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INTRODUCTION Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis characterised by marked thickening of the gallbladder wall and dense local adhesions. Pre-operative and intra-operative diagnosis is difficult and it often mimics a gallbladder carcinoma (GBC). Laparoscopic cholecystectomy (LC) is frequently unsuccessful with a high conversion rate. A series of patients with this condition led us to review our experience with XGC and to try to develop a care pathway for its management. PATIENTS AND METHODS A retrospective review of the medical records of 1296 consecutive patients who had undergone cholecystectomy between January 2000 and April 2005 at our hospital was performed. Twenty-nine cases of XGC were identified among these cholecystectomies. The clinical, radiological and operative details of these patients have been analysed. RESULTS The incidence of XGC was 2.2% in our study. The mean age at presentation was 60.3 years with a female:male ratio of 1.4:1. Twenty-three patients (79%) required an emergency surgical admission at first presentation. In three patients, a GBC was suspected both radiologically and at operation (10.3%), but was later disproved on histology. Seventeen patients (59%) had obstructive jaundice at first presentation and required an endoscopic retrograde cholangiopancreatography (ERCP) before LC. Of these, five had common bile duct stones. Abdominal ultrasound scan showed marked thickening of the gallbladder wall in 16 cases (55%). LC was attempted in 24 patients, but required conversion to an open procedure in 11 patients (46% conversion rate). A total cholecystectomy was possible in 18 patients and a partial cholecystectomy was the choice in 11 (38%). The average operative time was 96 min. Three patients developed a postoperative bile leak, one of whom required ERCP and placement of a biliary stent. The average length of stay in the hospital was 6.3 days. CONCLUSIONS Severe xanthogranulomatous cholecystitis often mimics a gallbladder carcinoma. Currently, a correct pre-operative diagnosis is rarely made. With increased awareness and a high index of suspicion, radiological diagnosis is possible. Preoperative counselling of these patients should include possible intra-operative difficulties and the differential diagnosis of gallbladder cancer. Laparoscopic cholecystectomy is frequently unsuccessful and a partial cholecystectomy is often the procedure of choice.

A 67-year-old woman presented with a nodule lateral to a scar from previous right breast wide local excision (WLE). It had been increasing in size over 2 months, but had been present for a year. A wireguided WLE and axillary clearance had been performed 3 years prior for an 11-mm screen-detected ductal carcinoma in the upper outer quadrant. This had been grade 1, T1N0M0, estrogen receptor (ER), and progesterone receptor (PR) positive with no lymphatic or vascular invasion. The margins were clear. After postoperative radiotherapy to the breast, she was maintained on an aromatase inhibitor. Follow-up mammography had been performed twice, the latest 3 months earlier to the consult, with no evidence of recurrence.On examination, there was a purple-coloured umbilicated lesion at the lateral end of the breast scar, measuring 10 mm. Clinically, it was suspicious of a cutaneous deposit of metastatic cancer. Clinical fine-needle aspiration (FNA) was carried out, and was scored C4 with the comment: Cellular, moderate to large sheets of epithelial cells with mild nuclear pleomorphism. The degree of cohesion is striking. Highly suspicious.Ultrasound of the area (Fig. 1) revealed: a 10-mm hypoechoic mass extending inferiorly from the skin surface into the breast tissue at 9 o'clock laterally.It was consistent with features of a recurrent breast malignancy and scored U5. Ultrasound-guided core biopsies (2 9 14 g) were then obtained (see Fig. 2).The results showed: large sheets of rather bland looking carcinoma cells consistent with a grade 2 invasive ductal carcinoma recurrence. The tumor is ER and PR negative (both score 0). Diagnosis: Grade 2 invasive ductal carcinoma (B5b).Following Multi-Disciplinary Team, the patient was advised to undergo completion mastectomy subject to staging, on the basis that the tumor was a more aggressive ER negative recurrence or second primary. Staging Computerised Tomography abdomen/thorax and bone scan showed no evidence of tumor spread.At the full histologic analysis of the mastectomy, the lesion was thought to have arisen from a cutaneous adnexal structure (Fig. 3). After referral to dermatohistopathologists, it was felt to probably be a benign solid/cystic hidradenoma of cutaneous origin, particularly in view of the cytokeratin staining and a lack of estrogen receptor expression. DNA profiling was performed to exclude the possibility of mislabelling and confirmed that the core biopsy Figure 1. Ultrasound image of 10-mm cutaneous lesion occurring at lateral end of previous breast wide local excision scar. The thick white arrow points to the lesion, the thin white arrow to the skin surface. 670 • ives et al.

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