Malignant Gallbladder Research Articles

Nodal induces epithelial-mesenchymal transition in gallbladder carcinoma via the Smad2/4 pathway

Objective To study the expressions of Nodal in normal gallbladder, and gallbladders with cholelithiasis, cholecystitis and carcinoma; and to study the impact of inhibiting or promoting Nodal expressions in gallbladder carcinoma on the Smad2/4 pathway and epithelial-mesenchymal transition. Methods Immunohistochemistry was used to detect the expressions and distributions of Nodal protein in 30 normal gallbladders, 96 simple cholecystitis/calculous cholecystitis specimens and 42 gallbladder carcinoma specimens. The mRNA and protein expressions of Nodal in normal and malignant gallbladder mucosal epithelium cells and breast cancer cells were detected by RT-PCR, western blotting and wound healing tests. The impact of activating agents and inhibitors on the expression levels of Nodal and its signaling pathway Smad2/4 and EMT-related proteins were analyzed. Results Immunohistochemistry showed that the positive rates of Nodal in the gallbladder cancer group was significantly higher than that in the gallbladder stone group and the normal gallbladder group. The results were 83.3% (35/42), 44.8% (43/96), 6.7% (2/30) respectively (P<0.01). RT-PCR and Western blotting showed the expressions of Nodal in gallbladder carcinoma cells were higher than normal gallbladder cells (P<0.05). After using rhNodal to up regulate the Nodal expression, the Smad2 protein phosphorylation was promoted and the EMT associated proteins were up-regulated. After using the inhibitor SB431542 to suppress the Nodal expression, the Smad2 protein phosphorylation decreased and the EMT associated proteins were down-regulated. Conclusions The expression of Nodal was closely related to cell proliferation and metastasis in gallbladder carcinoma. Tumor progression was promoted via the smad2/4 pathway through epithelial-mesenchymal transition. Key words: Gallbladder carcinoma, Gallstone; Transforming growth factor-beta, Nodal; Smad2/4, signal conduction; Epithelial-mesenchymal transition

Surgical treatment of cholangiocarcinoma at a single institution over 2 decades

Introduction: Bile duct adenocarcinoma develops at various regions and surgical treatment of cholangiocarcinoma (CCA) includes pancreaticoduodenectomy (PD), liver resection (LR), extrahepatic bile duct resection (EHBDrxn), LR+EHBDrxn, and orthotopic liver transplantation (OLT). This study reviews the surgical treatment of CCA including surgical outcomes, recurrence, and overall survival at a single institution over a 22-year time period. Methods: 170 patients undergoing surgical resection of CCA from 1995 to 2016 were reviewed. Patients with gallbladder or mixed hepatocellular variant malignancies were excluded. 90-day complications, recurrence, and survival were compared between types of CCA and surgical interventions for CCA. Results: Extrahepatic, hilar, and intrahepatic CCA was noted in 31 (18.2%), 75 (44.1%), and 64 (37.6%) respectively. The mean age and BMI was 61.7 years and 27.2 respectively and were predominately male (121, 71.2%). Surgical treatment included PD, LR, EHBDrxn, LR+EHBDrxn and OLT in 31 (18.2%), 40 (23.5%), 6 (3.5%), 37(21.8%) and 56 (32.9%) respectively. Mean operative time and blood transfusions given was 334 minutes and 4 units respectively. Average length of stay was 11.5 days and overall major complications occurred in 59 (34.7%) including reoperation in 13 (7.6%) and mortality in 6 (3.5%). Mean tumor size was 4.2 cm and 39 (22.9%) patients had node positive disease. Recurrence was noted in 74 (43.5%) at a mean of 23 months. Overall survival was found in 61 (35.9%) at a mean of 39.7 months. Conclusion: Surgical treatment of CCA is optimal. OLT for hilar and incidental intrahepatic CCA results in the best survival.

Is the routine histopathological analysis of all gallbladders justified?

66,000 cholecystectomies are performed annually in the UK. Nationwide, all gallbladders are routinely sent for histological analysis to exclude incidental malignancy. This comes at significant cost to an overstretched National Health Service. This study set out to assess the utility of routine histopathological analysis following cholecystectomy. We performed a large, single-centre, retrospective analysis of all gallbladder specimens examined between February 2013 and December 2016 at our district general hospital. Specimens obtained in elective and emergency cases, through laparoscopic or open surgery, were included. A total of 752 gallbladder specimens were analysed. The mean age at the time of resection was 51 years, and the female:male ratio was 2.8:1. Seven (0.93%) specimens were reported to show suspicious histopathological features; epithelial atypia (1), low-grade epithelial dysplasia (2), high-grade epithelial dysplasia (1), papillary adenoma (1), MALT lymphoma (1) and invasive adenocarcinoma (1). In all seven cases, there was no clinical suspicion of gallbladder malignancy prior to surgery or suspicious pre-operative ultrasound scan findings. Gross macroscopic changes were noted at the time of resection in three cases. Four patients required further investigation and subsequent follow-up. All specimens deemed to be suspicious derived from patients over 50 years of age at the time of resection. Pre-operative investigations and macroscopic appearance at cholecystectomy may be inadequate in identifying patients with clinically important pathology. Routine histological analysis allows early identification. However, further work will assess whether more selective requests may help achieve the balance between cost-saving and safety in the context of a resource-limited healthcare service.

Rare case of a gallbladder neuroendocrine carcinoma

There are no neuroectodermal cells in the gallbladder mucosa. Therefore, gallbladder neuroendocrine carcinoma (NEC) is extremely rare and has a poor prognosis. We report a case of a Japanese man in his 60s with this disease. The patient visited a family doctor for epigastralgia. Blood tests showed no abnormalities, including tumor markers, such as CEA and CA19-9. Abdominal ultrasonography (US) showed a low-echoic mass, 39 × 30mm, with clear boundaries to the liver from the fundus of the gallbladder. Contrast-enhanced computed tomography showed that the tumor was enhanced early and washed out. Diffusion-weighted MRI showed a high signal. We suspected liver invasion of gallbladder cancer and performed a cholecystectomy, S4 and S5 hepatectomy, and lymphadenectomy. The resected whitish tumor was 29 × 22mm. The tumor cells had honeycomb growth to the liver from the gallbladder. Tumor cells were poorly differentiated, and there was no stricture of the gland duct. Immunostaining showed that the tumor cells were positive for CD56, chromogranin A and synaptophysin, and about 30% were positive for Ki-67. Our diagnosis was gallbladder NEC with liver invasion. Although most malignant gallbladder tumors are adenocarcinomas, this case indicates that gallbladder NEC should be considered as a differential diagnosis of gallbladder tumor.

A comprehensive review on Primary gall bladder tuberculosis

Tuberculosis (TB) is a infectious disease that can involve any organ system of the body. Abdominal TB can be gastrointestinal, lymphnodal, visceral or perironeal. Gall bladder(GB) is rarely involved as a primary organ in abdominal TB. On extensive research the literature on gall bladder TB is limited to case reports. There has been no review on this rare abdominal pathology. The GB tuberculosis is a difficult diagnosis preoperatively. It is a rare differential among the more common gall bladder pathologies like cholelithiasis, or a gall bladder malignancy. Typical histopathology of the resected specimen helps establish this rare diagnosis. Subjecting every specimen to histopathological examination followed by medical treatment offers the chance of cure. Through this review the authors are trying to provide an insight into this entity.

A comprehensive review on Primary gallbladder tuberculosis.

Tuberculosis (TB) is an infectious disease that can affect any organ system of the body. Abdominal TB can be gastrointestinal, lymph nodal, visceral or peritoneal. The gallbladder (GB) is rarely involved in abdominal TB as a primary organ. Extensive research literature on gallbladder TB is limited to case reports. There has been no review on this rare abdominal pathology. GB tuberculosis is a difficult diagnosis preoperatively. It is a rare differential among the more common gallbladder pathologies such as cholelithiasis, or a gallbladder malignancy. Typical histopathology of the resected specimen helps to establish this rare diagnosis. Subjecting every specimen to histopathological examination followed by medical treatment offers the chance of cure. Through this review, the authors attempt to provide an insight into this disease entity.

Diagnostic performance of diffusion-weighted imaging for differentiating benign and malignant gallbladder lesions: A systematic review and meta-analysis.

Although diffusion-weighted imaging (DWI) has been characterized as an alternative imaging modality for gallbladder (GB) lesions, it has not been routinely used in clinical practice because of relatively low signal-to-noise ratio. To assess the sensitivity and specificity of the diagnostic performance of DWI for differentiating benign and malignant GB lesions. Meta-analysis. Patients with GB lesions. DWI at 3.0T or 1.5T. PubMed and EMBASE were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy guidelines. Bivariate modeling and hierarchical summary receiver operating characteristic (HSROC) modeling were performed to compare the overall diagnostic performance of DWI. Subgroup analyses were performed for qualitative and quantitative assessment of the DWI. Meta-regression analyses were performed according to the characteristics of the patients, study, and MRI. Eight studies (including 557 patients) were included. The DWI exhibited a pooled sensitivity of 91%, a pooled specificity of 87%, and HSROC of 0.95. In subgroup analyses, qualitative assessment (sensitivity, 90%; specificity, 87%; HSROC, 0.94) was more accurate than quantitative assessment (sensitivity, 82%; specificity, 86 %; HSROC, 0.88). On meta-regression analysis, studies that used 3.0T field strength and thinner slices (≤5 mm) reported a significantly higher sensitivity (P ≤ 0.02) than those using only 1.5T field strength and thicker slices (>5 mm). DWI can discriminate malignant from benign GB lesions with excellent diagnostic performance in both qualitative and quantitative assessments. To enhance the diagnostic ability of DWI, images obtained with thinner slices (≤5 mm) with 3T field strength and qualitative assessment are recommended. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1375-1388.

CT diagnosis of gallbladder adenomyomatosis: importance of enhancing mucosal epithelium, the "cotton ball sign".

To determine the diagnostic value of the cotton ball sign and other CT features in patients with gallbladder (GB) wall thickenings (WTs). Three blinded readers reviewed the preoperative CT and MR images of 101 patients with pathologically confirmed GB adenomyomatosis (GA) (n = 34) and other benign (n = 29), malignant (n = 41), and premalignant (n = 2) GBWTs. Three readers analysed the morphological features of GBWT and presence of the "cotton ball sign", defined as fuzzy grey dots in GBWT or a dotted outer border of the inner enhancing layer on contrast-enhanced (CE) CT. In addition, the "pearl necklace sign" on MR was analysed. In the GA group (n = 34), prevalence of the cotton ball sign and pearl necklace sign was 74% (25/34) and 44% (15/34), respectively. Presence of the cotton ball sign, smooth contour of the mucosa, double-layering enhancement, and enhancement degree weaker than the renal cortex on CT images were significant predictors of benign GBWT (p < 0.01). When differentiating GA from GB malignancy or premalignancy, accuracy of the cotton ball sign and pearl necklace sign was 81% (62/77) and 74% (57/77), respectively. The cotton ball sign on CE-CT showed higher sensitivity and comparable specificity to those of the pearl necklace sign in differentiating GA from malignancy. • Prevalence of the cotton ball sign on CT was 74% in gallbladder adenomyomatosis. • The cotton ball sign was useful in differentiating gallbladder adenomyomatosis from gallbladder cancer. • The cotton ball sign was more sensitive than the pearl necklace sign for adenomyomatosis diagnosis.

Role of Multidetector Computed Tomography (MDCT) in Evaluation of Gallbladder Malignancy and its Pathological Correlation in an Indian Rural Center

Clinically or sonographically suspected gallbladder carcinoma was evaluated on multidetector computed tomography. Based on the spectrum of multidetector computed tomography findings, staging of gallbladder carcinoma was done. Multidetector computed tomography diagnosis was compared with pathological diagnosis. This is a prospective study carried out in 100 patients at a rural Indian center between May 2012 and June 2015. Multidetector computed tomography was performed in all the cases and the findings were observed. Based on the radiological spectrum, staging of gallbladder carcinoma was done. The diagnosis was confirmed by ultrasound guided fine needle aspiration cytology/histopathological examination of surgical specimens. The most common multidetector computed tomography findings noted by us were mass replacing gallbladder, followed by diffuse/focal gallbladder wall thickening and polypoidal mass. Other findings noted were cholelithiasis, liver infiltration, intra hepatic biliary dilatation, liver metastases, portal vein invasion, antroduodenal and hepatic flexure involvement. Ultrasonography guided fine needle aspiration cytology done in all cases was positive in 92 cases and inconclusive in eight cases. Surgery was performed in only 22 patients, and histopathological findings were correlated with multidetector computed tomography findings. Multidetector computed tomography is also reliable in detection of extension of tumor and lymph nodes. multidetector computed tomography plays a major role in evaluating and staging of carcinoma gallbladder. It also guides the surgeons for operatibility and resectability of tumour.

Porcelain Gallbladder: Is Observation a Safe Option in Select Populations?

Management of gallbladder wall calcifications has been controversial for many decades. Although the traditionally perceived strong association with gallbladder cancer mandated prophylactic cholecystectomy, newer evidence suggests a much lesser association and might indicate an observational approach. A retrospective cohort study of 113 patients with gallbladder wall calcifications diagnosed between 2004 and 2016 at a single institution was conducted. Radiographic re-review identified patients with definitive (n= 70) and highly probable (n= 43) gallbladder wall calcifications. Patients were categorized according to their designated treatment plan. In the observation group (n= 90), delayed cholecystectomy for gallbladder-related symptoms was necessary in 4 patients (4%). None of the patients in this group were diagnosed with a gallbladder malignancy during a mean of 3.2 ± 3.2 years follow-up. In the operative group (n= 23), peri-operative complications occurred in 13%, and gallbladder malignancy was found in 2 patients. In comparison, although patients in the observation group were older and had more comorbidities, the rate of adverse events was not significantly different (4% vs 13%; p= 0.15) with an overall low risk for potentially life-threatening complications to the patient when observed clinically. For management of gallbladder wall calcifications, observation appears to provide no significant difference in adverse events, including the risk of gallbladder malignancy developing, compared with an operative approach. Although there is a need for intervention in the presence of symptoms and findings suggestive of malignancy, prophylactic cholecystectomy should be avoided in patients with limited life expectancy and significant comorbidities.

Multimodality management of incidentally detected gall bladder cancer: long term results from a tertiary care cancer centre.

Gall bladder cancer (GBC) is the most common biliary tract malignancy in India. GBC present either with incidental diagnosis after simple cholecystectomy (SC) or with a primary gall bladder mass. Incidentally detected gall bladder cancer (ICGB) has traditionally been thought to be a relatively early stage disease but there are controversies associated with various aspects of its management. In this article we describe our experience with multimodality management of ICGB. A retrospective analysis of incidentally detected GBC patients was performed to analyze the profile of presentation and treatment outcome. After initial radiological evaluation for operability, all the patients underwent surgical exploration. If found resectable, revision surgery including 2 cm wedge resection of liver and lymphadenectomy was done followed by concurrent chemo-radiation for tumors T2 and above stages. A total of 54 patients with incidentally detected GBC with a male to female ratio of 1:3 and mean age of 47.5 years were included in the study. Thirty-four (63%) patients underwent curative resection followed by adjuvant chemoradiotherapy. The remaining 20 patients had metastatic/unresectable disease. The 5 years disease free and overall survival (OS) for patients receiving curative treatment was 64% and 72% respectively. On univariate analysis, presence of residual disease in the gallbladder fossa and liver were significant risk factors for disease recurrence. Depth of invasion, adjuvant treatment received and stage were significant prognostic factors for OS. Incidentally detected GBC is increasing in incidence. A multi-modality approach with revision surgery and adjuvant chemo-radiation treatment may yield better outcome. Presence of residual disease is a poor prognostic factor. Optimal evaluation before SC and early referral to specialty center is therefore important in patients with suspicion of gallbladder malignancy because first chance is probably the best chance.

Neoplastic Meningitis: A Study from a Tertiary Care Hospital from Coastal India.

Introduction:Neoplastic involvement of cerebrospinal fluid (CSF) secondary to known or unknown primaries elsewhere is a poor prognostic factor and is equivalent to stage IV disease.Aim:The aim of the study is to analyse the cytological features of neoplastic meningitis in a tertiary care center.Materials and Methods:A retrospective study of 400 consecutive CSF samples was done in the cytology laboratory of our hospital. The fluid obtained by spinal tap was sent for microbiological, biochemical and cytological evaluation. Smears that showed the presence of malignant cells were included in this study.Results:Out of 400 cases, 36 (9%) showed neoplastic meningitis. Of which, 13 cases (36%) revealed leukemic infiltration, 2 (6%) lymphomatous infiltration and 21 (58%) carcinomatous meningitis. The leukemia cases included seven cases of acute lymphoblastic leukemia and six cases of acute myeloid leukemia. Among the carcinomatous meningitis cases, eight were metastasis from carcinoma breast, six from lung carcinoma and one each from malignancies of gallbladder, stomach and retinoblastoma. Four cases were metastatic adenocarcinoma from unknown primary. Pleocytosis was a significant finding seen in 58% cases (n = 21). Elevated protein and hypoglychorrhachia was noted in 68% cases (n = 18).Conclusion:A combined diagnostic approach including biochemical, microbiological and pathological evaluation was useful in eliminating infectious meningitis and confirming neoplastic meningitis in these cases. Cytology should be performed on cerebrospinal specimens from all patients with known or suspected malignancy with meningismus. Detection of malignant cells on cytological examination of CSF is the diagnostic gold standard for neoplastic meningitis.

Multimodality Imaging, including Dual-Energy CT, in the Evaluation of Gallbladder Disease.

Imaging of the gallbladder has a key role in the examination of patients with abdominal pain-especially pain localized to the right upper quadrant. Pathologic conditions that affect the gallbladder include cholelithiasis and associated complications such as acute and chronic cholecystitis, choledocholithiasis, gallstone pancreatitis, and cancer. Modalities used to image the gallbladder include ultrasonography (US), computed tomography (CT), magnetic resonance (MR) imaging, and nuclear scintigraphy. US is the primary imaging modality used to evaluate entities suspected of being gallbladder disease, as it is both sensitive and specific for demonstrating gallstones, biliary duct dilatation, and inflammatory features. However, CT is often the first imaging examination performed in patients who present to the emergency department with acute abdominal pain. Because the CT appearance of gallstones is variable, depending on the composition of the stone, pattern of calcification, and presence of gas, gallstones and other gallbladder conditions can be difficult to detect at conventional multidetector CT, with which data are acquired by using a single x-ray energy spectrum. Dual-energy CT, with which one takes advantage of the material-dependent x-ray absorption behavior of concurrently acquired high- and low-kilovolt-peak data, can add value by increasing the conspicuity of noncalcified gallstones and improving the detection of acute cholecystitis and gallbladder malignancy. In addition, MR cholangiopancreatography can be helpful for assessing choledocholithiasis and complicated biliary duct disease. ©RSNA, 2018.

A Rare case of synchronous primary malignancies of gall bladder and ovary

A Rare case of synchronous primary malignancies of gall bladder and ovary

An In silico method to study structure, function, and regulatory role alteration mediated by single-nucleotide polymorphisms in gallbladder cancer

Introduction: Gallbladder cancer (GBC) is a fatal malignancy of gallbladder and bile ductswhich shows delayed symptoms and sometimes can be asymptomatic, being fatal. Reported globally, for a very low survival rate, it suffers from the lack of early diagnostic and prognostic markers. Single nucleotide polymorphisms (SNPs) have been reported to be associated in different cancers. Methods: In this study using in silico methods, we report for the first time a combination of SNPs from the coding and noncoding region leading to alteration in GBC. Different pipelines were designed for the study of SNPs. Regulatory role alteration of Synonymous and non-coding SNPs were studied using RegulomeDB, DeepSEA analysis and funcPred. Structural alteration and energy parameters for non-synonymous SNPs were studied by Swiss-PDB, Chimera and Gromacs. Protein stability analysis was done using MutPred, mCSM and I-mutant. Results: As a result, three potential variants from the coding region rs1042838, rs11887534, and rs700519 associated with progesterone receptor, ATP binding cassette subfamily G member 8 (ABCG8), and cytochrome P450 19A1, respectively, were predicted to be potentially damaging SNPs in GBC leading to structure and function alteration. Three noncoding SNPs (rs2978974, rs4633 and rs2830) and 1 missense SNP(rs523349) were shown to be associated with damaging effect in GBC, and one of these SNPs (rs2978974) showed significant chromatin feature alteration. Conclusion: Our study strongly shows that SNPs both in the coding and noncoding region may be exploited as a combination of potential biomarkers in early diagnosis of GBC due to structure function alteration by nonsynonymous SNPs and regulatory role alteration by noncoding SNPs.

Carcinosarcoma Gallbladder: A Rare Variety of Gallbladder Malignancy

Carcinosarcoma Gallbladder: A Rare Variety of Gallbladder Malignancy

Indication and Usefulness of Bile Juice Cytology for Diagnosis of Gallbladder Cancer.

Aim We examined the effectiveness of bile juice cytology for distinguishing between benign and malignant gallbladder lesions of the protruding type with various sampling points, sampling methods, and macroscopic forms in order to discuss the effectiveness of the endoscopic transpapillary gallbladder drainage (ETGD) cytology. Methods We studied 162 cases of patients with a lesion localized within the gallbladder. At first, we examined the effectiveness for diagnosis of ETBD cytology using ERC and then that of the first ETGD cytology after placing the ETGD. Next, we examined the diagnostic effectiveness of the washed ETGD cytology by using the ETGD. Finally, we examined complications. Results In the final diagnoses, we identified 33 cases of adenocarcinoma, 10 cases of adenoma, 63 cases of ADM, 35 cases of nonneoplastic polyp, and 21 cases of chronic cholecystitis. It was found that the sensitivity of ETBD cytology was 3.6% and that of ETGD cytology was 59.1%. In the comparison of diagnostic effectiveness of cytologic diagnosis using samples of bile juice from the gallbladder collected by different methods, the sensitivities were 38.9% and 73.3% for the first and washed ETGD cytologies, respectively. In the comparison of the diagnostic effectiveness of gallbladder bile juice cytology using samples collected for different forms of lesion and by different methods, the sensitivities were 38.9% and 73.3%, respectively, for the first and washed ETGD cytologies for flat gallbladder wall thickening, while it was impossible to diagnose for lesions of GB polyp. Conclusion For diagnosis of gallbladder cancer, we consider that the ETGD cytology should be taken into consideration for lesions of flat gallbladder wall thickening, for which it is difficult to distinguish between benign and malignant lesions.

Thick Walled Gall bladder and Gall Bladder Malignancy: Management Options for Surgeons

Thick Walled Gall bladder and Gall Bladder Malignancy: Management Options for Surgeons

Diagnostic Accuracy of USG-Guided FNAC in Gall Bladder Mass

Introduction: Malignancy of gall bladder is quite common. However, it cannot always be diagnosed only by clinical history and examination. We have evaluated diagnostic accuracy of USG-guided FNAC in GB mass. Material and Methods: 37 cases were included in this study. USG-guided FNAC was done. Result: USG-guided FNAC gave 93.5% sensitivity, 100% specificity and 93.5% diagnostic accuracy. Conclusion: USG-guided FNAC is a good adjuvant to clinical and radiological findings in diagnosing carcinoma of gall bladder.

Xanthogranulomatous Cholecystitis: The Needle in the Haystack

Introduction: The rise of laparoscopic cholecystectomy (LC) as the gold standard for management of gallstone disease has exponentially increased the number of sacrificed gallbladders. In this gargantuan pool of specimens, several rare variants of inflammation, infection, premalignant and malignant transformation have become manifest. One of these is the xanthogranulomatous variety of cholecystitis (XGC), an aggressive inflammatory condition known for throwing the surgeon off course from a simple LC to aggressive liver resection by virtue of its malignant mimicry. Methods: We retrospectively analysed 1000 consecutive LCs performed in a tertiary care hospital from January 2010 to December 2016. In the cohort found to have XGC on histopathology, we analysed the gender predilection, age preponderance, associated comorbidities, clinical presentation, radiological features, intraoperative findings, complications and postoperative course. We then compared this with the rest of the source population. Results: Of the 1000 patients that constituted the study population, 35 patients were found to have XGC. We found a male predilection of 5:4, with age ranging from 32 to 76 years, in opposition to the study population that varied from 2 to 85 years. The cohort had a 20% incidence of diabetes mellitus, comparable to the source population. No difference was found in either duration or severity of symptoms in the two groups. Preoperative radiological diagnosis of XGC was not done in any of the cases. Intraoperatively, 14.3% of the patients were found to have Mirizzi's syndrome, which formed the majority of the Mirizzi's in the source population. Empyema of the gall bladder was found in 5 of the patients, with incidence similar to the source population. Operative time in the XGC cohort was significantly higher (80±23 vs 43±7 minutes) which also formed a sizable fraction of the subtotal excisions performed (26.7%). While the incidence of complications was similar in both groups, postoperative stay was significantly longer in the XGC cohort (2.7±1.3 days vs 1.1±0.3 days). Only 3 cases of gall bladder malignancy were found in the entire study population, none of whom exhibited features of XGC. Conclusion: XGC continues to be the bane of the surgeon, confounding findings and causing even seasoned professionals to second guess their clinical decisions. Albeit rare, a working knowledge of the condition is of paramount importance in order to provide the patient the best and most appropriate care.