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BENIGN GALL BLADDER MASS (XANTHOGRANULOMATOUS CHOLECYSTITIS) MASQUERADING AS GALL BLADDER CANCER
84 year gentleman presented to LPC Mumbai with 2 months history of vague abdominal discomfort and no significant clinical findings. A USG of the abdomen done prior to visit to LPC Mumbai showed gall stones with an infiltrative mass lesion in GB fossa. His work up at LPC Mumbai showed normal CBC, BUN, Creatinine, Liver Function Tests, PT & INR, blood sugars & CA19-9 levels. Triple phase CT scan of abdomen & pelvis, & MRCP with contrast MRI suggested a gall bladder mass with gallstones, normal CBD & IHBR. Mass was slightly invading segment 4b &5 & possibly involving the hepatic flexure of the colon. Pancreas & duodenum was normal. The enhancement pattern of the mass after IV contrast was indicative of a malignancy with a small possibility of xanthogranulomatous cholecystitis (XGC). There was no evidence of biliary obstruction (dilated IHBR CHD or CBD).Right hepatic artery (RHA) & right anterior portal vein (RAPV) was slightly adhered to the mass. CT volumetry of liver showed left lobe volume approximately 35% of standard liver volume (SLV) & right lobe volume approximately 65% of SLV.
In view of a resectable nature of the lesion (? malignancy) in an otherwise fit patient, a biopsy and PET scan was not done. He was worked up further for fitness for surgery. His x-ray chest, ECG, 2 D Echocardiography & dobutamine Stress Echocardiogram& pulmonary function tests were normal. He was advised an extended radical cholecystectomy.
Surgical exploration revealed
A firm to hard mass involving the body and fundus of the GB with invasion in the segment 4 of liver. Hepatic flexture of transverse colon was firmly adhered and involved in the mass.
There was no ascites, liver or peritoneal metastasis.
An extended radical cholecystectomy (cholecystectomy with segment 4 b & 5 of liver resection & regional lymph node clearance) & colonic sleeve resection was done. Liver transection was done using CUSA, bipolar cautery, clips & harmonic scalpel. The transection was done under intermittent inflow clamping. To achieve negative margins, anterior sectoral pedicle had to be included in the specimen as tumor was densely adhered to the pedicle and right posterior portal vein was reconstructed. Colonic resection- reconstruction was done using staplers. Patient recovered well after the surgery without any complications and was discharged on 10th postoperative day. Final histopathological examination showed Xanthogranulomatous cholecystitis (XGC). There was no evidence of malignancy.
IMPORTANT POINTS TO REMEMBER ABOUT XGC
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis characterized by focal or diffuse destructive inflammatory process of the gallbladder (GB).
Even though (GBCA) uncommon and benign, it is important to remember because it is confused with gall bladder cancer or the two can coexist.
India has a large incidence of gall stone associated chronic cholecystitis & GBCA and it underlines importance of this benign pathology.
India has one of the largest reports of XGC in the world apart from far-east nations.
Etiology of XGC is not known.
Most important risk factor is its association with presence of gall-stones. Biliary obstruction and cholestasis also add to the risk. Extravasation of bile into the gallbladder wall probably starts inflammatory process, followed by a granulomatous reaction.
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