Xanthogranulomatous cholecystitis: a premalignant condition?

Presentation and surgical management of xanthogranulomatous cholecystitis

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management. In addition, distinguishing XGC from gallbladder cancer preoperatively is still a challenge. The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC.

DATA SOURCES

The present systematic review was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases from inception until June 2020.

RESULTS

The laparoscopic cholecystectomy rate (34%) was almost equal to the open cholecystectomy rate (47%) for XGC. An important conversion rate (35%) was observed as well. The XGC cases treated by surgery were associated with low mortality (0.3%), limited intraoperative blood loss (58-270 mL), low complication rates (2%-6%), along with extended operative time (82.6-120 minutes for laparoscopic and 59.6-240 minutes for open cholecystectomy) and hospital stay (3-9 days after laparoscopic and 8.3-18 days after open cholecystectomy). Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome. In addition, complex surgical procedures, like wedge hepatic resections and bile duct excision were required during operations for XGC.

CONCLUSIONS

XGC seemed to be a rare, benign inflammatory disease that presents similar features as gallbladder cancer. The mortality and complication rates of XGC were low, despite the complex surgical procedures that might be required in some cases.

Xanthogranulomatous cholecystitis: experience in 100 cases

Background

Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe foam cells and fibrosis, and can be an inducement of difficulty in cholecystectomy. The purpose of this study was to review the clinical findings and imageology features of XGC and to optimize the treatment option.

Methods

This retrospective study collected clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications of 100 patients with XGC after evaluating 50005 cholecystectomy specimens between 2009 and 2018 in a single institute. heir clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications were collected and analyzed.

Results

Patients showed various clinical symptoms, ultrasonography was performed in all patients, CT and MRI were further arranged selectively before the operation, but none of the patients were prediagnosed. Fifty-two patients received open cholecystectomy. Laparoscopic cholecystectomy (LC) was planned in 48 patients within whom 8 cases were converted to open cholecystectomy. No partial cholecystectomy was performed. The intraoperative findings included cholecystolithiasis, choledocholithiasis, thickened gallbladder wall, lesions infiltrating into adjacent tissues, disordered Calot’s triangle anatomy, enlarged regional lymph nodes, internal gallbladder fistula, and hepatic abscesses. Frozen-section analysis was performed in 48 patients under the suspicion of gallbladder carcinoma (GBCa), but only 2 cases were finally confirmed.

Conclusions

The preoperative diagnosis of XGC was challenging. Open cholecystectomy was the most preferred treatment, and conversion to open was often necessary after LC.

Outcomes of laparoscopic cholecystectomy for xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder with distinct histopathological characteristics. Laparoscopic cholecystectomy (LC) is currently the standard treatment for gallbladder disease. However, the outcomes of LC for XGC have not been completely investigated, due to the rarity of XGC. The present study aimed to assess the surgical outcomes of LC for XGC. Among 3,037 patients undergoing cholecystectomy between 2005 and 2017 at our institution, 58 patients (1.9%) were diagnosed with XGC based on histopathology. Of the patients, LC was performed in 38 (65.5%), and they were enrolled in the present study. The outcome of LC for XGC in the cases was assessed, and was compared with outcomes of LC for other diseases. The average operation time was 109±36 min, and average intraoperative blood loss was 58±85 ml. LC was converted to open cholecystectomy in 6 (15.8%) of the 38 cases. No operative mortality occurred. One patient developed postoperative complications greater than grade II in the Clavien-Dindo classification, and the mean postoperative hospital stay was 6.1±5.8 days. Based on previous reports and the nature of XGC itself, the outcomes reported herein of LC for XGC seemed acceptable. It should be also noted that LC for XGC exhibited a higher conversion rate compared with LC than other benign gallbladder diseases, implying that LC for XGC remains challenging.

Organ-specific concept and controversy for premalignant lesions and carcinogenesis of gallbladder cancer

An analysis of premalignant lesions, risk factors and models of carcinogenesis of gallbladder cancer (GBC) involves the concept of organ specificity. In GBC, the dysplasia-carcinoma sequence and metaplasia-dysplasia-carcinoma sequence are considered to be more important models of carcinogenesis than the adenoma-carcinoma sequence. Cholecystectomy is recommended for gallbladder polyps ≥1.0 cm, and all pre-invasive adenomas and papillary neoplasms ≥1.0 cm are defined as intracholecystic papillary-tubular neoplasms (ICPTNs). Although adenomyomatosis (ADM) and xanthogranulomatous cholecystitis (XGC) are controversial lesions, a knowledge of their clinicopathological features would help clinicians to manage gallbladder lesions associated with ADM or XCG.

A case of xanthogranulomatous cholecystitis suspected to be adenocarcinoma based on the intraoperative peritoneal washing cytology

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. XGC remains difficult to distinguish from gallbladder cancer radiologically and macroscopically.

PRESENTATION OF CASE

A 63-year-old female was referred to our hospital because of a gallbladder tumor. Abdominal CT and MRI revealed a thickened gallbladder that had an obscure border with the transverse colon. FDG-PET showed a high uptake of FDG in the gallbladder. Therefore, under the preoperative diagnosis of an advanced gallbladder cancer with invasion to the transverse colon, a laparotomy was performed. Because adenocarcinoma was suspected based on the intraoperative peritoneal washing cytology (IPWC), cholecystectomy and partial transverse colectomy were performed instead of radial surgery. However, the case was proven to be XGC with no malignant cells after the operation.

DISCUSSION

In patients with gallbladder cancer who underwent surgery in our institute from 2000 to 2009, the prognosis after the operation of patients with only positive IPWC tended to be better than that of patients with definitive peritoneal disseminated nodules. It is true that in some cases, it is difficult to differentiate XGC from gallbladder carcinoma pre- and intra-operatively.

CONCLUSION

Surgical procedures should be selected based on the facts that there are long-term survivors with gallbladder cancer diagnosed with positive IPWC, and that some patients with XGC are initially diagnosed to have carcinoma by IPWC, as was seen in our case.

Mass-forming xanthogranulomatous cholecystitis masquerading as gallbladder cancer

BACKGROUND

Mass-forming xanthogranulomatous cholecystitis (XGC), an uncommon inflammatory pathology of gallbladder (GB), masquerades as gallbladder cancer (GBC) and diagnosis is often a histological surprise.

METHODS

A retrospective analysis of prospectively collected database of patients with GB mass operated between August 2009 and September 2012 was conducted to determine clinical, radiological, and intraoperative findings that might aid in the preoperative diagnosis of mass-forming XGC and ascertain their optimal management strategy.

RESULTS

Of the 566 patients with GB mass and suspected GBC, 239 were found to be inoperable on preoperative workup and 129 patients had unresectable disease on staging laparoscopy/laparotomy. Of the 198 with resectable disease, 31 were reported as XGC on final histopathology (Group A), while 167 were GBC (Group B). Of these 31 patients, six with an intraoperative suspicion of benign pathology underwent cholecystectomy with segments IVb and V resection, and frozen section histopathology. Twenty-five underwent radical cholecystectomy, with (n = 10) or without (n = 15) adjacent organ resection. In comparison, anorexia and weight loss were significantly more in Group B (p = 0.001 and <0.001). Intraoperatively, empyema and associated gallstones were more common in Group A (p = 0.011 and <0.001). On computed tomography (CT) of the abdomen, continuous mucosal line enhancement and intramural hypodense bands were significantly more in Group A (p < 0.001 and 0.025). While CT abdomen revealed one or more features suggestive of XGC in 64.5 % (20/31) of patients in Group A, 11(35.5 %) did not have any findings suggestive of XGC on imaging.

CONCLUSION

Mass-forming XGC mimics GBC, making preoperative and intraoperative distinction difficult. While imaging findings can help in suspecting XGC, definitive diagnosis require histopathological examination. Presence of typical radiological findings, however, can help in avoiding extended radical resection in selected cases.

Conversion of laparoscopic cholecystectomy to open surgical procedure due to complete fibrosis of the gallbladder

We present a case of transmural fibrotic gallbladder in a patient with previously undiagnosed gallbladder disease and describe our surgical approach to treating this patient.

Xanthogranulomatous cholecystitis: a clinicopathological study of its association with gallbladder carcinoma

OBJECTIVES

To determine the distribution of macrophages (MΦ) in both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma (GBC) and to analyze the association between XGC and GBC.

METHODS

From January 2009 to June 2011, 110 patients with gallbladder diseases, including 35 with GBC, 45 with XGC and 30 with chronic cholecystitis (CC), were enrolled. Immunohistochemistry stain and real-time polymerase chain reaction using oncogenes (BCL-2, c-Myc) and anti-oncogene genes (p53, p21) were performed, serum expressions of tumor marker (CA19-9, CA724 and CA242) were also conducted. MΦ were used to determine their potential role in the carcinogenesis of GBC.

RESULTS

BCL-2 and c-Myc expressions gradually increased among CC, XGC and GBC (P = 0.032 and P = 0.020, respectively); while p53 and p21 were similar in the three groups (P = 0.167 and P = 0.122, respectively). Serum BCL-2 and c-Myc were significantly correlated with their tissue levels; in terms of serum tumor markers, which gradually increased among CC, XGC and GBC, however, CA242 and CA724 were both negative in XGC but positive in GBC. Furthermore, gradually increasing MΦ counts were observed among CC, XGC and GBC groups; c-Myc and CA724 were independent predictors for the differentiation of XGC and GBC.

CONCLUSIONS

XGC is an uncommon inflammatory condition distinct from CC and may be associated with the precancerous nature of GBC for its upregulated oncogenes and MΦ biology. c-Myc and CA724 were independent predictors for the differentiation of XGC and GBC.

Xanthogranulomatous inflammation involving latissimus dorsi donor site and implant breast reconstruction: case report and literature review

Xanthogranulomatous inflammation is a rare clinico-pathological condition involving many organ systems. Breast involvement with this rare condition reported from a few cases of mastitis has been limited to only microscopic involvement on histology. We would like to report an unusual presentation of this inflammatory process presenting as a solid lump mimicking malignancy in latissimus dorsi donor site scar and implant-based breast reconstruction as a result of a ruptured silicone gel implant. To our knowledge there have been no previous reports on similar presentation published in the literature. This case highlights a rare complication of a leaked silicone gel implant triggering a xanthomatous response in the absence of the usual infective or obstructing etiologies. This condition is of benign nature with complete clearance on surgical excision and excellent clinical prognosis reported from other organ involvement.

Xanthogranulomatous salpingitis and oophoritis associated with endometriosis and uterine leiomyoma presenting as intestinal obstruction

Xanthogranulomatous inflammation is a rare form of chronic granulomatous inflammation. Bacterial infections, immunosuppression, chronic inflammatory conditions, luminal obstruction, endometriosis, leiomyoma, abnormal lipid metabolism, ineffective antibiotic therapy, ineffective clearance of bacteria by phagocytes and chronic irritation of the urachal remnant have been implicated in the pathogenesis. There are very few reported cases of xanthogranulomatous salpingitis and oophoritis. We present such a case in a 34-year-old female, with primary subfertility for eight years, endometriosis, uterine leiomyoma, type II diabetes mellitus and a history of surgery for endometriosis and fibroids and surgical wound infection, who presented with symptoms of intestinal obstruction. The patient underwent emergency laparotomy followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology revealed xanthogranulomatous salpingitis and oophoritis. Chronic inflammation due to inadequate treatment of bacterial infection, coupled with pelvic endometriosis and uterine leiomyoma may have led to xanthogranulomatous salpingitis and oophoritis.