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Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma

  • 2023 SAGES Oral
  • Published:
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Abstract

Background

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which can resemble gallbladder adenocarcinoma (GAC) on preoperative imaging and present technical challenges in the performance of cholecystectomy. We examined our experience with each pathology to identify distinguishing characteristics that may guide patient counseling and surgical management.

Methods

A retrospective review of all pathologically confirmed cases of XGC and GAC following cholecystectomy between 2015 and 2021 at a single institution was performed. Clinical, biochemical, radiographic, and intraoperative features were compared.

Results

There were 37 cases of XGC and 20 cases of GAC. Patients with GAC were older (mean 70.3 years vs 58.0, p = 0.01) and exclusively female (100% vs 45.9%, p < 0.0001). There were no significant differences in accompanying symptoms between groups (nausea/vomiting, fevers, or jaundice). The mean maximum white blood cell count was elevated for XGC compared to GAC (16.4 vs 8.6 respectively, p = 0.044); however, there were no differences in the remainder of the biochemical profile, including bilirubin, liver transaminases, CEA, and CA 19–9. The presence of an intraluminal mass (61.1% vs 9.1%, p = 0.0001) and lymphadenopathy (18.8%. vs 0.0%, p = 0.045) were associated with malignancy, whereas gallbladder wall thickening as reported on imaging (87.9% vs 38.9%, p = 0.0008) and gallstones (76.5% vs. 50.0%, p = 0.053) were more often present with XGC. Cases of XGC more often had significant adhesions/inflammation (83.8% vs 55.0%, p = 0.03).

Conclusion

Clinical features that may favor benign chronic cholecystitis over gallbladder adenocarcinoma include younger age, male gender, current or prior leukocytosis, and the absence of an intraluminal mass or lymphadenopathy. Laparoscopic cholecystectomy is a safe surgical option for equivocal presentations. Intraoperative frozen section or intentional staging of more extensive procedures based upon final histopathology are valuable surgical strategies.

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Authors and Affiliations

  1. Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA

    Estella Y. Huang, James J. Reeves, Ryan C. Broderick, Joaquin L. Serra, Nicole H. Goldhaber, Bryan J. Sandler, Garth R. Jacobsen & Santiago Horgan

  2. Department of Radiology, University of California, San Diego, San Diego, CA, USA

    Julie Y. An & Kathryn J. Fowler

  3. Department of Pathology, University of California, San Diego, San Diego, CA, USA

    Mojgan Hosseini

  4. Division of Surgical Oncology, Department of Surgery, University of California, San Diego, San Diego, CA, USA

    Bryan M. Clary

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  1. Estella Y. Huang
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  2. James J. Reeves
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Correspondence to Estella Y. Huang.

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Disclosures

Dr. Horgan is a consultant for Stryker Corporation, Intuitive Surgical, Fortimedix Surgical, and Alume Biosciences. Dr. Jacobsen is a consultant for Gore Medical and Viacyte. Dr. Sandler is a consultant for Intuitive Surgical and Boston Scientific. Dr. Fowler receives grant support from Bayer, Pfizer, Median, FNIH, Siemens, and GE, provides institutional consulting for GE and Bayer, was an expert witness for Quantix Bio, and has the following non-financial roles: ACR GI panel chair, Radiology Editorial Board, SAR portfolio director, ACR LI-RADS leadership. Dr. Broderick is a consultant for Stryker Corporation. Drs. Clary, Huang, Reeves, Serra, Goldhaber, An, and Hosseini have no relevant disclosures.

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Huang, E.Y., Reeves, J.J., Broderick, R.C. et al. Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma. Surg Endosc 38, 348–355 (2024). https://doi.org/10.1007/s00464-023-10461-8

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