Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2015; 21(35): 10166-10173
Published online Sep 21, 2015. doi: 10.3748/wjg.v21.i35.10166
Xanthogranulomatous cholecystitis: Difficulty in differentiating from gallbladder cancer
Hideki Suzuki, Satoshi Wada, Kenichiro Araki, Norio Kubo, Akira Watanabe, Mariko Tsukagoshi, Hiroyuki Kuwano
Hideki Suzuki, Satoshi Wada, Kenichiro Araki, Norio Kubo, Akira Watanabe, Mariko Tsukagoshi, Hiroyuki Kuwano, Department of General Surgical Science (Surgery I), Gunma University Graduate School of Medicine, Gunma University, Maebashi 371-8511, Japan
Author contributions: Suzuki H and Kuwano H designed the research; Suzuki H wrote the paper; Wada S, Araki K and Kubo N performed the research; Watanabe A and Tsukagoshi M analyzed the data.
Institutional review board statement: This study is not a formal study with a protocol; therefore, no submission was made the Hospital Ethics Review Board.
Informed consent statement: In this retrospective study, written informed consent was not provided by the participants, but the presented data are anonymized and risk of identification is low.
Conflict-of-interest statement: None of the authors of this manuscript have any conflicts of interest to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at hidesuzuki044@gmail.com. Participants gave informed consent for data sharing.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Hideki Suzuki, MD, Department of General Surgical Science (Surgery I), Gunma University Graduate School of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi 371-8511, Japan. hidesuzuki044@gmail.com
Telephone: +81-272-208224 Fax: +81-272-208230
Received: March 20, 2015
Peer-review started: March 25, 2015
First decision: April 23, 2015
Revised: May 13, 2015
Accepted: July 18, 2015
Article in press: July 18, 2015
Published online: September 21, 2015
Processing time: 181 Days and 18.9 Hours
Abstract

AIM: To compare cases of xanthogranulomatous cholecystitis (XGC) and advanced gallbladder cancer and discuss the differential diagnoses and surgical options.

METHODS: From April 2000 to December 2013, 6 XGC patients received extended surgical resections. During the same period, 16 patients were proven to have gallbladder (GB) cancer, according to extended surgical resection. Subjects chosen for analysis in this study were restricted to cases of XGC with indistinct borders with the liver as it is often difficult to distinguish these patients from those with advanced GB cancer. We compared the clinical features and computed tomography findings between XGC and advanced GB cancer. The following clinical features were retrospectively assessed: age, gender, symptoms, and tumor markers. As albumin and the neutrophil/lymphocyte ratio (NLR) are prognostic in several cancers, we compared serum albumin levels and the NLR between the two groups. The computerized tomography findings were used to compare the two diseases, determine the coexistence of gallstones, the pattern of GB thickening (focal or diffuse), the presence of a hypoattenuated intramural nodule, and continuity of the mucosal line.

RESULTS: Based on the preoperative image findings, we suspected GB carcinoma in all cases including XGC in this series. In addition, by pathological examination, we found that the group of patients with XGC developed inflammatory disease after surgery. Patients with XGC tended to have abdominal pain (4/6, 67%). However, there was no significant difference in clinical symptoms, including fever, between the two groups. Serum albumin and NLR were also similar in the two groups. Serum tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), tended to increase in patients with GB cancer. However, no significant differences in tumor markers were identified. On the other hand, gallstones were more frequently observed in patients with XGC (5/6, 83%) than in patients with GB cancer (4/16, 33%) (P = 0.0116). A hypoattenuated intramural nodule was found in 3 patients with XGC (3/6, 50%), but in only 1 patient with GB cancer (1/16, 6%) (P = 0.0024). The GB thickness, continuous mucosal line, and bile duct dilatation showed no significant differences between XGC and GB cancer.

CONCLUSION: Although XGC is often difficult to differentiate from GB carcinoma, it is possible to obtain an accurate diagnosis by careful intraoperative gross observation, and several intraoperative frozen sections.

Keywords: Xanthogranulomatous cholecystitis; Advanced gallbladder cancer; Differential diagnosis

Core tip: Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. Differentiating between XGC and malignant gallbladder lesions is often difficult, especially in patients with severe proliferative fibrosis involving the gallbladder and surrounding organs. We compared the clinical features and computed tomography findings between patients with XGC and patients with advanced gallbladder cancer. There were almost no significant differences between the two groups. Although XGC is often difficult to differentiate from gallbladder carcinoma, it is possible to obtain an accurate diagnosis by careful intraoperative gross observation and several intraoperative frozen sections which could prevent extended resections.