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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 1  |  Page : 144-147
Florid xanthogranulomatous cholecystitis masquerading as invasive gallbladder cancer leading to extensive surgical resection


Department of Pathology, G B Pant Hospital, New Delhi-110 002, India

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Date of Web Publication19-Jan-2010
 

   Abstract 

Xanthogranulomatous inflammation of gallbladder wall can extend and infiltrate adjacent organs which can be mistaken for malignancy on preoperative investigations and, intraoperatively, often leads to extensive surgical resections. Only the histopathologic examination of the specimen allows correct diagnosis. We hereby review clinicopathologic findings of six cases which underwent extensive surgeries on clinical, radiological and intraoperative suspicion of gallbladder carcinoma which turned out to be xanthogranulomatous cholecystitis (XGC). There was no evidence of malignancy on histopathologic examination. Xanthogranulomatous inflammation extended into liver, duodenum, colon and stomach in case 1; liver and colon in case 2; liver, duodenum, colon in case 3; stomach, duodenum, colon in case 4; stomach and duodenum in case 5 and duodenum and colon in case 6. Lymph nodes in all the six cases showed reactive hyperplasia. We present here the clinico-radiologic findings of these cases, techniques which may help differentiate between an XGC and a gallbladder carcinoma and also discuss the management of these cases.

Keywords: Carcinoma, cholecystitis, gallbladder, xanthogranulomatous

How to cite this article:
Rastogi A, Singh DK, Sakhuja P, Gondal R. Florid xanthogranulomatous cholecystitis masquerading as invasive gallbladder cancer leading to extensive surgical resection. Indian J Pathol Microbiol 2010;53:144-7

How to cite this URL:
Rastogi A, Singh DK, Sakhuja P, Gondal R. Florid xanthogranulomatous cholecystitis masquerading as invasive gallbladder cancer leading to extensive surgical resection. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Oct 13];53:144-7. Available from: http://www.ijpmonline.org/text.asp?2010/53/1/144/59209



   Introduction Top


Florid xanthogranulomatous cholecystitis (XGC) is a rare destructive, inflammatory lesion involving adjacent organs and clinically resembling invasive gallbladder carcinoma leading to needless and extensive surgical resections. [1],[2],[3],[4],[5],[6],[7] We present six cases of florid XGC that clinically mimicked advanced gallbladder carcinoma. We discuss ways to differentiate XGC from gallbladder carcinoma and manage XGC.


   Case Reports Top


Out of 1628 cholecystectomies performed in our institute from January 2007 to December 2008, 57 (3.49%) had XGC. Six (0.36%) of them had florid XGC which clinically resembled advanced gallbladder carcinoma. The clinical, radiologic and preoperative findings of these six patients are given in [Table 1]. Average age was 58 years and male to female ratio 1:5. The duration of symptoms ranged from one to four months. Radiologic investigations in all cases showed an infiltrative gallbladder mass with one case showing associated choledochal cyst, fistula between gallbladder, duodenum and colon.

Surgical specimens in all cases showed thickened gallbladder wall. Yellowish areas were seen in the gallbladder wall, gallbladder bed and infiltrating into adjacent organs as given in [Table 1]. Liver and colon were the most frequently involved organs. Frozen sections from lymph nodes in cases 4-6, showed reactive lymphoid hyperplasia. In cases 1-3, frozen section could not be done due to technical reasons. Microscopic examination in all cases revealed sheets of foamy macrophages, plasma cells, lymphocytes, neutrophils, eosinophils, foreign body type giant cells and cholesterol clefts infiltrating the mucosa, muscle layer and adventitia of gallbladder. [Figure 1]A, B There was extension of xanthogranulomatous inflammation into adjacent organs like liver and colon. [Figure 2]A, B, and [Figure 3]A-D The infiltrating cells were positive with immunohistochemistry for CD68. ([Figure 2]B and [Figure 3]B) Lymph nodes in all cases showed reactive lymphoid hyperplasia. The growth in all cases was extensively sampled but no evidence of malignancy was found in any case. Postoperative course of all the patients was uneventful, patients are doing well on follow-up.


   Discussion Top


XGC is a fibro-xanthogranulomatous inflammation of the gallbladder found in one to four per cent of resected specimens. Direct involvement of extra-gallbladder organs by florid XGC is a rare occurrence. To the best of our knowledge only seven cases have been reported in literature till date which showed extensive involvement of extra-gallbladder organs and required extended surgical resections. [1],[2],[3],[4],[5],[6],[7] [Table 2] Importance of XGC lies in the fact that it is a potential cause of confusion with gallbladder carcinoma on clinical and radiological evaluation and malignancy may co-exist with XGC in the same case. [1],[4]

Most of the patients with XGC are females; dominant symptoms are vomiting and upper right quadrant pain. Patients of XGC with associated gallbladder carcinoma are of older age, males with anorexia, weight loss, palpable lump and jaundice. [8] Ultrasonography (USG) in XGC characteristically shows intraluminal hypoechoic nodules and bands in the gallbladder wall. [2],[9] Gallstones and thickening of gallbladder wall are frequently seen. USG can also detect perforation of the gallbladder, abscesses and fistulas which are a common occurrence in these cases. CECT scan shows thickened gallbladder wall, hypo dense band and homogeneous contrast enhancement of the mucosa. On contrast-enhanced computed tomography (CECT) scan, a continuous mucosal lining indicates that the mucosal surface overlying the lesion is intact and the lesion is intramural pointing towards a diagnosis of XGC. Gallbladder carcinoma, however, shows absence or extensive disruption of the mucosal lining. Magnetic resonance imaging (MRI) may show a diffuse thickening of gallbladder wall. [8],[9],[10]

Tumor markers are not very helpful in differentiating XGC from gallbladder carcinomas but may help in post operative follow-up. High serum CA 19.9 elevation may occur both in carcinoma and XGC. However, CA 19.9 normalizes early after surgery for XGC whereas it remains high for a longer duration in gall bladder cancer. [9]

Fine-needle aspiration cytology is an extremely important preoperative investigation for differentiating carcinoma from XGC and confirming the presence of coexisting carcinoma in cases where the lesion is confined to the gallbladder. [8],[9] One study showed an overall sensitivity of 90.6% and specificity of 94.7% in detecting carcinoma of the gallbladder. When adenocarcinoma was associated with XGC, the sensitivity of detecting malignancy was 80%. [9]

Intraoperative frozen section examination is another very valuable tool for differentiating XGC from malignancy and guiding optimum surgery when the xanthogranulomatous inflammation is confined to gallbladder and invasion of adjacent organs is not present. If hematoxylin and eosin frozen section examination is combined with immunohistochemistry it becomes much easier to differentiate XGC from gallbladder cancer peroperatively. EnVision system is a highly sensitive two-step immunohistochemical (IHC) technique for rapid immunostaining of frozen sections. A modification of the routine technique reported by Ulrike et al. allows the detection of antigens in frozen sections in less than 13 min. Authors concluded that this rapid, simple, and sensitive immunostaining method can be used to greatly enhance frozen section diagnosis during surgery. [10]

However, in cases showing extensive invasion of extra-gallbladder organs the surgical strategy is not influenced by frozen section examination. [11],[12] On gross examination, XGC shows a yellow-brown lesion, well-demarcated foci of mural thickening with or without surface ulceration. Gallstones are present in most cases. Microscopy in cases of florid XGC is similar to that seen in our cases. The infiltrate can be focal, multinodular or diffuse. The overlying mucosa may show partial denudation or ulceration. Xanthogranulomatous foci are composed of abundant lipid laden histiocytes, lymphocytes, plasma cells, neutrophils, and fibroblasts. The xanthogranulomatous foci can infiltrate adjacent organs. [2],[3],[5],[6],[7] In this study all the cases showed extension of xanthogranulomatous inflammation into adjacent organs. This led to peroperative confusion of infiltration with carcinoma.

The best management of XGC is cholecystectomy and excision of xanthogranulomatous tissue. When inflammation is localized to gallbladder the patients should be considered for laparoscopic cholecystectomy after an adequate patient selection, preoperative FNAC and an intraoperative frozen-section examination to rule out coexisting malignancy. In cases of XGC with extensive infiltration of adjacent organs, a radical resection of the mass is the only reasonable option because of the possibility of carcinoma associated with XGC and to treat symptoms like jaundice and prevent possible complications like bowel obstruction and perforation. [8],[9],[10],[11],[12]

To conclude, preoperative identification of XGC is important for proper surgical management of the patients. Although clinical features and radiological investigations can help probably the only way to clearly differentiate XGC from malignancy is by intraoperative frozen section examination and immunohistochemistry on frozen sections for markers such as CD68, EMA and CK.

 
   References Top

1.Okamoto S, Konan T, Yamaguchi K, Nakamura K, Maeda S, Kitamura K. Xanthogranulomatous cholecystitis masquerading as gallbladder carcinoma. Tann to Sui 1990;11:1415-9.  Back to cited text no. 1      
2.Maeda T, Shimada M, Matsumata T, Adachi E, Taketomi A, Tashiro Y, et al. Xanthogranulomatous cholecystitis masquerading as gallbladder carcinoma. Am J Gastroenterol 1994;89:628-30.  Back to cited text no. 2      
3.Furuta A, Ishibashi T, Takahashi S, Sakamoto K. MR imaging of xanthogranulomatous cholecystitis. Radiat Med 1996;14:315-9.  Back to cited text no. 3      
4.Natori S, Takimoto A, Endoh K, Ishikawa T, Yamaguchi S, Fjii Y, et al. A case of xanthogranulomatous cholecystitis diffi cult to be differentiated from gallbladder cancer. Tann to Sui 1997;18:593-6.  Back to cited text no. 4      
5.Enomoto T, Todoroki T, Koike N, Kawamoto T, Matsumoto H. Xanthogranulomatous cholecystitis mimicking stage IV gallbladder cancer. Hepatogastroenterology 2003;50:1255-8.  Back to cited text no. 5      
6.Pinocy J, Lange A, König C, Kaiserling E, Becker HD, Kröber SM. Xanthogranulomatous cholecystitis resembling carcinoma with extensive tumorous infiltration of the liver and colon. Langenbecks Arch Surg 2003;388:48-51.  Back to cited text no. 6      
7.Spinelli A, Schumacher G, Pascher A, Lopez-Hanninen E, Al-Abadi H, Benckert C, et al. Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature. World J Gastroenterol 2006;12:2293-6.  Back to cited text no. 7      
8.Robert KM, Parsons MA. Xanthogranulomatous cholecystitis: a clinicopathological study of 13 cases. J Clin Pathol 1987;40:412-7.  Back to cited text no. 8      
9.Krishnani N, Shukla S, Jain M, Pandey R, Gupta RK. Fine needle aspiration cytology in xanthogranulomatous cholecystitis, gallbladder adenocarcinoma and coexistent lesions. Acta cytologica 2000;44;508-14.  Back to cited text no. 9      
10.Kämmerer U, Kapp M, Gassel AM, Richter T, Tank C, Dietl J, et al. A new rapid immunohistochemical staining technique using the EnVision antibody complex. J Histochem Cytochem 2001;49:623-30.  Back to cited text no. 10      
11.Parra JA, Acinas O, Bueno J, Güezmes A, Fernández MA, Fariñas MC. Xanthogranulomatous Cholecystitis: Clinical, Sonographic, and CT Findings in 26 Patients. AJR 2000;174:977-83.  Back to cited text no. 11      
12.Rao RV, Kumar A, Sikora SS, Saxena R, Kapoor VK. Xanthogranulomatous cholecystitis: Differentiation from associated gallbladder carcinoma. Trop Gastroenterol 2005;26:31-3.  Back to cited text no. 12      

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Correspondence Address:
Deepak Kumar Singh
597, Z - Type Flats, Lucknow Road, Timarpur, Delhi - 110 054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.59209

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]

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