Xanthogranulomatous Cholecystitis Mimicking Cholangiocarcinoma

Abstract

Introduction: Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. It is a benign but locally invasive process that involves the adjacent organs and mimics malignancy often leading to a more radical surgery than needed to treat the condition. Case Report: A 42-year-old otherwise healthy male presented with progressive jaundice and 30-lb weight loss over 1 month. He had no prior history of liver disease, no significant alcohol use, no new medications or supplements. Physical exam was unremarkable except for scleral icterus. Laboratory tests were significant for elevation of aspartate aminotransferase (118 u/L), alanine aminotransferase (265 U/L), alkaline phosphatase (282 U/L), total bilirubin (6.1 U/L), and conjugated bilirubin (4.3 U/L). Abdominal ultrasound showed a 2.7-cm fixed stone in the gallbladder neck and dilation of the common bile duct (CBD) to 1.3 cm with intrahepatic biliary ductal dilatation. An ERCP was performed and revealed a severe stricture at the junction of CBD and common hepatic duct (CHD) with non-visualization of the cystic duct. The biliary stricture was balloon dilated and a plastic biliary stent was placed across the stricture. Mirizzi’s syndrome was suspected and an MRCP was performed, which revealed an enhancing, infiltrative mass-like process near the neck of the gallbladder, proximal CBD, and duodenum. It caused effacement of the CHD, cystic duct, and proximal CBD with intrahepatic duct dilatation. An endoscopic ultrasound was performed revealing a hypoechoic mass around the neck of the gallbladder and proximal common bile duct. The mass involved the muscularis propria layer of the duodenal wall. There was also 1.1-cm enlarged reactive-appearing periportal lymph node. Enodscopic ultrasound-guided final needle aspiration (EUS-FNA) of the mass and lymph node were performed. Bile duct brushings were obtained. FNA from the mass returned chronic inflammation with histiocytes. FNA from the lymph node revealed benign lymphoid tissue. Bile duct brushing showed atypical cells favor reactive and FISH was negative for polysomy. Due to the atypical appearance of the mass, possibility of malignancy and presence of symptoms an exploratory laparotomy was performed. The gallbladder and perihilar nodes were resected and submitted to frozen section that revealed inflammation without cancer. Final pathological examination returned xanthogranulomatous tumor-like inflammation and fibrosis without malignancy. Conclusion: Differentiating XGC from cholangiocarcinoma is a challenge especially when the inflammation involves the CBD and causes obstructive jaundice. However, keeping this differential in mind can help surgical planning and the use of frozen section pathology can limit radical surgery.