Computed tomography of xanthogranulomatous cholecystitis

Expression of GLUT-1 and GLUT-3 in xanthogranulomatous cholecystitis induced a positive result on ¹⁸F-FDG PET: report of a case

Although several reports have revealed that fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) is useful for differentiating between benign and malignant lesions in the gallbladder, the positive results of (18)F-FDG PET are not specific for malignancy because (18)F-FDG is also accumulated in inflammatory lesions. It is known that the most important pathway for (18)F-FDG to enter the cell body is mediated by the facilitative glucose transporter-1 (GLUT-1) through GLUT-3. We herein present a case of xanthogranulomatous cholecystitis (XGC) with a positive result on (18)F-FDG PET. In this case, GLUT-1 and GLUT-3 were both positively expressed in inflammatory cells at the gallbladder wall of XGC and this is the first report to reveal GLUT expression in XGC. This report reveals that surgeons should carefully consider the appropriate treatment of gallbladder tumor, even with a positive result on (18)F-FDG PET.

Xanthogranulomatous cholecystitis: diagnostic performance of CT to differentiate from gallbladder cancer

PURPOSE

To retrospectively evaluate CT findings of xanthogranulomatous cholecystitis (XGC) and to measure diagnostic performance for distinguishing it from gallbladder (GB) cancer.

METHODS AND MATERIALS

Our institutional review board approved this retrospective study. Three blinded radiologists, first independently and then in consensus, retrospectively evaluated postcontrast CT images of 35 patients with histopathologically proved XGC and GB cancer, all of whom subsequently had cholecystectomy. These included 18 patients with XGC (13 male, 5 female; age range, 35-84, mean 63 years) and 17 with GB cancer (6 male, 11 female; age range, 45-95, mean 69). Differences in CT findings between XGC and GB cancer and diagnostic performances for each CT finding were calculated. Sensitivity, specificity, and accuracy were calculated for each radiologist and observer performance was also determined by receiver-operating-characteristic curve analysis.

RESULTS

Five CT findings showed significant differences between XGC and GB cancer. Sensitivity, specificity, and accuracy of each finding for the differentiation of XGC were 89%, 65%, 77% with diffuse GB wall thickening, 67%, 82%, 74% with a continuous mucosal line, 61%, 71%, 66% with intra-mural hypo-attenuated nodules, 72%, 77%, 74% with absence of macroscopic hepatic invasion, and 67%, 71%, 69% with absence of intra-hepatic bile duct dilatation, respectively. When at least three of these five CT findings were observed in combination, sensitivity, specificity, and accuracy were 83%, 100% and 91%, respectively. Sensitivities, specificities and Az values for the differentiation of XGC from GB cancer were 83%, 88%, 0.94 for reader 1, 78%, 88%, 0.93 for reader 2, and 78%, 82%, 0.84 for reader 3.

CONCLUSIONS

The combination of three of the five CT findings that are common with XGC can provide excellent accuracy for the differentiation of XGC and GB cancer.

Differential diagnosis of gallbladder cancer using positron emission tomography with fluorine-18-labeled fluoro-deoxyglucose (FDG-PET)

BACKGROUND AND OBJECTIVES

The purpose of this paper is to evaluate the utility of positron emission tomography (PET) with fluorine-18-labeled fluoro-deoxyglucose (FDG) in the preoperative differential diagnosis of gallbladder tumors. We performed PET studies of gallbladder tumors in order to predict the malignancy of these tumors preoperatively.

METHODS

Sixteen patients who had protuberant lesions in the gallbladder and who were scheduled to undergo surgery were studied with PET using FDG. Focally increased FDG uptake in the gallbladder region was considered malignant. The FDG-PET findings were compared with the histological findings of surgical pathology.

RESULTS

Sensitivity of FDG-PET was 75% (6/8 patients). One of two false-negative cases suffered from diabetes mellitus, and in the other case, the lesion was small. Specificity was 87.5% (7/8 patients). A case with xanthogranulomatous cholecystitis (XGC) was the only false-positive case.

CONCLUSIONS

FDG-PET may be able to provide important information for evaluating the malignancy of gallbladder tumors.

Xanthogranulomatous cholecystitis: clinical, sonographic, and CT findings in 26 patients

OBJECTIVE

The purpose of our study was to evaluate the sonographic and CT features of xanthogranulomatous cholecystitis, correlating the pathologic and surgical findings.

MATERIALS AND METHODS

Xanthogranulomatous cholecystitis was pathologically diagnosed in 26 patients from January 1996 to August 1998. The patients were 15 women and 11 men with a mean age of 63 years. All patients had preoperative sonography and nine also underwent CT In five patients, sonography was performed on the surgical specimen. Clinical indications for imaging included cholecystitis (14 patients), biliary colic (six patients), stone-induced pancreatitis (three patients), tumor (two patients), and gallstone ileus (one patient).

RESULTS

The most characteristic sonographic finding, confirmed by sonographic study of the surgical specimens, was the presence of hypoechoic nodules or bands in the gallbladder wall, which were seen in 35% of the patients. Cholelithiasis and a thickened gallbladder wall were frequent findings. The most characteristic (specific) CT finding was a hypodense band in the gallbladder wall, seen in 33% of the patients. Two of twelve patients who underwent laparoscopic cholecystectomy required conversion to open surgery.

CONCLUSION

Although the preoperative imaging diagnosis of xanthoganulomatous cholecystitis is difficult, the presence of hypoechoic nodules or bands in the gallbladder wall on sonography or of a hypodense band around the gallbladder on CT, is highly suggestive of this disease.

US findings of xanthogranulomatous cholecystitis

The ultrasound (US) scans of eleven patients with histologically proven xanthogranulomatous cholecystitis have been reviewed. The thickness of the gallbladder (GB) wall, echogenicity of the thickened GB wall, the presence of intramural nodules, gallstones, pericholecystic fluid, loss of wall definition with the liver, and intrahepatic ductal dilatation were specifically assessed by two radiologists. The range of thickness of the GB wall was 3-20mm (mean, 11.2 mm). Thickening was diffuse in nine cases and focal in two. The thickened GB wall, excluding intramural nodules, was echogenic in seven, isoechoic in three and hypoechoic in one, compared with hepatic echogenicity. Intramural nodules were found in eight cases. These were discrete, oval or flat, and of low echogenicity. These ranged in size from 6 to 12 mm (mean, 10.5 mm). Gallstones were present in six cases and there was intrahepatic duct dilatation in two of these. Definition between the liver and the GB was obliterated in seven cases. One case of GB perforation, confirmed at operation, demonstrated pre-operatively a GB wall defect and connection with the surrounding pericholecystic fluid. Pericholecystic fluid was absent in the other 10 cases. Xanthogranulomatous cholecystitis presents ultrasonically as GB wall thickening, and the majority of cases in this series also demonstrated intramural hypoechoic nodules. These findings can be helpful in the diagnosis of xanthogranulomatous cholecystitis.

Xanthogranulomatous cholecystitis: a radiological study of 12 cases and a review of the literature

BACKGROUND

Twelve cases of xanthogranulomatous cholecystitis (XGC) are presented, and their radiologic appearance is described.

METHODS

Four men and eight women, aged 31-82 years old, with XGC were reviewed. Abdominal ultrasound (US) was performed in all patients. Computed tomography (CT) was performed in five patients, barium enema examination in two, and percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder in one.

RESULTS

Barium enema examination showed an indentation of the hepatic flexure. Cholelithiasis was present in all patients, and sludge was present in six. The gallbladder wall was thickened in all patients, irregular in nine, and could not be properly differentiated from surrounding liver parenchyma or from other adjacent structures in most patients. A curvilinear halo, hypoechoic on US and with low attenuation on CT, within the gallbladder wall was found in three patients and pericholecystic fluid in two others. On CT, the pericholecystic fat had streaky soft tissue densities in three cases. Percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder was nondiagnostic. The diagnosis of gallbladder carcinoma was considered preoperatively in three patients.

CONCLUSION

Despite the characteristic histologic appearance of XCG, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm.

Xanthogranulomatous cholecystitis

Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an 'inoperable tumour' of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.

Xanthogranulomatous cholecystitis. Histopathological study and classification

Xanthogranulomatous cholecystitis (XC) is a chronic inflammatory lesion of the gallbladder histologically characterized by the presence of varying amounts of foamy histiocytes in the inflammatory infiltrate. In this study a review of 63 cases selected from 1207 surgically removed gallbladder is presented; the percentage found (5.2%) is slightly higher than that of previous reports showing that XC is less uncommon than generally believed. A detailed microscopic study is performed: the authors observed according to the histological features particularly the different patterns of distribution of the inflammatory infiltrate and postulate the existence of three subtypes of XC: multinodular, focal and diffuse XC. Finally, the main etiopathogenetic hypotheses are briefly discussed.