Gallbladder Cancer or Diffuse Xanthogranulomatous Cholecystitis: A Case of Management Dilemma During Elective Cholecystectomy With Unexpected Severe Mass-Like Pericholecystic Fibrosis and Inflammation

Abstract

A 52-year-old man was scheduled to undergo an elective laparoscopic cholecystectomy for an increasingly symptomatic cholelithiasis. The pre-operative diagnosis was established clinically and confirmed with ultrasonography (US), showing gallstones and thickened gallbladder wall. Intraoperatively, extensive dense adhesions of the omentum to the entire subdiaphragmatic surface of the liver and the diaphragm were encountered. The adhesions of the omentum and colon were completely obscuring the Morrison's space with cartilage-like consistency at the supposed anatomical projection of the gallbladder fundus. Due to these unexpected pathological findings and uncertain disease biology, a decision was made to abort and re-schedule the surgery after obtained tissue biopsy results, magnetic resonance cholangiopancreatography (MRCP), and tumor markers carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and alpha fetoprotein (AFP) were available. CA 19-9 was found elevated 10-fold, while AFP and CEA levels were within normal limits. A follow-up cholecystectomy was performed, and final pathology revealed diffuse xanthogranulomatous cholecystitis (XC) and extensive inflammatory changes, adhesions, and fibrosis and no malignancy. The patient tolerated the procedure well and was discharged home on day two after surgery. His follow-up examination was unremarkable. Distinguishing between XC and gallbladder carcinoma is important to appropriately guide management and treatment.

Keywords: laporoscopic cholecystectomy; pericholecystic inflammation; surgery general; tumor marker; xanthogranulomatous cholecystits.

Figure 1. Imaging and surgical pathology of gallbladder specimen

A. Axial MRI/MRCP plane; and B. Coronal MRI/MRCP plane, showing an irregular heterogeneous mass occupying the gallbladder (white arrow) with possible contained perforation involving the gallbladder fundus (red arrow); C. Low power image of hematoxylin and eosin stained section of normal-appearing gallbladder mucosa (white arrow) and neighboring areas of ruptured Rokitansky-Aschoff sinuses (red arrow); and D. High power image showing areas of adenomyosis with deep, ruptured Rokitansky-Aschoff sinuses penetrating the muscle layer (red arrow); E. Low power image of hematoxylin and eosin stained section showing foci of crowding of foamy macrophages (xanthoma cells); and F. High power image of foreign body granulomas consisting of cholesterol (white arrows). MRI: magnetic resonance imaging, MRCP: magnetic resonance cholangio pancreatography