Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: An analysis of 42 cases

Abstract

Aim: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis (XGC) clinically.

Methods: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma (GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section (FS) analysis and surgical procedure data of these patients were collected and analyzed.

Results: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven (17%) cases presented with mild jaundice without choledocholithiasis. Thirty-five (83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29 (69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40 (95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon's macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon's macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups (21% vs 20%, P > 0.05).

Conclusion: Neither clinical manifestations and laboratory tests nor radiological methods provide a practical and effective standard in the differential diagnosis between XGC and GBC.

Keywords: Cholecystectomy; Frozen-section analysis; Gallbladder carcinoma; Xanthogranulomatous cholecystitis.

Figure 1

The surgical procedures for the 42 cases of xanthogranulomatous cholecystitis. XGC: Xanthogranulomatous cholecystitis; GBC: Gallbladder carcinoma; IFS: Intra-operative frozen section analysis; TC: Total cholecystectomy; SC: Subtotal cholecystectomy; CBD: Common bile duct.

Figure 2

A 50-year-old woman with xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma based on computed tomography findings. A: Contrast-enhanced computed tomography shows the diffuse gallbladder wall thickening with intramural hypo-attenuated nodules (arrows) and heterogeneous enhancement in hepatic parenchyma neighboring gallbladder, indicating gallbladder carcinoma with direct liver invasion; B: Macroscopic examination of gallbladder specimen revealed multiple yellow nodules and bands in the wall (arrows). The gallbladder was sent for intra-operative frozen section (FS) analysis and demonstrated inflammatory lesions; C: Based on the FS diagnosis, a simple cholecystectomy was performed. Note that no macroscopic hepatic invasion was found (arrows). Ultimately, xanthogranulomatous cholecystitis was diagnosed by the pathological examination. CDS: Cystic duct stump; CBD: Common bile duct.