in the pattern of gallbladder wall thickening (diffuse or focal) and the presence of changes outside the gallbladder. Multivariate logistic regression analysis revealed from the CT features that the enhanced continuous mucosal line (P = 0.0013) and the presence of gallstones (P = 0.0072) were independently correlated with XGC.

Conclusion

CT features of the enhanced continuous mucosal line in a thickened gallbladder wall, together with gallstones in a patient with chronic gallbladder disease, are highly suggestive of XGC. Accurate diagnosis of XGC may therefore indicate the need to select a less aggressive surgical approach.     

Mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis and ulcerative colitis

Mucin-producing carcinoma of the gallbladder is very rare. We report here a case of mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). A 74-year-old female had been treated with salazosulfapyridine and ursodesoxycholic acid becase of UC and PSC. After 7 years of treatment, laboratory data showed that the liver function took a turn for the worse, and the patient was admitted to our hospital for further examination. Enhanced computed tomography and ultrasonography showed an enlarged gallbladder associated with wall thickening and diffuse papillary protrusion. Endoscopic retrograde cholangiography showed stenosis and dilatation of the bile duct, which were compatible with PSC. Under the diagnosis of an early carcinoma of the gallbladder, we performed simple cholecystectomy. The tumor showed a papillary growth pattern located diffusely in the gallbladder with a massive amount of mucin filling the gallbladder. Histologically, it was diagnosed as a papillary adenocarcinoma localized in the mucosal layer. To the best of our knowledge, this is the first case of mucin-producing carcinoma of the gallbladder associated with PSC and UC. PSC and UC patients should be regarded as a high-risk group not only for cholangiocarcinoma but also carcinoma of the gallbladder.     

Xanthogranulomatous Cholecystitis and Gallbladder Cancer: Two Diseases with Difficult Differential Diagnoses

BackgroundXanthogranulomatous cholecystitis (XGC) etiology has not yet been precisely determined; it is often confused with gallbladder cancer (GBC) in the differential diagnosis. Methods:This study retrospectively evaluated patients who underwent surgery with the pre-diagnosis of cholelithiasis, cholecystitis, or gallbladder carcinoma at a tertiary center, and were confirmed to have XGC or GBC according to the histological examinations.ResultsIn the GBC group, there was a higher number of female patients, patients with magnetic resonance imaging (MRI) and computed tomography (CT) imaging, those that directly underwent open surgery, and those requiring catheters and developed complications; while in the XGC group, there was a higher number of patients with ultrasonography (USG) imaging and those requiring conversion from laparoscopic to open surgery (P < .05). The rate of patients with a preoperative diagnosis of cholelithiasis was higher in the XGC group than in the GBC group, and cases with intrahepatic bile duct (IHBD) dilatation were higher in the GBC group than in the XGC group, and the GBC group also had a higher rate of cases with a malignant diagnosis in the preoperative examination compared to the XGC group (P < .05).ConclusionWhen a suspicious malignant mass is detected in the localization of the gallbladder, XGC must be considered in the differential diagnosis. Although it is not a malignant pathology, early diagnosis and treatment are particularly important due to the associated complications and the possibility of coexistence with GBC.     

A case of well differentiated mucinous carcinoma of the gallbladder

We report a case of well differentiated mucinous carcinoma of the gallbladder. An 80-year-old man was admitted to our hospital because of fever and CT showed a mass in the fundus of the gallbladder and choledocholithiasis. Endoscopic removal of the common bile duct stones was done. Abdominal ultrasonography and CT showed a 4 cm mass in the fundus of the gallbladder. Based on a diagnosis of adenomyomatosis or mucinous carcinoma of the gallbladder, a laparotomy revealed a white mass in the fundus of gallbladder. Intra-operative pathological diagnosis of lymph node of cystic duct was mucinous carcinoma. Therefore, we conducted partial resection of the liver with D1 lymph node dissection. Pathological diagnosis confirmed well differentiated mucinous carcinoma of the gallbladder. His postoperative course was uneventful, and he is doing well without recurrence.     

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-...     

Resected case of eosinophilic cholangiopathy presenting with secondary sclerosing cholangitis

Eosinophilic cholangiopathy is a rare condition characterized by eosinophilic infiltration of the biliary tract and causes sclerosing cholangitis. We report a patient with secondary sclerosing cholangitis with eosinophilic cholecystitis. A 46-year-old Japanese man was admitted to our hospital with jaundice. Computed tomography revealed dilatation of both the intrahepatic and extrahepatic bile ducts, diffuse thickening of the wall of the extrahepatic bile duct, and thickening of the gallbladder wall. Under the diagnosis of lower bile duct carcinoma, he underwent pyloruspreserving pancreatoduodenectomy and liver biopsy. On histopathological examination, conspicuous fibrosis was seen in the lower bile duct wall. In the gallbladder wall, marked eosinophilic infiltration was seen. Liver biopsy revealed mild portal fibrosis. He was diagnosed as definite eosinophilic cholecystitis with sclerosing cholangitis with unknown etiology. The possible etiology of sderosing cholangitis was consequent fibrosis from previous eosinophilic infiltration in the bile duct. The clinicopathological findings of our case and a literature review indicated that eosinophilic cholangiopathy could cause a condition mimicking primary sclerosing cholangitis （PSC）. Bile duct wall thickening in patients with eosinophilic cholangitis might be due to fibrosis of the bile duct wall. Eosinophilic cholangiopathy might be confused as PSC with eosinophilia.     

A case of superficial bile duct carcinoma showing extensive intraductal spread without bile duct stenosis, diagnosed by intraductal ultrasonography]

We report a case of superficial bile duct carcinoma showing extensive intraductal spread without dilatation of the bile duct in which diagnosis was established preoperatively by transpapillary forceps biopsy and intraductal ultrasonography. A 78-year-old man was given a diagnosis of acute cholecystitis, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. Cholangiography via the PTGBD tube revealed a tiny irregularity in the hilar bile duct. Transpapillary intraductal ultrasonography showed that this irregularity extended from the intrahepatic bile duct to the middle of the bile duct. Bile duct biopsy revealed malignancy, and thus bile duct resection and hepaticojejunostomy were performed. Histological examination verified a well-differentiated adenocarcinoma confined to the epithelium and the fibromuscular layer.     

A CASE OF PEDUNCULATED POLYPOID CANCER ASSOCIATED WITH FLAT‐TYPE CANCER OF THE GALLBLADDER

Pedunculated polypoid cancer of the gallbladder ordinarily shows cancer spread within the polyp consisting mainly of adenoma. We experienced a case of pedunculated mucosal cancer associated with flat‐type cancer of the gallbladder without an adenomatous component, the details of which are reported herein. The lesion was first detected by transabdominal ultrasonography (US) as a polypoid lesion of the gallbladder, 5 mm in size. Distinct growth of the lesion was revealed at follow‐up US after a year. Endoscopic ultrasonography showed not only a pedunculated polypoid lesion, 9 mm in size, with a solid internal echo pattern and a nodular surface, but also slight thickening of the surrounding gallbladder wall. Cholecystectomy was performed with a preoperative diagnosis of early gallbladder cancer, and a pedunculated polypoid lesion, 8 × 8 × 3 mm in size with a thin stalk and a nodular contour, surrounded by a widely spreading flat lesion with a coarse‐granular surface, was confirmed. Microscopically, the stalk was 700 µm in size, and both the pedunculated polypoid lesion and flat lesion consisted of well‐differentiated tubular adenocarcinoma limited to the mucosa, without an adenomatous component.     

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.     

Primary sclerosing cholangitis in which differential diagnosis from gallbladder carcinoma was difficult

We report a case of localized primary sclerosing cholangitis (PSC) which was difficult to distinguish from gallbladder carcinoma. A 75-year-old woman with elevated serum bilirubin was hospitalized and underwent endoscopic nasobiliary drainage (ENBD). There was no history of diseases such as gallbladder stone, pancreatitis, or ulcerative colitis. Cholangiography through the ENBD tube showed localized stenosis of the common bile duct; the gallbladder could not be seen. Angiography showed no encasement of the hepatic artery. Ultrasonography showed a tumor in the cystic duct, and the tumor had invaded the gallbladder and common bile duct. We diagnosed gallbladder carcinoma on radioimaging, and performed an S4aS5 subsegmentectomy of the liver and resection of the extrahepatic biliary tree. Pathologically, no malignant cells were detected, and fibrosis around bile ducts and infiltration of inflammatory cells into hepatic tissue were found. It is well known that PSC is sometimes difficult to differentially diagnose from cholangiocarcinoma. Our case is of high interest because ultrasonography showed findings suggestive of gallbladder carcinoma. It is therefore necessary to keep the possibility of PSC in mind for the diagnosis and treatment of such localized biliary stenosis.     

Comparative imaging of gallbladder cancer

We reviewed various imaging approaches in 22 patients with gallbladder cancer. Nineteen had had ultrasonography and nine computed tomography performed. A gallbladder mass or diffuse wall thickening was seen by ultrasonography in 42% and computed tomography in 33% of patients. A significant number of patients had no gallbladder wall abnormality detected by ultrasonography (37%) or computed tomography (56%). Performing both ultrasonography and computed tomography improved the diagnostic rate; in this subgroup the detection rate was 51%. Cholelithiasis, dilated biliary ducts, the liver metastases were associated findings. Percutaneous cholangiography in jaundiced patients revealed the level of bile duct occlusion and often suggested the diagnosis. Radionuclide hepatobiliary imaging simply revealed non-visualization of the gallbladder.     

Xanthogranulomatous cholecystitis: report of a case and literature review on clinical differentiating factors from gallbladder carcinoma

Xanthogranulomatous cholecystitis (XGC) is a rare, benign, destructive inflammatory disease of the gallbladder that is assumed to be a variant of chronic cholecystitis. We herein present a rare case of XGC, which simulates gallbladder carcinoma with extensive involvement of the liver, omentum and the biliary trees. At surgery, total cholecystectomy with partial hepatectomy of the gallbladder bed and excision of adjacent xanthogranulomatous tissue was performed, but bilio‐enteric anastomosis for biliary decompression, which was the procedure preoperatively planned, was impossible to indicate because the common bile duct could not be clearly exposed by its infiltration showing mass formation. Therefore, retrograde transhepatic biliary drainage was eventually indicated for subsequent endoscopic therapy using stent placement to deal with the biliary structure caused by XGC. The patient has been leading a normal life after stent placement in the biliary tract for 6 months duration without any symptoms suggesting biliary stricture. In conclusion, XGC can simulate gallbladder cancer in its clinical presentation, radiological findings and even gross operative features. It is important to make preoperative ultrasound‐guided fine‐needle aspiration cytological diagnosis or intraoperative pathological diagnosis in order to avoid misdiagnosis and unnecessary therapy. Cholecystectomy, excision of adjacent xanthogranulomatous tissue, which often includes partial hepatic resection, are still the best management of XGC.     

The Diagnosis of the Anomalous Connection of Pancreaticobiliary Ducts Without Biliary Dilatation—The Usefulness of US/EUS Serial Examination—

The anomalous connection of the pancreaticobiliary duct (ACPBD) without accompanying dilatation of the bile duct (non-dilated type of ACPBD) has recently been found to be associated with gallbladder cancer at a rather high rate. We analyzed the diagnostic process of 5 patients with non-dilated type of ACPBD including 3 asymptomatic cases and reviewed the literature. Symptoms and laboratory data were not useful in detecting this type of lesion. All our patients were checked by ultrasonography for gallbladder lesions which are suggested by: wall thickening, multiple polyps, intramural gall stones, cholecystolithiaisis, and debris. ACT revealed only wall thickening of the gallbladder. An EUS revealed a high rate of ACPBD in addition to the ultrasonographic findings of gallbladder lesions obtained by US. An ERCP was effective in clearly demonstrating ACPBD, but was not so useful for the diagnosis of concomitant gallbladder lesions. Therefore, an US is considered to be a useful means for screening this disease, and EUS is useful as a procedure to follow in order to select patients with or without ACPBD, because EUS can be conducted on an outpatient basis and is highly sensitive in detecting ductal anomalies in ACPBD. Therefore, the US/EUS serial examination is thought to be an effective means for diagnosing this disease.     

Preoperative diagnosis of gallbladder torsion by magnetic resonance cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

Preoperative Diagnosis of Gallbladder Torsion by Magnetic Resonance Cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

Definitive diagnosis of a duplicate gallbladder can only be made intraoperatively: report of a case

Duplicated gallbladders are rare congenital anomalies that are important in clinical practice as they may cause clinical, surgical, and diagnostic problems. Here, we describe the case of a 79-year-old female patient who presented with acute cholangitis. Abdominal ultrasonography, endoscopic ultrasonography, computed tomography, and magnetic resonance imaging revealed an intrahepatic cystic lesion, suggesting communication with the intrahepatic bile duct; no evidence of a polypoid lesion within the cystic lesion was observed. Based on these findings, intrahepatic cholangiectasis, intrahepatic bile duct cystadenoma, and the presence of a duplicated gallbladder were suspected, and surgery was performed. During surgery, a tube inserted into the common bile duct from a cystic duct facilitated intraoperative cholangiography, which indicated the presence of a duplicated gallbladder. Thus, we believe that a duplicated gallbladder should be an additional consideration when typical gallbladder disease symptoms are present under certain circumstances. A multimodal imaging approach can help to establish the diagnosis preoperatively or intraoperatively.     

Choledochocele associated with superficial spreading cancer with cholesterolosis of the bile duct

A 74-year-old woman, who had suffered from acute cholangitis, was referred to our department for further evaluation of the biliary tree. A diagnosis of choledochocele was made by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. A small flat elevation with cholesterolosis was observed in the lower bile duct, and circumferential wall thickening was apparent in some parts of the upper and middle bile duct by intraductal ultrasonography and peroral cholangioscopy. With the diagnosis of choledochocele associated with superficial spreading cancer and cholesterolosis of the bile duct, pylorus-preserving pancreaticoduodenectomy was carried out. Microscopically, the tumor had spread extensively from the lower to the upper bile duct. Its invasion was limited to the mucosa for the most part, with microinvasion of the subserosa in the upper bile duct. In the lower bile duct, foamy cells were located beneath the neoplastic epithelium of the elevation. The number of cases of choledochocele associated with biliary cancer is becoming higher than previously reported. This anomaly may play some role in the development of biliary malignancy. Histological examination seems to be mandatory before making a diagnosis of cholesterolosis of the bile duct, since this condition may occasionally accompany cancer.     

A case of gallbladder carcinoma associated with pancreatobiliary reflux in the absence of a pancreaticobiliary maljunction： A hint for early diagnosis of gallbladder carcinoma

A 62-year-old man with progressive thickening of the gallbladder wall visited our outpatient clinic. The biliary amylase level in the common bile duct was 19900 IU/L and that of the gallbladder was 127000 IU/L, although endoscopic retrograde cholangiopancreatography revealed no pancreaticobiliary maljunction. Histology demonstrated a moderately differentiated adenocarcinoma of the gallbladder. Pancreatobiliary reflux and associated gallbladder carcinoma were confirmed in the present case, in the absence of a pancreaticobiliary maljunction. Earlier detection of the pancreatobiliary reflux and progressive thickening of the gallbladder wall might have led to an earlier resection of the gallbladder and improved this patient's poor prognosis.     

A case of mucinous cystic neoplasm of the gallbladder

The patient was a 70-year-old woman in whom examination revealed a high level of carbohydrate antigen 19-9. Abdominal ultrasonography and computed tomography (CT) revealed a multilocular cystic lesion compressing the gallbladder. CT indicated the presence of a multilocular cystic tumor (67?×?68?×?72 mm) in contact with the right hepatic lobe. Intraoperative findings indicated that the cyst diameter was 8.5?×?6.0 cm, and the cyst was continuous with the gallbladder. The gallbladder was resected along with the cyst. The cyst was multilocular and originated from the cystic duct and gallbladder wall. The cyst wall contained cuboidal to columnar mucin-producing epithelial cells and ovarian-like stroma (OS). The final diagnosis was mucinous cystic neoplasm (MCN) of the gallbladder with low-grade dysplasia. In the 2010 WHO classification of tumors of the digestive system, MCN have been newly defined as a type of hepatobiliary tract epithelial neoplasms. MCN of the gallbladder with OS is extremely rare. Only three cases have been published in the literature. The presence of OS is necessary for diagnosis of MCN.     

Xanthogranulomatous cholecystitis expressing high levels of DUPAN-II

We report a case of xanthogranulomatous cholecystitis (XGC) showing high levels of serum DUPAN-II in a 65-year-old woman. Preoperative radiologic examination showed no abnormal findings except in the gallbladder. Endoscopic ultrasonography was effective for differentiating chronic cholecystitis from gallbladder cancer before the operation. Cholecystectomy was performed by laparotomy, and the diagnosis of XGC was confirmed intraoperatively by examining a frozen section. Histologically, no cancer lesion was observed in the gallbladder, while immunochemical reactivity to DUPAN-II was demonstrated in the brush-border area of the epithelium and in histiocytes in the gallbladder. The half-life of serum DUPAN-II in our patient after cholecystectomy was approximately 1 month, and finally dropped to within the normal range after cholecystectomy.