Gallbladder tuberculosis: False-positive PET diagnosis of gallbladder cancer

Gall bladder tuberculosis: Review of literature

Gall bladder tuberculosis (GB TB) is a very rare disease and scarce data is available on exact incidence and clinicopathogenesis even in endemic areas. The aim is to provide an insight into epidemiology, pathophysiology and management for better understanding of gall bladder tuberculosis. We collected data available from the literature on all histologically proven gall bladder tuberculosis. Case reports with either no article or only abstracts were available excluded from the study. Fifty two case reports and series with total 73 patients were included in this study. Mean age of patients was 48 years (Range 8-86 years) with male: female ratio of 1:1.7. 53 (73%) patient had isolated disease and 18 (24%) had associated abdominal tuberculosis. 3 (4%) of patients had concomitant and 7 (9%) had past history of pulmonary tuberculosis. 39 patients presented as cholecystitis and 25 as gall bladder mass. 44 (60%) patients had gall stones and majority of them (56%) are multiple. Granuloma and caseous necrosis was found in 80% & 60% of patients respectively. In conclusion, Gall bladder tuberculosis is a very uncommon presentation of abdominal tuberculosis. Pre-operative diagnosis is not possible due to lack of specific diagnostic test so increase in awareness and a high index of suspicious is required.

Misdiagnosis of carcinoma gall bladder in endemic regions

Background

Incidental carcinoma gall bladder and benign disease in radical cholecystectomy specimen is the cause of concern. We attempted to find out the incidence and reasons thereof in the present study.

Methods

Present study is a retrospective analysis of a prospectively maintained database between July 2002 and July 2019. All patients with a diagnosis of carcinoma gall bladder admitted for surgery were included.

Results

Out of 148 patients, 110 patients had carcinoma gall bladder (CAGB), while 38 patients (25.7%) had incidental carcinoma (under-diagnosis). Radical resection was done in 61/110 (55.4%) patients with clinical CAGB, where 15 (24.6%) patients had benign pathology (“over-diagnosis”). Overdiagnosis was due to xanthogranulomatous cholecystitis (n = 9), chronic cholecystitis (n = 2), tuberculosis (n = 2) and IgG4 related cholecystitis (n = 2). Among 61 patients, a history of weight loss and anorexia were significantly associated with malignancy. Asymmetrical wall thickness was significantly more common in benign mimickers.

Among patients with incidental carcinoma, preoperative ultrasonography reported normal wall thickness of gall bladder in 28 (73.7%), thickened gall bladder wall in 6, and polyp in 3 patients. The resectability rate among incidental carcinoma was 27/38 (71.05%).

Conclusion

Over-diagnosis of the carcinoma gall bladder was present in 24.6%. On the other hand, incidental carcinoma comprised 25.7% of all admissions for carcinoma gall bladder with resectability of 71%.

18F-FDG-PET/CT Imaging for Gastrointestinal Malignancies

Gastrointestinal malignancies encompass a variety of primary tumor sites, each with different staging criteria and treatment approaches. In this review we discuss technical aspects of 18F-FDG-PET/CT scanning to optimize information from both the PET and computed tomography components. Specific applications for 18F-FDG-PET/CT are summarized for initial staging and follow-up of the major disease sites, including esophagus, stomach, hepatobiliary system, pancreas, colon, rectum, and anus.

Infiltrative gallbladder tuberculosis versus locally infiltrating tumour of the gallbladder: a diagnostic dilemma unmasked by histopathology

Gallbladder tuberculosis (TB) as an isolated infection and is an extremely rare entity even in parts of the world with endemicity. Though it has myriad ways of presentation, it can be cured successfully. We present a case of a 53-year-old man who presented with epigastric fullness and bloating with on and off low-grade fever for 2 months and significant weight loss. He underwent a CT scan, which showed a soft tissue gallbladder mass causing mural thickening of the antrum and lesser curvature. This was followed by a CT-guided core biopsy and gastric antrum biopsy via gastroscopy. Histopathology revealed chronic granulomatous inflammation in both samples. Various clinical presentations of gallbladder TB have been reported in literature, but to the best of our knowledge, the present case has a unique presentation and has never been reported before.

Cancer or Tuberculosis: A Comprehensive Review of the Clinical and Imaging Features in Diagnosis of the Confusing Mass

Confusing masses constitute a challenging clinical problem for differentiating between cancer and tuberculosis diagnoses. This review summarizes the major theories designed to identify factors associated with misdiagnosis, such as imaging features, laboratory tests, and clinical characteristics. Then, the clinical experiences regarding the misdiagnosis of cancer and tuberculosis are summarized. Finally, the main diagnostic points and differential diagnostic criteria are explored, and the characteristics of multimodal imaging and radiomics are summarized.

Isolated gallbladder tuberculosis mimicking acute cholecystitis: A case report

BACKGROUND

Isolated tuberculosis of the gallbladder is extremely rare due to its intrinsic resistance to tuberculous infections. There are reports of gallbladder tuberculosis mimicking cholecystitis or malignancy. However, these presentations were chronic. The diagnosis of gallbladder tuberculosis warrants the need for investigation of additional sites of inoculation and contact tracing of all tuberculosis contacts. Gallbladder tuberculosis is a rare entity but should be suspected in patients from endemic regions with risk factors such as underlying immunosuppression or history of tuberculosis.

CASE SUMMARY

We present a case of gallbladder tuberculosis presenting as acute cholecystitis. A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals with no significant past medical history. She underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis and diagnosed as gallbladder tuberculosis after histopathological examination. The patient did not have features of pulmonary or systemic tuberculosis nor was she immunocompromised. She recovered uneventfully. She was subsequently discharged and followed-up at a hospital in her home country due to financial and social reasons.

CONCLUSION

Clinicians should have a high index of suspicion for patients in endemic regions presenting with cholecystitis.

An uncommon case of gall bladder mass: gall bladder tuberculosis

Gall bladder tuberculosis (TB) is a rare entity and differentiation of gall bladder TB from gall bladder malignancy is difficult. We hereby present an unusual case of incidental diagnosis of gall bladder TB during the evaluation of a gall bladder with suspicion of gall bladder cancer in a 49-year-old woman. The diagnosis of gall bladder TB was made with fine needle aspiration cytology (FNAC) from the gall bladder mass as the disease was found unresectable after cross-sectional imaging. Even with the advancement of cross-sectional imaging, the differentiation of gall bladder TB from gall bladder malignancy is not possible without tissue diagnosis.

Gallbladder tuberculosis camouflaging as gallbladder cancer - case series and review focussing on treatment

INTRODUCTION

Gallbladder tuberculosis, in an endemic region, is a common infectious etiology affecting a rare organ. The high prevalence of carcinoma gallbladder in the endemic regions of tuberculosis, like India, poses diagnostic dilemma.

CASE SERIES

We are reporting three cases of gallbladder tuberculosis mimicking carcinoma gallbladder of which the first two cases were operated with a presumptive diagnosis of malignancy. The third case presented to us after laparoscopic cholecystectomy elsewhere and on evaluation was found to have disseminated tuberculosis.

DISCUSSION

The lack of pathognomonic clinical and radiological characters results in histological surprise of gallbladder tuberculosis following surgery performed for other indications like malignancy. In preoperatively diagnosed patients medical management plays pivotal role in management. Surgery is required in symptomatic patients. On the other hand, histologically proven cases following surgical resection require antitubercular therapy.

CONCLUSION

Previous history of tuberculosis or concomitant tuberculosis at other sites may provide clue to the diagnosis of biliary tuberculosis. Antitubercular treatment after surgery plays an important role in preventing further dissemination.

Tuberculosis of Gal-Blader Mimicking Malignancy - A Case Report

A correct preoperative diagnosis of gall-bladder tuberculosis is exceptionally unusual in the absence of pathognomic features both on clinical presentation and on imaging. Herein we present a case of 50 year female who was operated with a provisional diagnosis of gall-bladder malignancy and was found to have tuberculosis of gall-bladder on histopathology.

Ultrasound-guided fine needle aspiration cytology of gallbladder lesions: a study of 596 cases

OBJECTIVE

Fine needle aspiration (FNA) is not a commonly performed procedure for gallbladder lesions for fear of causing biliary peritonitis; hence data on gallbladder cytology is scarce. The aims of the present study were to evaluate the diagnostic application of ultrasound-guided (US) FNA cytology in the pre-operative diagnosis of neoplastic as well as non-neoplastic lesions of the gallbladder and to review the cytomorphological spectrum of gallbladder lesions encountered along with various diagnostic difficulties that can arise during reporting.

METHODS

The study was carried out on 596 patients with gallbladder lesions in whom US-guided FNA was performed over a 5-year period. In 130 cases, simultaneous aspirations from other organs were done. The histological correlation was available in 32 cases. No major complications such as haemorrhage, peritonitis, etc. were encountered related to the procedure.

RESULTS

The majority were mass lesions whereas in 73 cases (12.2%) only focal or diffuse gallbladder wall thickening was present. Cytological examination of 596 cases revealed malignancy in 462 (77.6%), 26 (4.4%) suspicious of malignancy, 23 (3.8%) inflammatory lesion, 29 negative (4.8%) and 56 cases showed necrosis only or were inadequate for any definite opinion. The lesions diagnosed on FNA cytology included carcinoma (predominantly adenocarcinoma), xanthogranulomatous cholecystitis (XGC), acute suppurative inflammation and tuberculosis. Of 26 with adequate cytology, 24 were accurate with respect to malignant (including one suspicious FNA) versus benign: one false positive and one false negative both involved xanthogranulomatous change.

CONCLUSION

The present study is the largest series evaluating the role of US-guided FNA in the diagnosis of gallbladder lesions. It is a safe, rapid, reliable, cost-effective and reasonably accurate method for diagnosing gallbladder lesions. FNA should always be attempted in cases with a mass lesion.

Adrenal tuberculosis mimicking a malignancy by direct hepatic invasion: emphasis on adrenohepatic fusion as the potential route

A 64-year-old female with primary adrenal insufficiency presented with a right adrenal mass showing quantitative nonadenoma features on dedicated adrenal computed tomography (CT). CT showed direct invasion of the mass to the adjacent hepatic parenchyma, and high uptake was noted on 18F-fluorodeoxyglucose positron emission tomography/CT. Laparoscopy revealed gross invasion of the adrenal lesion into the liver, which led to the en bloc resection including the involved liver. Polymerase chain reaction analysis of the surgical specimen revealed adrenal tuberculosis.

[A case of gallbladder tuberculosis diagnosed by positive tuberculosis-polymerase chain reaction]

Gallbladder tuberculosis is an extremely rare disease that is rarely reported in the literature. Arriving at the correct diagnosis of gallbladder tuberculosis is difficult, and it is usually made by histopathologic examination after cholecystectomy. However, due to the low sensitivity of acid-fast stain and culture result, diagnosing gallbladder tuberculosis is still demanding even after tissue acquisition. To overcome this problem, tuberculosis-polymerase chain reaction (TB-PCR) is performed on the resected specimen, which has high sensitivity and specificity. A 70-year-old female who had previously undergone total gastrectomy for advanced gastric cancer was admitted with right upper quadrant pain. Abdominal ultrasonography and computed tomography revealed acute cholecystitis without gallstones or sludge. She underwent cholecystectomy and the histopathologic finding of the specimen showed chronic active cholecystitis without gallstones or sludge. Because she was suspected to have pulmonary tuberculosis, TB-PCR was also performed on the resected gallbladder. TB-PCR showed positive reaction for Mycobacterium tuberculosis and we could diagnose it as gallbladder tuberculosis. Herein, we present a case of gallbladder tuberculosis diagnosed by TB-PCR from resected gallbladder.

Stepwise approach and surgery for gallbladder adenomyomatosis: a mini-review

BACKGROUND

Gallbladder adenomyomatosis (GBA) is a hyperplastic disease affecting the wall of the gallbladder, with some typical features. It has historically been considered a benign condition, nevertheless recent reports highlighted a potential role of GBA in predisposing to malignancies of the gallbladder.

DATA SOURCES

We reviewed the literature concerning GBA from its identification until July 2012. Owing to the relative rarity of the disease, studies often are case reports or case series. Thus we herein report a summary of the key-points concerning diagnosis and treatment of GBA, easily applicable in everyday practice, rather than a systematic review. Also, results are integrated with our recent experience.

RESULTS

In our experience, we observed a trend toward an increase of GBA during the last years, probably due to enhanced ultrasonographic technical advancements and physician's expertise. GBA has distinctive imaging features. Several recent reports highlight the potential risk of cancer associated with GBA; however the disease is still classified as a benign condition. Although its correlation with malignancy has not been demonstrated, it is prudent to recommend cholecystectomy in some cases. However, in selected asymptomatic patients, a wait-and-see policy is a viable alternative. We propose an algorithm, based on GBA pathological pattern (diffuse, segmental, localized or fundal), suitable for decision-making.

CONCLUSIONS

In symptomatic patients and if the diagnosis is doubtful, cholecystectomy is mandatory. Postponing surgery is an option to be offered to asymptomatic patients with low-risk GBA pattern who adhere to scheduled follow-ups.

Mycobacterial infection of the gallbladder masquerading as gallbladder cancer with a false positive pet scan

Isolated mycobacterial infection of gall bladder is an extremely rare entity. Only anecdotal reports are evident in the literature. A preoperative diagnosis of mycobacterial infection of gallbladder is therefore very difficult. The case of a 72-year-old male who underwent surgery for suspected gallbladder cancer is presented. The diagnosis of cancer was based on radiological findings and an abnormal uptake of fluorine-18-fluoro-2-deoxy-D-glucose (FDG) on positron emission tomography (PET) scan whilst being followed up for colorectal cancer. He underwent cholecystectomy and gallbladder bed resection. Histopathology was consistent with mycobacterial infection of the gallbladder.

Differentiation of malignant from benign heart and pericardial lesions using positron emission tomography and computed tomography

OBJECTIVE

To assess the feasibility of (18)F-FDG PET-CT for the differentiation of malignancy from benign lesions of the heart and the pericardium.

METHODS

A total of 23 cases (malignancy:benign = 13:10) with cardiac and pericardial lesions, confirmed by pathology or on clinical grounds, were analyzed in this study. All lesions were evaluated semi-quantitatively using maximum standard uptake values (SUV(max)) and SUV(max) lesion/blood, and the density of the heart and pericardium lesions and the relation with surrounding tissues were evaluated. The differences of SUV(max) and SUV(max) lesion/blood between benign and malignant lesions were analyzed by the Mann-Whitney test. Subsequently, the diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for CT and PET-CT, respectively.

RESULTS

The maximum SUV showed significant difference between malignancy (avg ± SD 6.5) and benign (avg ± SD 1.5) (Z = -3.601, P < .01), the SUV(max) lesion/blood of malignancy and benign were avg ± SD 3.4 and avg ± SD 0.9, respectively, also with a significant difference (Z = -3.600, P < .01). In this pilot study, the optimal cutoff value to separate benign vs malignant lesions of SUV(max) was 3.5-4.0 and the cutoff for SUV(max) lesion/blood was 1.3-2.0. The sensitivity, specificity, accuracy, PPV, and NPV of CT and PET-CT were 76.9%(10/13), 100.0%(10/10), 87.0%(20/23), 100.0%(10/10), 76.9%(10/13) and 100.0%(13/13), 90.0%(9/10), 95.7%(22/23), 92.9%(13/14), 100.0%(9/9), respectively.

CONCLUSION

(18)F-FDG PET-CT appears promising for correctly differentiating benign vs malignant cardiac and pericardial lesions.

[Positron tomography with 18F-fluorodeoxyglucose in the preoperative evaluation of gall bladder lesions suspicious of malignancy. Diagnostic utility and clinical impact]

BACKGROUND

Gallbladder carcinoma is a neoplasm having a poor prognosis in which the role of the positron emission tomography with (18)F-fluordeoxyglucose as a diagnostic tool, although of possible usefulness, has not been well-defined.

METHODS/DESIGN

It is a prospective cohort of patients with radiologically malignant suspicious gallbladder lesions. A staging diagnostic presurgical FDG-PET study was carried out in each patient using both dedicated PET and multimodality PET-CT scanners. Diagnostic accuracy parameters were calculated from the results of PET imaging and were correlated with the condition and/or the clinical course of the patients. The clinical impact of its implementation in the diagnosis of gallbladder carcinoma was also analyzed.

RESULTS

A total of 42 patients were recruited (22 malignant lesions, 20 benign). Overall diagnostic accuracy was 83.33% for the diagnosis of the primary lesion, 88.89% for the evaluation of lymph node involvement and 85.1% for the evaluation of metastatic disease. Mean SUVmax in malignant gallbladder lesions was 6.14±2.89. ROC curve showed a cut-off value of 3.65 in the SUVmax for malignancy. Accuracy of PET studies alone (n=21) was slightly lower than that of the PET/CT (n=21). FDG-PET changed the management of 14.8% of the population due to the identification of unsuspected metastatic disease.

COMMENTS

FDG-PET accurately diagnoses malignancy or benignity of suspicious gallbladder lesions, with the addition of its capacity to identify unsuspected metastatic disease. PET-CT improves the diagnostic accuracy of the procedure, due to the metabolic-structural complementarity of their information. The SUVmax has a complementary value added to the visual analysis.

Gallbladder tuberculosis: CT findings with histopathologic correlation

Objective

We wanted to describe the computed tomography (CT) findings of gallbladder tuberculosis (TB) and to correlate them with pathologic findings.

Materials and Methods

There were seven patients (M:F = 3:4; mean age, 46.3 years; age range, 32 to 78 years) in whom gallbladder TB was eventually diagnosed. All of them underwent cross-sectional imaging with CT, a pathologic examination and a retrospective review. CT imaging evaluation was done in each case, including the findings of a mass versus nodule, wall thickening (uniform or irregular) and the enhancement patterns (homogeneous or heterogeneous).

Results

All the cases of gallbladder TB revealed the following three different CT findings: micronodular lesion of the gallbladder wall (n = 1), a thickened wall (n = 4) and a gallbladder mass (n = 2). There were three cases of homogeneous enhancement of the lesions, including homogeneous enhancement with nodular lesion, homogeneous uniform thickness enhancement and homogeneous thickness enhancement in one case each, and these cases pathology showed tuberculous granuloma with a little caseating necrosis in one case and tuberculous granuloma with rich fibrous tissue, but little or no evident caseating necrosis in two cases. Four cases of heterogeneous enhancement of the lesions, including heterogeneous uniform-thickness enhancement in two cases, heterogeneous enhancement with a local mass lesion in one case and heterogeneous enhancement with a mass that replaced the gallbladder in one case; in these cases, pathology showed tuberculous granuloma with marked caseation or liquefaction necrosis in three cases and tuberculous granuloma by fibrous and calcifications accompanied by caseating necrosis in one case. Among the seven cases of gallbladder TB, six cases were accompanied by abdominal extra-gallbladder TB, including abdominal lymph node TB in five cases and hepatic TB in four cases.

Conclusion

Gallbladder TB has various CT manifestations, and the enhanced CT findings are well matched with pathological features. An irregularly thickened gallbladder wall or a gallbladder wall mass with multiple-focus necrosis or calcifications accompanied by the typical CT findings of abdominal extra-gallbladder TB should suggest the diagnosis of gallbladder TB.

Ovarian mass mimicking malignancy: a case report

A 32-year-old female who suffered from abdominal pain underwent (18)F-fluorodexoyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for the diagnostic workup of pelvic mass lesions. Cystic mass lesions in the bilateral ovaries showed wall thickening and intense hypermetabolism along the rim. In addition, multifocal intense hypermetabolic lymphadenopathies were seen in the left paraaortic lymph node (LN), aortocaval LN, and both common iliac LNs. We interpreted these findings as bilateral ovarian cancer with retroperitoneal metastatic lymphadenopathies rather than endometriosis with reactive lymphadenopathies. However, histopathological examination confirmed the ovarian mass lesions as tubo-ovarian abscesses. We report a case that even if simultaneous hypermetabolic retroperitoneal LNs are seen, intense hypermetabolic lesions in both ovaries can be in consequence of inflammatory change.

Tuberculosis and malignancy

BACKGROUND

Tuberculosis (TB) and malignancy represent global threats claiming millions of lives and inflicting formidable suffering worldwide. Surprisingly, the pathophysiological and practical implications of their co-existence have received little attention.

METHODS

Therefore, we sought to review the available literature on the field and identify data regarding the association between TB and malignancy in order to highlight the neglected aspects of this association and probably derive clinically useful information. We searched PubMed up to June 2008 for case reports, case series, non-comparative and comparative studies that were written in English and reported data on the occurrence of both TB infection and a neoplastic disorder in the same patient(s). The development of mycobacterial infections in patients with immunocompromized conditions is well known and was considered outside the scope of this review.

EVIDENCE SYNTHESIS

The synthesis of the available evidence enabled us to establish three different types of association between malignancy and TB: (i) the development of cancer on the background of a previous tuberculous infection; (ii) the concurrent existence of TB and malignancy in the same patient(s) or clinical specimen(s); and (iii) the diagnostic challenges arising from the multi-faceted presentations of these two disorders.

CONCLUSION

We conclude that clinicians need to be aware of the protean manifestations of TB and cancer and maintain a high index of suspicion for simultaneous and/or misleading presentations. In addition, further research is required to determine if a tuberculous infection, being similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis.

[Pseudotumoral gallbladder tuberculosis]

Gallblader tuberculosis is uncommon and may mimic a neoplasia. We report a 55-year-old man who presented with fever and abdominal pain compatible with cholecystitis. Abdominal ultrasound and computed tomographic scan showed a tumoral aspect of the bottom of the gallbladder and invasion of adjacent liver. Diagnosis of pseudo-tumoral gallbladder tuberculosis was obtained with the histologic examination of surgical sampling. Disease course was uneventful with appropriate antituberculous therapy.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET

Recently, several reports have demonstrated that fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.

Disseminated nontuberculous mycobacterial infection mimic metastases on PET/CT scan

A 68-year-old man had malaise, weight loss, and enlarged right cervical lymph nodes. The first biopsy from a right cervical lymph node showed granulomas with negative acid-fast bacillus (AFB) staining, and he was treated for extrapulmonary tuberculosis with isoniazid, rifampin, ethambutol, and pyrazinamide. Symptoms persisted even after receiving antituberculosis drugs for 2 months. He was transferred to our center for F-18 FDG PET/CT scan under the suspicion of occult malignancy. The PET/CT scan showed increased FDG uptake in the right cervical lymphadenopathy and multiple bony lesions. The second biopsy from the FDG-avid cervical lymph node and bone marrow confirmed nontuberculous mycobacterial (NTM) infection. After another 6 months of adjusted antituberculosis therapy with isoniazid, rifampin, ethambutol, and clarithromycin, a repeat PET/CT scan showed remission of previous lesions.