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Surgical treatment of xanthogranulomatous cholecystitis: experience in
33 cases.Hepatobiliary
Pancreat Dis Int. 2007 Oct;6(5):504-8.
BACKGROUND:
Xanthogranulomatous cholecystitis (XGC) is a rare presentation of
chronic cholecystitis, characterized by xanthogranuloma, severe
fibrosis and foam cells, and can be a cause of difficulty in
cholecystectomy. Patients with XGC are frequently misdiagnosed
intraoperatively as having carcinoma of the gallbladder and are
treated with extensive excision. This study aimed at providing proper
surgical treatment for patients with XGC. METHODS: The clinical data
of 33 patients with XGC definitely diagnosed by pathological
examination over a period of 10 years were analyzed retrospectively
(mean age of onset, 60 years; male/female ratio, 1.5:1). RESULTS:
Preoperatively, the 33 patients were examined by abdominal B-ultrasonography
while 20 of them were further examined by computed tomography (CT).
Intraoperatively, XGC associated with cholecystolithiasis was found in
97.0% of the patients, thickening of the gallbladder wall in 90.9%,
xanthogranulomatous tissue invading into other tissues in 87.9%, XGC
associated with choledocholithiasis in 15.2%, and Mirizzi syndrome in
9.1%. In addition, a gallbladder fistula was observed in 4 patients.
Open cholecystectomy was performed on 15 patients, partial
cholecystectomy on 7, cholecystectomy and partial liver wedge
resection on 5, and gallbladder cancer radical correction on 6. The
intraoperative misdiagnosis rate was 24.2%. Frozen-section examination
was carried out in 9 patients. Postoperative complications were
observed in 5 patients. CONCLUSIONS: XGC is difficult to diagnose
either preoperatively or intraoperatively and definite diagnosis
depends exclusively on pathological examination. Firm adhesions of the
gallbladder to neighboring organs and tissues are common and lead to
difficulty in surgical treatments. The mode of operation depends on
specific conditions in varying cases, and since frozen-section
examination plays an important role in determining the nature of the
lesions, intraoperative frozen-section examination should be carried
out to differentiate XGC from carcinoma of the gallbladder.
Involvement of
Escherichia coli in pathogenesis of xanthogranulomatous cholecystitis
with scavenger receptor class A and CXCL16-CXCR6 interaction.Pathol
Int. 2007 Oct;57(10):652-63.
Xanthogranulomatous cholecystitis (XGC) is characterized by the
infiltration of numerous foamy macrophages. Bacterial infection is
thought to be involved in the pathogenesis of XGC. Using XGC and
cultured murine biliary epithelial cells (BEC), the participation of
E. coli and the role of the scavenger receptor class A (SCARA), as
well as chemokine(C-X-C motif) ligand 16 (CXCL16) and its receptor
chemokine(C-X-C motif) receptor 6 (CXCR6), were examined in the
pathogenesis of XGC. E. coli components and genes were detected in XGC
on immunohistochemistry and polymerase chain reaction (PCR),
respectively. SCARA-recognizing E. coli was found in foamy macrophages
aggregated in xanthogranulomatous lesions. CXCL16, which functions as
a membrane-bound molecule and soluble chemokine to induce adhesion and
migration of CXCR6(+) cells, was detected on gallbladder epithelia,
and CXCR6(+)/CD8(+) T cells and CXCR6(+)/CD68(+) macrophages were also
accumulated. In cultured BEC, CXCL16 mRNA and secreted soluble CXCL16
were constantly detected and upregulated by treatment with E. coli and
lipopolysaccharide through Toll-like receptor 4. These suggest that
SCARA in macrophages is involved in the phagocytosis of E. coli
followed by foamy changes and that bacterial infection causes the
upregulation of CXCL16 in gallbladder epithelia, leading to the
chemoattraction of macrophages via CXCL16-CXCR6 interaction and
formation of the characteristic histology of XGC.
Perfidious
gallbladders - a diagnostic dilemma with xanthogranulomatous
cholecystitis.Ann
R Coll Surg Engl. 2007 Mar;89(2):168-72.
INTRODUCTION:
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of
chronic cholecystitis characterised by marked thickening of the
gallbladder wall and dense local adhesions. Pre-operative and
intra-operative diagnosis is difficult and it often mimics a
gallbladder carcinoma (GBC). Laparoscopic cholecystectomy (LC) is
frequently unsuccessful with a high conversion rate. A series of
patients with this condition led us to review our experience with XGC
and to try to develop a care pathway for its management. PATIENTS AND
METHODS: A retrospective review of the medical records of 1296
consecutive patients who had undergone cholecystectomy between January
2000 and April 2005 at our hospital was performed. Twenty-nine cases
of XGC were identified among these cholecystectomies. The clinical,
radiological and operative details of these patients have been
analysed. RESULTS: The incidence of XGC was 2.2% in our study. The
mean age at presentation was 60.3 years with a female:male ratio of
1.4:1. Twenty-three patients (79%) required an emergency surgical
admission at first presentation. In three patients, a GBC was
suspected both radiologically and at operation (10.3%), but was later
disproved on histology. Seventeen patients (59%) had obstructive
jaundice at first presentation and required an endoscopic retrograde
cholangiopancreatography (ERCP) before LC. Of these, five had common
bile duct stones. Abdominal ultrasound scan showed marked thickening
of the gallbladder wall in 16 cases (55%). LC was attempted in 24
patients, but required conversion to an open procedure in 11 patients
(46% conversion rate). A total cholecystectomy was possible in 18
patients and a partial cholecystectomy was the choice in 11 (38%). The
average operative time was 96 min. Three patients developed a
postoperative bile leak, one of whom required ERCP and placement of a
biliary stent. The average length of stay in the hospital was 6.3
days. CONCLUSIONS: Severe xanthogranulomatous cholecystitis often
mimics a gallbladder carcinoma. Currently, a correct pre-operative
diagnosis is rarely made. With increased awareness and a high index of
suspicion, radiological diagnosis is possible. Preoperative
counselling of these patients should include possible intra-operative
difficulties and the differential diagnosis of gallbladder cancer.
Laparoscopic cholecystectomy is frequently unsuccessful and a partial
cholecystectomy is often the procedure of choice.
Cytopathologic
diagnosis of xanthogranulomatous cholecystitis and coexistent lesions.
A prospective study of 31 cases.Acta
Cytol. 2007 Jan-Feb;51(1):37-41.
OBJECTIVE: To evaluate the diagnostic accuracy and reliability of
preoperative ultrasound (US)-guided fine needle aspiration cytology (FNAC)
in the diagnosis of xanthogranulomatous cholecystitis (XGC) and
coexistent lesions (carcinoma) and also to evaluate the possibility
ofmissing either carcinoma or XGC on cytology. STUDY DESIGN: The
cytologic diagnoses of XGC and coexistent lesions were made according
to standard criteria. In a prospective, 5-year study, preoperative
US-guided FNAC from 42 cases of XGC was compared with follow-up
histologic diagnoses, which were available in 31 cases. When FNAC
after the first aspiration showed the aspirate to be nondiagnostic,
FNAC was repeated under US guidance. RESULTS: Preoperative US-guided
FNAC diagnoses of XGC were made in 31 cases, for which follow-up
histology was available in all cases. US-guided FNAC diagnosis ofXGC
only was made in 30 cases and coexistent lesions in 1 case. Followup
histology revealed 26 cases of XGC, 4 of a coexistent lesion and 1 of
squamous cell carcinoma only. The overall diagnostic accuracy of
preoperative US-guided FNAC was 96.77%. The overall possibility of
missing XGC was 3.33% and that of carcinoma, 12.01%. CONCLUSION:
Preoperative US-guided FNAC is safe, rapid, reliable, cost-effective
and accurate in diagnosing XGC. However, the possibility ofcoexistent
carcinoma cannot be definitely ruled out. It is therefore recommended
that FNAC be performed from multiple suspicious sites under radiologic
guidance. Thus, preoperative US-guided FNAC diagnosis would help in
determining the urgency of treatment and also in planning the surgical
procedure for gallbladder lesions.
Extended surgical resection for
xanthogranulomatous cholecystitis mimicking advanced gallbladder
carcinoma: A case report and review of literature.World
J Gastroenterol. 2006 Apr
14;12(14):2293-6.
Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory
disease of the gallbladder, rarely involving adjacent organs and
mimicking an advanced gallbladder carcinoma. The diagnosis is usually
possible only after pathological examination. A 46 year-old woman was
referred to our center for suspected gallbladder cancer involving the
liver hilum, right liver lobe, right colonic flexure, and duodenum.
Brushing cytology obtained by endoscopic retrograde cholangiography (ERC)
showed high-grade dysplasia. The patient underwent an en-bloc
resection of the mass, consisting of right lobectomy, right
hemicolectomy, and a partial duodenal resection. Pathological
examination unexpectedly revealed an XGC.Only six cases of extended
surgical resections for XGC with direct involvement of adjacent organs
have been reported so far. In these cases, given the possible
coexistence of XGC with carcinoma, malignancy cannot be excluded, even
after cytology and intraoperative frozen section investigation. In
conclusion, due to the poor prognosis of gallbladder carcinoma on one
side and possible complications deriving from highly aggressive
inflammatory invasion of surrounding organs on the other side, it
seems these cases should be treated as malignant tumors until proven
otherwise. Clinicians should include XGC among the possible
differential diagnoses of masses in liver hilum.
Xanthogranulomatous cholecystitis: differentiation from associated
gall bladder carcinoma.Trop
Gastroenterol. 2005 Jan-Mar;26(1):31-3.
Xanthogranulomatous cholecystitis (XGC) is a destructive form of
chronic cholecystitis. In some patients it coexists with gall bladder
carcinoma (GBC) and is often difficult to differentiate between the
two. Present study was performed with an aim to identify
differentiating features of XGC and those of XGC with associated Gall
bladder carcinoma (XGC ass. GBC). A retrospective analysis of
prospectively maintained data of 4800 cholecystectomies performed from
January 1988 to December 2003 was carried out. On histopathology 453
cholecystectomy specimens revealed XGC. These patients were divided
into two groups, those with associated GBC (n=26) and those without
GBC (n=427). Clinical, radiological and operative findings were
compared in these two groups. P value of < 0.05 was considered
statistically significant. The incidence of associated GBC in present
series was 6%. XGC patients with associated GBC, at presentation were
older than those with XGC alone and there was male preponderance. XGC
patients with associated GBC were more likely to present with
anorexia, weight loss, palpable lump and jaundice. Gall stones were
present in majority of patients in both the groups. GB wall
thickening, GB mass, enlarged abdominal lymph nodes may be found on
imaging in both the groups but more so in patients with associated GBC.
Both preoperative FNAC and peroperative FNAC/imprint cytology failed
to reveal the associated GBC with XGC in some patients.
Epidemiology
of xanthogranulomatous cholecystitis.Cir
Cir. 2005 Jan-Feb;73(1):19-23.
OBJECTIVE: In
order to study patients with a diagnosis of xanthogranulomatous
cholecystitis (XGC), we analyzed their demographics, epidemiology and
clinical data. MATERIAL AND METHODS: We analyzed the clinical records
of XGC during a period of 6 years, obtaining demographic,
epidemiologic and clinical data. RESULTS: Of a total of 1425
cholecystectomies performed between January 1991 and December 1996, we
found 35 cases of XGC (2.4%). Twenty six (74%) were women (median age:
44 years), 60% were from a low socioeconomic group, 34% has a history
of alcoholism and smoking, and 25 patients (71%) had a blood type of O
positive. Thirteen patients (37%) presented obstructive jaundice, 11
had dilatation of the choledocus and were treated with ERCP. Of the 35
cholecystectomies, 15 were urgent and 20 elective. Eight were operated
laparoscopically and two were converted because of firm adhesions. We
had 5 transoperative complications. DISCUSSION: Pre-operative XGC
diagnosis is difficult, often mistaken for gall bladder cancer. The
incidence in our study (2.4%) is higher than reports in industrialized
countries (0.7-1.8%), with a female predominance. The most frequent
clinical presentation is that of chronic cholecystitis, but we found a
high percentage of patients with obstructive jaundice. We had 0%
mortality and 26% morbidity, and no association was found between XGC
and gallbladder cancer.
Xanthogranulomatous cholecystitis: retrospective analysis of 6 cases.Rev
Gastroenterol Peru. 2005
Jan-Mar;25(1):93-100.
Xanthogranulomatous cholecystitis (CX) is a rare kind of chronic
cholecystitis, not yet reported in our media, characterized by the
presence of chronic, inflammatory infiltration, formation of
granulomas, with fibrosis and severe histiocytic reaction with
macrophages rich in foam cells. The object of this study is to
establish the clinical, radiological and histopathological pattern of
CX, by means of the analysis of 6 cases identified in a retrospective
check of 191 medical histories of cholecystectomized patients
suffering from anatomopathological diagnosis of chronic cholecystitis,
in the Department of Abdomen of the Institute of Neoplastic Diseases,
from 1939 to 2004. The clinical presentation was characterized by the
presence of a palpable mass on physical examination and weight loss.
There were complications in two patients. The ultrasonigraph,
tomograph and/or laparotomy scans of the vesicle were similar in
appearance to a locally advanced vesicular cancer. In none of the
specimens was the coexistence of a vesicular carcinoma identified. The
vesicle was dried out in block with adjacent hepatic parenchyma in all
cases. The CX can simulate a hepatobiliary malignant neoplasia and
require suitable oncological surgical treatment. In cases of vesicular
tumors, which can be considered inoperable there is the possibility of
being faced with a xanthogranulomatous cholecystitis (CX), a benign
condition treatable with surgery.
Xanthogranulomatous cholecystitis in laparoscopic surgery.J
Gastrointest Surg. 2005 Apr;9(4):494-7
Xanthogranulomatous cholecystitis (XGC) is one presentation of
cholecystitis and can be a cause of difficulty in cholecystectomy. We
reviewed the clinical files of 12,426 patients who had undergone
cholecystectomy. In this group, there were 182 cases of XGC, and 41 of
these patients had undergone laparoscopic surgery. Patients with XGC
represented 1.46% of the cholecystectomies that were performed. Of the
41 patients who underwent laparoscopic surgery, 27 were men (66%) and
14 were women (34%) (average age, 52 years). A total of 36 patients
(88%) presented with a chronic condition. XGC was found to be
associated with lithiasis in 85%, with jaundice in 22%, and with
cancer in 2.4% (one patient). A total of 33 patients (80%) required
conversion to open surgery, because of technical difficulties; of
these patients, 64% underwent partial cholecystectomy. We conclude
that XGC creates difficulty at laparoscopy and therefore any
preoperative suspicion of XGC should cause the clinician to consider
open cholecystectomy.
Surgical
procedures and histopathologic findings for patients with
xanthogranulomatous cholecystitis.:
J Am Coll
Surg. 2004 Aug;199(2):204-10.
BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an unusual and
destructive inflammatory process of the gallbladder. Laparoscopic
cholecystectomy (LC) may be contraindicated in XGC because of a high
incidence of complications and coexistent malignancy. In this study,
we examined the management of LC in patients with XGC. STUDY DESIGN:
LC was attempted on 1,408 consecutive patients, including 27 (1.9%)
patients with histopathologically diagnosed XGC. All patients
underwent preoperative spiral computed tomography after IV infusion
cholangiography and intraoperative cholangiography. We examined the
correlation between the inflammatory grade of XGC and the difficulty
of LC. RESULTS: LC was completed in 22 (81%) of the 27 patients
diagnosed with XGC. Two patients with common bile duct injuries
(partial lacerations) were confirmed by laparoscopic cholangiography,
and injuries were simply closed using a laparoscopic technique. An
intraoperative frozen-section examination revealed gallbladder
carcinomas in two patients, and additional hepatectomies were
performed in these patients after LC. Five patients (19%) with XGC
required open operation. All of the laparoscopic failures were
attributable to dense fibrotic adhesions in Calot's triangle and in
the surrounding tissues. Histopathologically, nine patients had a
xanthogranuloma with severe fibrotic reaction in the gallbladder wall,
and four of these patients were treated by open operation.
CONCLUSIONS: Although XGC has a relatively high conversion rate to
open cholecystectomy, we conclude that patients with XGC should be
considered for LC after an adequate patient selection, a clear
visualization of anatomic structures and landmarks, and an
intraoperative frozen-section examination.
Xanthogranulomatous cholecystitis
mimicking stage IV gallbladder cancer.Hepatogastroenterology.
2003 Sep-Oct;50(53):1255-8.
Patients with
xanthogranulomatous cholecystitis often undergo excessive surgical
resections because of difficulty in distinguishing their condition
from gallbladder cancer. Herein we present a patient with
xanthogranulomatous cholecystitis mimicking stage IVA gallbladder
cancer who underwent a hepatopancreatoduodenectomy. The 64-year-old
man was admitted to the local hospital with a chief complaint of high
fever, hypochondrolgia and jaundice. One month later, he transferred
to Tsukuba University Hospital with a hard palpable fixed large tumor
in the right hypochondrium. Computed tomography and ultrasonography
showed a tumor originating from the gallbladder extending to the
adjacent liver parenchyma, as well as nodes in the hepatoduodenal
ligaments approaching the head of the pancreas. Endoscopic retrograde
cholangiopancreatography failed to exhibit the gallbladder despite the
visualization of irregular narrowing of the common hepatic duct.
Angiography demonstrated encasement of the right hepatic artery and
narrowing of the right portal vein. On the other hand, the level of
serum carbohydrate antigen 19-9 was within normal range. Based on
those findings, a right hepatic lobectomy with pancreaticoduodenectomy
was conducted under the preoperative and intraoperative diagnosis of
gallbladder cancer; stage IVA. The gross findings of the surgical
specimen showed an ill-defined yellowish hard mass, but microscopic
examination demonstrated xanthogranulomatous cholecystitis. The
presented case shows that xanthogranulomatous cholecystitis can mimic
an advanced gallbladder carcinoma when the severe chronic inflammatory
changes have extended to the liver hilum down to the head of the
pancreas. However, the normal level of tumor markers in all clinical
courses might be a reason to consider xanthogranulomatous
cholecystitis instead of gallbladder cancer. Even when the correct
diagnosis is made, the possibility that the adjacent organs should be
resected is not remote.
Xanthogranulomatous cholecystitis. Retrospective analysis of 12 cases.Acta
Chir Belg. 2003 Jun;103(3):297-9.
Xanthogranulomatous cholecystitis is a rare variant of chronic
cholecystitis characterized by severe proliferative fibrosis and
accumulation of lipid-laden macrophages in areas of destructive
inflammation. The macroscopic appearance generally mimics a
gallbladder carcinoma. Twelve cases of xanthogranulomatous
cholecystitis were identified from a retrospective analysis of the
patient records of 770 cholecystectomy cases operated on in our
department from January 1996 to October 2001. There were four men and
eight women. Mean age of presentation was 52.5 years. Eleven patients
had gallbladder stones. Seven patients had a history of acute
cholecystitis and five patients of biliary colicky pain. Five cases
were presented with obstructive jaundice and five with acute
cholecystitis. Right upper quadrant mass was palpable in three
patients. All patients underwent cholecystectomy. Open surgery was
planned and performed in three patients. Laparoscopic cholecystectomy
was planned in nine patients but converted to open surgery in three
cases. Nine patients had an uneventful postoperative course. One
patient developed wound infection and one patient a postoperative
pulmonary infection. One patient developed acute abdomen in the 2nd
postoperative day and was re-operated for bile peritonitis. No
mortality was seen in the series.
Genetic analysis of
xanthogranulomatous cholecystitis: precancerous lesion of gallbladder
cancer?Hepatogastroenterology.
2002 Jul-Aug;49(46):935-7.
Xanthogranulomatous Cholecystitis is a chronic inflammatory disease of
the gallbladder, a variant of the chronic cholecystitis. As
xanthogranulomatous cholecystitis is occasionally seen with carcinoma
of the gallbladder, the association with cancer is a controversial
issue. A focal type of xanthogranulomatous cholecystitis is found
simultaneously with gastric cancer diagnosed preoperatively. The
resected specimen was genetically studied. Polymerase chain reaction
amplification, single-strand conformational polymorphism analysis for
mutation of p53 showed no abnormality indicating that less association
with cancer in which the mutation of p53 is often seen. Etiopathologic
factors of xanthogranulomatous cholecystitis might have relation with
cancer, but xanthogranulomatous cholecystitis itself may not be the
direct cause for cancer.
Xanthogranulomatous cholecystitis mimicking gallbladder cancer: report
of a case.Kurume
Med J. 2001;48(4):321-4.
A 61-year-old
woman was admitted to our hospital with abnormal findings of abdominal
computed tomography. Whereas she had neither fever nor abdominal pain,
a cholecystitis was suspected. Ultrasonography showed a mass in the
gallbladder with several stones, and an unclear border between the
gallbladder and liver. Computed tomography showed a large-mass in the
gallbladder with findings that seemed to indicate hepatic invasion and
para-aortic lymph node metastasis. On the basis of these findings, we
made a diagnosis of gallbladder cancer associated with hepatic
invasion and lymph node metastasis. We treated this gallbladder tumor
by hepatic arterial infusion chemotherapy via catheter with cisplatin
and 5-fluorouracil. Four weeks after administration of the anti-cancer
drugs, the tumorous lesion of the gallbladder could not be detected by
abdominal imagings, and the gallbladder wall revealed no irregular
findings. During laparotomy, the gallbladder showed signs of chronic
cholecystitis, and a cholecystectomy was performed. Findings of the
resected specimens showed severe inflammation, fibrosis, and bleeding
in the gallbladder wall with infiltration by many foamy cells.
Histopathological diagnosis was xanthogranulomatous cholecystitis. We
report here a case of xanthogranulomatous cholecystitis mimicking
gallbladder cancer and review the literature.
Infectious
etiology of xanthogranulomatous cholecystitis: immunohistochemical
identification of bacterial antigens in the xanthogranulomatous
lesions.Pathol
Int. 1999;49(10):849-52.
The
clinicopathologic features of 31 surgical patients with
xanthogranulomatous cholecystitis were analysed in relation to the
immunohistochemical demonstration of bacterial antigens using a
polyclonal anti-E. coli antibody. The time period after the initial
clinical manifestation was critical for identifying the bacterial
antigens in the cytoplasm of foamy macrophages. Of 12 lesions removed
within 4 weeks of the onset (subacute group), 7 lesions showed
positive staining. No positivity was seen in 19 gall-bladder specimens
with a clinical course of more than 4 weeks (chronic group). Abscess
formation was seen in 7 cases in the subacute group, 5 of which were
positive for the bacterial antigens. Gram-negative bacteria were
cultured from the bile in four in the subacute group and three in the
chronic group. All the four culture-positive subacute lesions were
immunoreactive for the bacterial antigens. Accumulation of ceroid
pigment in the cytoplasm of foamy macrophages was characteristically
seen in 16 of 20 chronic lesions. Three subacute lesions with ceroid
pigmentation was negative for the bacterial antigens. In conclusion,
xanthogranulomatous cholecystitis can be divided into two forms:
subacute and chronic, and the subacute form is closely related to
bacterial infection.
Xanthogranulomatous cholecystitis.Dig
Dis Sci. 1998 May;43(5):940-2.
Xanthogranulomatous cholecystitis exists in a small but significant
proportion of routine cholecystectomy specimens. A few recent reports
have shown a possible association of this disease with carcinoma of
the gallbladder. All cholecystectomized specimens were prospectively
evaluated over a period of two and half years in a single surgical
unit to examine the incidence of xanthogranulomatous cholecystitis and
its association, if any, with carcinoma of the gallbladder in an area
that is prone to gallbladder diseases. A total of 460
cholecystectomies were performed for various gallbladder diseases.
Histological confirmation revealed chronic cholecystitis in 311
(67.6%) cases, carcinoma of the gallbladder in 62 (13.5%), acute
cholecystitis in 29 (6.3%), xanthogranulomatous cholecystitis in 41
(8.9%), and xanthogranuloma and carcinoma of the gallbladder in one
case (0.2%) only. Almost all cases were suspected to have chronic
cholecystitis on clinical and ultrasonographic features. Two specimens
on gross examination showed mass lesions, and hence were suspected to
be carcinoma of the gallbladder. Subsequent frozen section and
histopathology demonstrated xanthogranulomatous cholecystitis. Only
one case of xanthogranuloma was found to be associated with carcinoma
of the gallbladder but no firm association could be established
between xanthogranulomatous cholecystitis and carcinoma of the
gallbladder.
Xanthogranulomatous cholecystis.
Cell composition and a possible pathogenetic role of cell-mediated
immunity.Pathol
Res Pract. 1995 Nov;191(11):1078-86.
Thirty-three
cases of xanthogranulomatous cholecystitis (XGC) exhibiting the
typical morphologic features were studied by light and electron
microscopy and immunohistochemical techniques. Incidence of XGC was
4.2% of the surgically resected gallbladder diseases. Histologically,
the granulomatous lesion of XGC principally consisted of accumulations
of foam cells and lymphocytes. Variable numbers of multinucleated
giant cells, granulocytes and fibroblastic cells were also noted. With
respect to the origin of foam cells, it was considered that the vast
majority of foam cells were derived from monocytes/macrophages because
they were invariably positive for KP1, HAM56, CD11b and CD68.
Interspersed among macrophage foam cells, many T lymphocytes were
identified. The subtyping of T cells indicated a heterogenous
population composed of both CD4+ and CD8+ lymphocytes typically in a
ratio of 1:2. Macrophages and T lymphocytes demonstrated a marked
expression of HLA-DR antigen. Electron microscopic and
immunohistochemical double-staining observation demonstrated intimate
apposition of T lymphocytes to macrophages or macrophage foam cells.
The results indicate that XGC is a granulomatous disorder
characterized by accumulations of macrophage foam cells and T cells.
Delayed type hypersensitivity reaction of cell-mediated immunity may
be implicated in the pathogenesis of XGC.
Preoperative
diagnosis of xanthogranulomatous cholecystitis.J
Radiol. 1995 Jul;76(7):445-8.
Xanthogranulomatous cholecystitis (XGC) is a benign chronic
inflammation of the gallbladder, rarely described in the radiologic
literature. Like xanthogranulomatous pyelonephritis, it can clinically
and radiologically mimic carcinoma. This unusual entity is
characterized morphologically by a broad spectrum of
xanthogranulomatous changes seen from a small limited focus within
yellow nodule in the gallbladder wall, to diffuse involvement of the
entire gallbladder with extension of the fibrosis into surrounding
tissues. It is clear that recurrent inflammation and calculi are
important for the pathogenesis, which is not well understood. The
clinical presentation and radiologic findings of XGC are non specific.
Irregular thickening of the gallbladder wall and local extension of
the process can mimic carcinoma. Diagnosis of XGC is always
established by histological examination, characterized by the
infiltration of round cells, lipid laden histocytes and multinucleated
giant cells in the muscle layer. We report a case of 76-year-old woman
who had an episode of epigastric and right upper quadrant pain, 4
months before admission. Physical examination demonstrated a palpable
mass in gallbladder region. Echography and computed tomography showed
a large gallbladder, a thickened wall and an infiltration of the
adjacent liver. The relatively well defined gallbladder internal
border and the absence of biliary tract's dilatation allowed us to
suggest the diagnosis of XGC, which was confirmed intraoperatively by
frozen section histology. Once the diagnosis was established,
cholecystectomy was performed. Occasionally, the inflammatory reaction
is so severe that a subtotal cholecystectomy is required.
Postoperative recovery was, as usually, uneventful. Although a rare
entity, XGC should be considered in the differential diagnosis of
complex right upper quadrant masses, as well as neoplastic gallbladder
disease.
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