New scoring system for differentiating xanthogranulomatous cholecystitis from gall bladder carcinoma: a tertiary care centre experience

Radiological Findings for Distinguishing Between Xanthogranulomatous Cholecystitis and Gallbladder Cancer

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare, chronic gallbladder inflammation often mistaken for gallbladder cancer (GBC) on imaging. Accurate differentiation is vital for appropriate treatment. This study aims to enhance computed tomography (CT) scan diagnostic accuracy for distinguishing XGC from GBC.

METHODS

This retrospective study included patients diagnosed with XGC and GBC between 2014 and 2023. CT images of 70 patients (16 GBC, 54 XGC) were reviewed. Radiologists assessed CT parameters: gallbladder wall thickening, intramural hypoattenuating nodules, enhancement characteristics, mucosal line continuity, pericholecystic fat stranding, presence of stones, bile duct dilatation, hepatic invasion, invasion to adjacent structures, and lymph node size.

RESULTS

Among 70 patients, there were 38 males (54%) and 32 females (46%), with a median age of 62 years. GBC patients were significantly older (median age 72 years) compared to XGC patients (60 years) (P=0.001). Diffuse gallbladder wall thickening was more frequent in XGC (70%) than GBC (12.5%) (P<0.001). Continuous mucosal lines and intramural hypoattenuating nodules were more common in XGC (P<0.001 and P=0.010, respectively). Intrahepatic bile duct dilatation and invasion to adjacent structures were significantly linked with GBC (P<0.001 and P=0.043). Lymph nodes with a short axis>8 mm indicated GBC (P<0.001), with a cutoff providing 71.4% sensitivity and 84% specificity (AUC: 0.843, P<0.001). CT showed 75% sensitivity (95% CI: 48-93%), 74% specificity (95% CI: 60%-85%), and 74% accuracy (95% CI: 62%-84%).

CONCLUSION

CT imaging can effectively differentiate XGC from GBC, and larger studies can further improve diagnostic accuracy.

Gallbladder cancer: Progress in the Indian subcontinent

Gallbladder cancer (GBC) is one of the commonest biliary malignancies seen in India, Argentina, and Japan. The disease has dismal outcome as it is detected quite late due to nonspecific symptoms and signs. Early detection is the only way to improve the outcome. There have been several advances in basic as well as clinical research in the hepatobiliary and pancreatic diseases in the West and other developed countries but not enough has been done in GBC. Therefore, it is important and the responsibility of the countries with high burden of GBC to find solutions to the many unanswered questions like etiopathogenesis, early diagnosis, treatment, and prognostication. As India being one of the largest hubs for GBC in the world, it is important to know how the country has progressed on GBC. In this review, we will discuss the outcome of the publications from India highlighting the work and the developments taken place in past several decades both in basic and clinical research.

Risk score for malignancy in patients with suspicious gallbladder lesions: Retrospective analysis of 175 cases

BACKGROUND

Among cancers, carcinoma gallbladder has one of the most dismal prognosis. Early lesions are difficult to biopsy because of proximity to luminal structures and risk of biliary peritonitis. However, early surgery offers the only chance of a complete cure. Utilizing a risk score would allow characterization of the risk of malignancy and early referral to an oncology centre thereby resulting in better outcomes for patients with carcinoma gallbladder.

METHODS

The aim of this study was to develop a risk score for carcinoma in patients with suspicious gallbladder lesions based on clinical presentation and imaging. All patients with suspicious gallbladder lesions on radiological imaging who underwent surgery were analyzed. Patients were considered for scoring if the ultrasound showed the gallbladder wall thickening (more than 4 mm) and computed tomography scan showed operable disease. Statistical analysis was done to derive a score for malignancy.

RESULTS

Total 175 patients underwent an operation for suspicious gallbladder lesions from January 2005 to December 2014. The factors analyzed were clinical biochemical and imaging findings. Of these, 71 were benign on the final histopathology and 104 were malignant. The score was constructed with the following variables: female sex, high total bilirubin (≥ 1 mg/dL), presence of a mass, focal location of the lesion, presence of gallbladder stones and nodal involvement in the hepatoduodenal region on imaging. A model score and modified score were obtained. In this modified score, score of more than 8 out of 20 predicted malignancy with a sensitivity of 78% and specificity of 70.4%. Receiver operating characteristic (ROC) curve constructed with these variables had an area under curve of 0.828. There was no statistically significant difference between the model score and the modified score.

CONCLUSIONS

A pre-operative risk score was obtained for carcinoma gallbladder, which needs to be validated prospectively in future.

Xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma - Analysis of 8 cases

Background/Aim

Xanthogranulomatous cholecystitis (XGC) is a rare destructive inflammatory disease of the gallbladder. It is frequently misdiagnosed as gallbladder carcinoma (GBC) as it mimics latter with regard to clinical manifestations, imaging and intraoperative findings, often leading to extended surgical resection in these patients. The aim of this study was to evaluate the diagnostic dilemma of XGC cases clinico-radiologically diagnosed with GBC.

Materials and Methods

From January 2017 to June 2019, a total of eight cases histopathologically diagnosed as XGC, were misdiagnosed with GBC based on preoperative and intra-operative findings. The clinical characteristics, imaging, intra-operative findings, and surgical data of these patients were collected and analyzed.

Results

A total of 2154 cholecystectomy specimens were received in the histopathology section during the study period. Sixty-nine cases (3.2%) were histologically diagnosed as XGC, of which 8 cases (11.6%) were preoperatively diagnosed with GBC. These cases were predominantly seen in males in the age range of 24-62 years. The most common clinical presentation was chronic cholecystitis. Gallstones were present in all the 8 cases. Six cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging. Intraoperatively, adhesions to adjacent organs were observed in seven cases. All these eight cases misdiagnosed with GBC underwent aggressive surgical treatment following which histopathology ultimately revealed XGC.

Conclusion

Neither clinical manifestations nor laboratory tests/radiological methods can provide an effective means of differentiating between XGC and GBC. Preoperative diagnosis is difficult, and histopathology remains the gold standard to differentiate the two entities.

Xanthogranulomatous cholecystitis: Diagnosis and management

Xanthogranulomatous cholecystitis (XGC) is a rare form of cholecystitis, characterized by the presence of xanthogranuloma, prominent yellow structures within the gallbladder wall that is very often lithiasic. When XGC presents in its pseudo-tumoral form with occasional adjacent organ involvement, it can mimic gallbladder carcinoma (GBC). The etiopathogenesis of XGC is inflammatory destruction of Rokitansky-Aschoff sinuses containing biliary and cholesterol pigments within the gallbladder wall; this leads to a florid granulomatous histiocytic inflammatory reaction. The prevalence ranges from 1.3% to 8.8% of all cholecystectomies and varies from country to country; XGC occurs predominantly in patients over 50 years of age, and is equally distributed between males and females. Its association with GBC remains a topic of debate in the literature (between 0 and 20%). Symptoms are non-specific and generally similar to those of acute or chronic cholecystitis. XGC, when associated with altered health status, leads to the suspicion of GBC. XGC can also come to light due to an acute complication of cholecystolithiasis, in particular, gallstone migration. Imaging by sonography and CT scan is suggestive, but magnetic resonance imaging is more specific. In difficult cases, biopsy may be necessary to eliminate the diagnosis of tumor. In case of pre- or intra-operative diagnostic doubt, the opinion of a hepatobiliary specialty center can be of help. When diagnosis of GBC has been eliminated, laparoscopic cholecystectomy is recommended, although with a high risk of conversion to laparotomy and complications.

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report

•

Acute cholecystitis with empyema and Mirizzi Syndrome mimics both XGC and malignancy.

•

Subtotal fenestrating cholecystectomy is both safe and effective in these cases.

•

PTC can be considered over ERCP for first-line pre-operative biliary drainage.

Introduction

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma.

Presentation of case

A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis.

Discussion

Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient.

Conclusion

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

Scoring System to Predict pt2 in Gallbladder Cancer Based on Carcinoembryonic Antigen and Tumor Diameter

BACKGROUND AND AIMS

T2 gallbladder cancer requires lymph node dissection for curative resection, whereas simple cholecystectomy is adequate to treat T1 gallbladder cancer. Hence, this study aimed to develop an accurate scoring system to preoperatively predict pT2 in gallbladder cancer.

MATERIAL AND METHODS

We retrospectively assessed data from 57 patients with suspected gallbladder cancer who underwent curative resection between September 2003 and May 2017. Six with apparent invasion of adjacent organs on preoperative images were excluded. We evaluated preoperative computed tomography, magnetic resonance and endoscopic ultrasonographic images, blood biochemistry, and the maximum standard uptake value in fluorodeoxyglucose-positron emission tomography images. We analyzed whether correlations between preoperative findings and the depth of tumor invasion could predict pT2.

RESULTS

The pathological diagnosis was gallbladder cancer in 30 (58.8%) patients, of whom 21 (69.9%) had pT2 or worse. Multivariate analyses selected carcinoembryonic antigen and tumor diameter as independent predictors of pT2 or worse (odds ratios = 1.741 and 1.098, respectively; 95% confidence intervals = 1.004-3.020 and 1.008-1.197, respectively). A regression formula was created using carcinoembryonic antigen and tumor diameter to calculate pT2 predictive scores. The area under the receiver operating characteristics curve of the pT2 predictive score was 0.873.

CONCLUSION

We created a scoring system to predict pT2 in gallbladder cancer using carcinoembryonic antigen and tumor diameter. The present findings suggested that carcinoembryonic antigen is important for the preoperative evaluation of gallbladder cancer.

What should be done in patients diagnosed with xanthogranulomatous cholecystitis? Case-control study

OBJECTIVE:

In this study, we aimed to compare development of complications, malignancy and confusion rates in the preliminary diagnosis in patients with xanthogranulomatous cholecystitis identified.

METHODS:

In this study, 2803 patients undergone cholecystectomy between January 2010 and December 2016 were retrospectively evaluated. Patients with xanthogranulomatous cholecystitis identified in the histopathological examination were classified as Group 1 and patients with cholelithiasis, cholecystitis, and malignancy detected were classified as Group 2.

RESULTS:

Forty-five patients with xanthogranulomatous cholecystitis were classified as group 1 and 2758 patients as group 2. of group 1, 18 were male and group 2 consisted of 2758 patients with 707 (26%) being male (p=0.04). In the ultrasonographic examination, the wall thickness was increased in 40 patients in Group 1 and 662 patients in Group 2 (p<0.0001). The operation was converted to the open type in 24 patients in Group 1 and 61 patients in Group 2 (p<0.0001). Five patients in Group 1 and 32 patients in Group 2 developed complications in the postoperative period (p<0.0001).

CONCLUSION:

Xanthogranulomatous cholecystitis should be considered for the differential diagnosis and the operation should be performed, especially by carefully exposing the anatomy in these patients.

A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis

Background

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The differential diagnoses of XGC include gallbladder cancer (GBC), adenomyomatosis, and actinomycosis of the gallbladder.

Purpose

To assess the usefulness of computed tomography (CT) findings in the diagnosis of XGC and differentiation from GBC.

Material and Methods

We retrospectively assessed the pathological and radiological records of 13 patients with pathologically proven XGC and 33 patients with GBC.

Results

Significant differences were observed for the following five CT findings: diffuse wall thickening (XGC = 85%, GBC = 15%, P < 0.01); absence of polypoid lesions (XGC = 100%, GBC = 48%, P < 0.01); intramural nodules or bands (XGC = 54%, GBC = 9%, P < 0.01); pericholecystic infiltration (XGC = 69%, GBC = 9%, P < 0.01); and pericholecystic abscess (XGC = 23%, GBC = 0%, P = 0.018). We defined the scoring system based on how many of the five CT findings were observed. Our scoring system, which included these findings, revealed that patients with three or more findings had sensitivity of 77% (95% confidence interval [CI] = 57–87) and specificity of 94% (95% CI = 86–98).

Conclusion

Our scoring system can assist in the differentiation of XGC from GBC.

Usefulness of Ultrasound in Differentiating Xanthogranulomatous Cholecystitis from Gallbladder Carcinoma

Our study was aimed at finding the ultrasound (US) features of xanthogranulomatous cholecystitis (XGC) and evaluating the usefulness of US in differentiating XGC from gallbladder carcinoma (GBC). Through use of an electronic medical record system and the picture archiving and communication system, 31 cases of XGC and 52 cases of GBC with both sonograms and pathologic results were identified. Sonographic features of the abnormal gallbladder were evaluated. The smooth and intact interface between gallbladder lumen and mucosa was observed in most XGC cases (23/31, 74.2%) but in no GBC cases. XGC featured hyper-echoic foci, small hypo-echoic nodules and a layered appearance in the lesion, which were more frequently seen in the XGC group than in the GBC group. In conclusion, US may prove useful in the differential diagnosis of XGC and GBC, but more studies are required.

A unique case of xanthogranulomatous cholecystitis complicated by multiple liver abscesses and portal vein and hepatic artery thrombosis and occlusion

Xanthogranulomatous cholecystitis (XGC) is difficult to diagnose preoperatively because it often mimics gallbladder cancer. We present a case of a 64-year-old Caucasian male who presented with multiple intrahepatic abscesses, left portal vein and segmental right hepatic arterial thrombosis suspicious for extrahepatic cholangiocarcinoma who ultimately underwent an extended left hepatectomy and was noted to have XGC on final pathology. This case presents a new challenge in diagnosing XGC prior to final pathology results given the unique left portal vein, and later, right anterior portal vein thrombosis and occlusion. XGC should be in the differential diagnosis when diffuse gallbladder wall thickening is associated with involvement of biliary and vascular structures. While diagnosing these cases can be challenging, increased awareness of varied involvement of the liver and hilar structures associated with this diseases process may aid in the selection of the most appropriate surgical techniques.

Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum, provoked biliary dilatation and jaundice, and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder, extrahepatic bile duct, and hilar lymph nodes, as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases, the best option may be radical resection following oncological principles performed by expert surgeons, in order that postoperative complications may be minimized if not avoided altogether.