The Radiologic Features of Xanthogranulomatous Cholecystitis: An Important Mimic of Gallbladder Carcinoma Poster No.: C-0691 Congress: ECR 2014 Type: Authors: Keywords: DOI: Educational Exhibit H. L. khosa 1, W. Torregiani 2 ; 1 galway/ie, 2 Dublin/IE Biliary Tract / Gallbladder, Abdomen, Gastrointestinal tract, CT, MR, Education, Acute, Inflammation, Neoplasia 10.1594/ecr2014/C-0691 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 13
Learning objectives To discuss imaging features of xanthogranulomatous cholecystitis and gall bladder CA. To understand the overlapping clinical and imaging features. To evaluate the efficacy of different imaging modalities in diagnosis. Background Xanthogranulomatous cholecystitis (XGC) is a rare variant of chronic cholecystitis characterized by a focal or diffuse destructive inflammatory process resulting in accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic inflammatory cells in the gallbladder wall. It is an active inflammatory process that can lead to significant morbidity. Radiologically it's an important mimic of gallbladder carcinoma. Gallstones are present in all patients, and like most symptomatic gallbladder diseases, there is a female predominance. The pathogenesis is thought to be due to extravasation of bile into the GB wall, inciting an inflammatory reaction, analogous to xanthogranulomatous pyelonephritis microscopically which is also a mimicker of Renal cell carcinoma. In this poster we demonstrate two cases of xanthogranulomatous cholecystitis from our practise comparing it with a case of gallbladder carcinoma; all the cases were diagnosed on post operative histology. Images for this section: Page 2 of 13
Fig. 1: Longitudinal US image through a gall bladder with normal mural thickness using 5MHz transducer via subcostal approach. Fig. 2: Axial contrast enhanced CT through gall bladder demonstrating normal mural thickness. Page 3 of 13
Fig. 3: Axial contrast enhanced CT demonstrating mural thickening with surrounding fat stranding(arrowheads). Large gall stone is also shown(arrow) Page 4 of 13
Findings and procedure details Patients with clinical features suggestive of cholecystitis were imaged with US and subsequently with CT and MRI as clinically indicated for suspected gall bladder malignancy. Imaging features were not unequivocal and patients subsequently underwent surgery. Post operative histology demonstrated xanthogranulomatous cholecystitis in two cases and primary gall bladder cancer in the third. Imaging features were overlapping. Case 1: A 61 year lady presented with chronic history of epigastric discomfort. US (Fig 4) and CT (Fig 5) showed eccentric mural thickening with progressive enhancement on dynamic MRI (Fig 6, 7) Post operative histology was: Fibrotic thickening and proliferation of foamy histiocytes along with chronic inflammation, cholesterol clefts and giant cells. Focal acute inflammation was also present in keeping with xanthogranulomatous cholecystitis. Case 2: A 75 year female presented with a history of chronic upper abdominal discomfort and postprandial bloating. An external ultrasound had shown gallbladder wall thickening, and further cross sectional imaging was performed at our institute. CT (Fig 8) demonstrated eccentric mural thickening with obliteration of fat plane with liver. MRI (Fig 9, 10) showed persistent mural enhancement on delayed images. An open cholecystectomy and frozen section of liver was performed. Post operative histology demonstrated transmural acute and chronic inflammation in gall bladder with foamy histiocytes, fibrosis and lymphoid follicle formation, consistent with xanthogranulomatous cholecystitis. No malignancy was found. Sections through the liver showed steatosis only. Case 3: A 73 year female with multiple medical comorbidities underwent cross sectional imaging to investigate a 6 month history of upper abdominal pain and anaemia. Cross sectional imaging (Fig 11-13) revealed focal eccentric wall thickening with resulting stricture of gall bladder. It showed delayed persistent post contrast enhancement. Histological findings were of invasive moderately differentiated gallbladder adenocarcinoma, without serosal involvement. Page 5 of 13
Images for this section: Fig. 4: US through short axis of gall bladder demonstrating mural thickening with increased vascularity on colour doppler. Fig. 5: Axial CT through abdomen demonstrating eccentric crescent of enhancing gall bladder wall thickening. Page 6 of 13
Fig. 6: Axial pre contrast T1-weighted MRI demonstrates hypointense gallbladder wall thickening. Fig. 7: Axial post-gadolinium T1-Fat Sat MRI in the late arterial phase (left) demonstrates progressive intense enhancement of the thickened gallbladder wall which persisted on the late portal venous phase (right). Page 7 of 13
Fig. 8: Axial post contrast CT demonstrating focal eccentric mural gall bladder thickening. Page 8 of 13
Fig. 9: Axial (top) and Coronal (bottom) True FISP MRI demonstrates a focal segment of gall bladder wall thickening obliterating the fat plane between the liver and gall bladder, which raised concern for malignancy. Cholelithiasis is also noted. Page 9 of 13
Fig. 10: Axial post-gadolinium MRI, whilst significantly degraded by respiratory motion artefact, shows eccentric avid gallbladder mural enhancement, which persisted on later phases. Page 10 of 13
Fig. 11: Coronal(above) and Axial(bottom) CT with IV and oral contrast demonstrates nodular segmental gallbladder wall thickening at the fundus, with resultant stricture formation. Page 11 of 13
Fig. 12: Axial T2 true FISP MRI reaffirms nodular segmental gall bladder mural thickening and stricturing, on a background of cholelithiasis. Fig. 13: Axial post-gadolinium T1-weighted fat sat MRI, degraded by motion artefact, demonstrates intense enhancement of the nodular soft tissue thickening. Page 12 of 13
Conclusion Xanthogranulomatous cholecystitis is a destructive inflammation of the gallbladder, which mimics malignancy radiologically. Our two cases of xanthogranulomatous cholecystitis and one case of primary gall bladder carcinoma demonstrated entirely similar imaging features across modalities; the two entities cannot be reliably differentiated. This is an important pitfall of imaging in differentiating benign and malignant process. Xanthogranulomatous cholecystitis is an important differential diagnosis to consider when segmental eccentric GB wall thickening and enhancement is identified on cross sectional imaging; cholecystectomy is indicated in all cases and tissue diagnosis is crucial in establishing final diagnosis. Personal information References 1. Shuto R, Kiyosue H, Komatsu E, Matsumoto S, Kawano K, Kondo Y, Yokoyama S, Mori H. CT and MR imaging findings of xanthogranulomatous cholecystitis: correlation with pathologic findings. Eur Radiol. 2004 Mar;14(3):440-6. 2. Parra JA, Acinas O, Bueno J, Güezmes A, Fernández MA, Fariñas MC. Xanthogranulomatous Cholecystitis: Clinical, Sonographic and CT findings in 26 patients. American Journal of Roentgenology. 2000;174: 979-983. 3. Uchiyama K, Ozawa S, Ueno M, Hayami S, Hirono S, Ina S et al. Xanthogranulomatous cholecystitis: the use of preoperative CT findings to differentiate it from gallbladder carcinoma. J Hepatobiliary Pancreatic Surg. 2009;16(3):333-8. doi: 10.1007/s00534-009-0067-9. Epub 2009 Mar 12. Page 13 of 13