Abdominal inflammatory myofibroblastic tumours in children

Treatment and outcomes in pediatric inflammatory myofibroblastic tumors - A systematic review of published studies

Inflammatory myofibroblastic tumor (IMT) is a soft tissue neoplasm which can be locally invasive, recur, or in rare cases metastasize. Often originating from the abdomen or thorax, IMT most commonly affects children and young adults. Due to its rarity comprehensive reports detailing clinical management and outcome(s) are sparse and often based on limited index case numbers. This study systematically analyzes outcome metrics of pediatric IMT and identifies risk factors for mortality. Medline/Embase databases were searched in accordance with PRISMA guidelines. Final analysis included 57 studies with 673 IMT patients (355 males, 53 %). Individual patient data was available for 405 cases with a median follow-up period of 36 months. Tumor sites included abdomen/pelvis (n = 233, 58 %), thorax (n = 125, 31 %), head/neck (n = 34, 8 %), and extremities (n = 13, 3 %). Surgical tumor resection was the mainstay of treatment, while only 20 patients (5 %) were treated non-operatively. Recurrence(s) were reported in 80 patients (20 %) with 34 (12 %) requiring reoperation. Positive tumor margins were a significant risk factor for tumor recurrence (p < 0.0001). Chemo/radiotherapy was reported in 98 patients (25 %). Most patients (94 %) survived; 81 % (n = 237) with no evidence of recurrent disease, 14 % (n = 41) were alive with disease, and 25 (6 %) died of disease. Positive margins at primary operation, and metastatic disease were associated with mortality (p < 0.0001 for both). IMT is a rare tumor with favorable outcome for the majority of patients. Whilst most patients will present with benign tumors, complete surgical resection (R0) is crucial, as positive surgical margins are a significant risk factor for tumor recurrence and mortality.

Inflammatory Myofibroblastic Tumour in Children: A Report of Two Cases and Review of Literature

ABSTRACT

Inflammatory myofibroblastic tumour in paediatric patients present with a diagnostic dilemma because of its clinical, radiological and histopathological features overlapping with other mesenchymal tumours common in this age. Because of its rarity, the exact features are still unclear. Here, we are reporting clinical, radiological and histopathological appearances of two such cases. In both cases, the exact diagnosis was confirmed only after immunohistochemistry. There is a need for further detailed study to exactly determine the natural course and prognosis of these tumours.

Anaplastic Lymphoma Kinase Positive Mesenteric Inflammatory Myofibroblastic Tumor in Adult Woman

Inflammatory myofibroblastic tumors (IMTs) are rare mesenchymal neoplasms containing spindle cells and inflammatory components that can be locally aggressive. They have unclear biological behavior and may recur after resection.

A 31-year-old woman presented with three months of cough, fatigue, weight loss, abdominal pain, anemia, and elevated inflammatory markers. CT showed a large well-circumscribed enhancing mass in the right colic mesentery. The patient underwent a laparoscopic right colectomy. Pathologic review showed fascicular spindle cells with admixed chronic inflammatory cells. Cells stained diffusely positive for SMA and anaplastic lymphoma kinase (ALK), diagnostic of an IMT. Post-operatively, the patient reported symptom resolution and had normalization of lab values. She remains disease-free at 20 months.

IMT is rare in adults, accounting for 0.7%-1.0% of lung tumors. Up to 30% of patients present with elevated inflammatory markers. On imaging, IMTs are soft tissue masses with variable enhancement and fibrosis, often suspected to be malignant neoplasms. Up to 80% of IMTs are driven by altered tyrosine kinase signaling and half of IMTs express ALK, which may be treated in unresectable/recurrent cases using ALK-inhibitors. IMT may recur in 10%-15% of patients. The roles of adjuvant treatments are unclear given the rarity and unpredictable biological behavior. Long-term follow-up with regular radiologic and laboratory surveillance is recommended given possible local recurrence. IMTs are best managed in a multidisciplinary setting given their unpredictable nature. Surgery is the mainstay of IMT treatment with long-term control expected in >80% of adult patients.

Paediatric Gastrointestinal, Hepatic and Pancreatic Inflammatory Myofibroblastic Tumours, A Single Centre Experience

ABSTRACT

Inflammatory myofibroblastic tumours (IMTs) are rare soft tissue tumours. Reports of gastrointestinal tract, liver and pancreas tumours are limited. The objective of this study is to identify presenting features, contributing prognostic / etiological factors and any variability in outcomes in the context of different historical treatments. We retrospectively reviewed the records of seven children treated at our hospital between 2006 and 2019 and assessed the demographic, presentation, treatment, immunohistochemistry, and outcomes of their tumours. Age range at presentation was 4 months-15 years with a male predominance. Presentations were typically due to local mass effect or incidental discovery. Systemic symptoms were rare. Outcomes were good with six out of seven stable or in remission irrespective of treatment. Surgical resection where possible is the treatment of choice. Medical therapy had good outcomes with chemotherapy acting as first line treatment when required. The only negative prognostic factor identified was local spread at the time of presentation.

Inflammatory myofibroblastic tumours of the duodenopancreaticobiliary tract

Inflammatory myofibroblastic tumours (IMTs) are rare benign neoplasms of intermediate malignant potential that are found in the lungs and rarely at extrapulmonary sites common in children and young adults. IMTs tend to be locally invasive and have some amount of metastatic potential as well. We present two cases of IMTs involving the duodenum, pancreas and distal bile duct. The first case presented with extensive involvement of the first three parts of the duodenum and head of the pancreas, while the second presented with a pancreatic and biliary tree involvement. Upon examinations and investigations, these tumours mimicked malignant neoplasms. A Whipple procedure for surgical resection was undertaken in both cases. The histological findings showed fascicles of spindle cells with infiltration of lymphocytes and plasma cells. The inflammatory myofibroblastic tumour was diagnosed based on pathological grounds with immunohistochemistry. Preoperative diagnosis of IMTs is difficult and complete surgical resection is the primary treatment.

Recurrent infantile inflammatory myofibroblastic tumor of mesentery--Case report and review of imaging findings

Inflammatory myofibroblastic tumors (IMT) are rare soft tissue tumors of intermediate malignant potential with tendency for local recurrence. Although they can occur at all age groups, occurrence in infants is extremely unusual and their imaging characteristics are not well described. A 3-month-old female infant presented with gradually progressive abdominal distention without any fever or weight loss. She had a large ill-defined homogenous hypodense lesion of size 8.4 × 11.4 × 11.3 cm (APxTraxSag) in the abdomen showing mild delayed post contrast enhancement. She underwent exploratory laparotomy with gross total excision of mesenteric mass, histopathology of which was suggestive of IMT. She had recurrence within 6 months of complete resection with a well-defined heterogeneously enhancing lesion of size 1.8 × 1.8 × 2.3cm (APxTraxSag) in right paravesical region abutting the bladder without invasion with a similar lesion of size 4.4 × 2.1 × 3 cm (APxTraxSag) in left subdiaphragmatic region abutting superior surface of spleen (no invasion). Since, surgery in our patient would have entailed splenectomy and partial cystectomy, systemic therapy with ceritinib (anaplastic lymphoma kinase [ALK] inhibitor) was planned for her with which she had a near complete response after 2 months. A high index of suspicion is required to differentiate IMT from other common causes of mesenteric masses in children and role of radiologist is quintessential in this regard. Local recurrence with abutment but without invasion of surrounding structures points to the intermediate malignant pathology of IMT and may provide a clue to diagnosis. Systemic therapy is effective in patients who are ALK positive and destructive surgery should be avoided.

Combined liver transplant and pancreaticoduodenectomy for inflammatory hilar myofibroblastic tumor: Case report and review of the literature

IMT, previously known as IPT, is a relatively rare tumor that was originally described in the lungs, but case reports have reported the tumor in almost every organ system. Surgical resection is typically the mainstay of therapy; however, tumors have also been shown to respond to chemotherapy or anti-inflammatory therapy and some have spontaneously regressed. We present a literature review and case report representing the first documentation to date of liver transplant combined with PD for surgical resection of a myofibroblastic tumor non-responsive to medical therapy.

Voluminous omental inflammatory myofibroblastic tumor in an elderly man: a case report and literature review

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm of intermediate biologic potential, with uncertain etiology. This tumor occurs primarily in the lung, but the tumor may affect any organ system. A 75-year-old male was evaluated for voluminous palpable high abdominal mass with continuous and moderately abdominal pain, associated with abdominal distension for the last two months. Abdominal computed tomography showed a large (32 × 29 × 15 cm) heterogeneously enhanced mass with well-defined margins. At surgery, the mass originated from the greater omentum was completely excised. Histologically the tumor was a mesenchymal neoplasm in smooth muscle differentiation and was characterized by spindle-cell proliferation with lymphocytes, plasma cells, and rare eosinophils. Immunohistochemically, the tumor cells were positive for vimentin and smooth muscle actin and negative for anaplastic lymphoma kinase. Complete surgical resection of IMTs remains the mainstay of treatment associated with a low rate of recurrence. Final diagnosis should be based on histopathological and immunohistochemical findings. Appropriate awareness should be exercised by surgeons to abdominal IMTs in combination with constitutional symptoms, abnormal hematologic findings, and radiological definition, to avoid misdiagnosed.

Intra-abdominal infantile inflammatory myofibroblastic tumors: A report of three cases

Inflammatory myofibroblastic tumor occurring at intra-abdominal sites in children can be confused with malignancy because of its large size and location. It is a tumor classified as ‘intermediate’ between benign and malignant, but usually benign, with a strong tendency for recurrence. Treatment is surgical excision. Here, we present a brief outline of three such cases presenting as abdominal mass in infants.

A case of inflammatory myofibroblastic tumor originated from the greater omentum in young adult

Inflammatory myofibroblastic (IMF) tumor is a rare solid tumor that often affects children. IMF tumors occur primarily in the lung, but the tumor may affect any organ system with protean manifestations. A 22-year-old woman was evaluated for palpable low abdominal mass that had been increasing in size since two months prior. Abdominal computed tomography showed a lobulated, heterogeneous contrast enhancing soft tissue mass, 6.5 × 5.7 cm in size in the ileal mesentery. At surgery, the mass originated from the greater omentum laying in the pelvic cavity and was completely excised without tumor spillage. Histologically, the mass was a spindle cell lesion with severe atypism and some mitosis. Immunohistochemistry for anaplastic lymphoma kinase-1 revealed that the lesion was an IMF tumor. Because of its local invasiveness and its tendency to recur, this tumor can be confused with a soft tissue sarcoma. Increasing physician awareness of this entity should facilitate recognition of its clinical characteristics and laboratory findings.

Abdominal inflammatory myofibroblastic tumor a clinicopathologic study with reappraisal of biologic behavior

BACKGROUND AND PURPOSE

Inflammatory myofibroblastic tumor (IMT) is a proliferative lesion of controversial nosology and uncertain prognosis. In an attempt to acquire further understanding of pathogenesis and biologic behavior, we surveyed abdominal IMTs managed over the last 12 years at a single institution.

METHODS

Intra-abdominal IMTs treated between 1995 and 2007 were reviewed concerning demographic, clinical, and pathologic features as well as therapeutic management and outcome. All specimens were reevaluated by histologic examination and immunohistochemistry.

RESULTS

There were 7 patients (4 males; age range, 28 days to 14 years). Five lesions were located in alimentary tract: 1 gastric presenting with bleeding, 1 hepatic presenting with a thoracic wall mass, 1 pancreatic and 2 colonic presenting with obstructive symptoms. One splenic IMT was found incidentally. The remaining case arose from the adrenal gland and presented with a palpable mass. The gastric and adrenal IMTs had evidence of a previous or concomitant infectious setting. Five lesions were excised. The pancreatic IMT underwent a drainage procedure followed by steroid administration, and the hepatic lesion received antibiotics. Histopathology revealed characteristic findings of IMT. Expression of anaplastic lymphoma kinase was negative in all cases. At a median follow-up of 6 years (range, 3-15), all children were asymptomatic with no recurrences. The hepatic and pancreatic IMT displayed complete and near total regression, respectively.

CONCLUSION

A benign behavior of abdominal IMTs was observed even in patients not undergoing surgical excision. Although IMT remains a surgical disease, a conservative approach may be reasonable in select cases.

Unusual case of pancreatic inflammatory myofibroblastic tumor associated with spontaneous splenic rupture

Background

Spontaneous splenic rupture considered a relatively rare but life threatening. The three commonest causes of spontaneous splenic rupture are malignant hematological diseases, viral infections and local inflammatory and neoplastic disorders. We describe a unique and unusual case of inflammatory myofibroblastic tumor of the tail of pancreas presented with massively enlarged spleen and spontaneous splenic rupture.

Case presentation

A 19 years old male patient with no significant past medical history presented to emergency room with abdominal pain and fatigue. Massively enlarged spleen was detected. Hypotension and rapid reduction of hemoglobin level necessitated urgent laparatomy. About 1.75 liters of blood were found in abdominal cavity. A large tumor arising from the tail of pancreas and local rupture of an enlarged spleen adjacent to the tumor were detected. Distal pancreatectomy and splenectomy were performed. To our knowledge, we report the first case of massively enlarged spleen that was complicated with spontaneous splenic rupture as a result of splenic congestion due to mechanical obstruction caused by an inflammatory myofibroblastic tumor of the tail of pancreas. A review of the literature is also presented.

Conclusion

Inflammatory myofibroblastic tumor of the tail of pancreas should be included in the differential diagnosis of the etiological causes of massively enlarged spleen and spontaneous splenic rupture.

Inflammatory Myofibroblastic Tumor of the Pancreatic Head: An Unusual Cause of Recurrent Acute Pancreatitis - Case Presentation of a Palliative Approach after Failed Resection and Review of the Literature

Inflammatory myofibroblastic tumors (IMTs) are a rare cause of echo-poor pancreatic head enlargement. Histologically, IMTs are characterized by spindle-shaped myofibroblasts or fibroblasts accompanied by a mixed immune cell infiltration. The most common localizations of IMTs have been reported in lung, mesentery and omentum, especially in children and young adults. IMTs show infiltrating growth, multilocular appearance and also metastasis have been reported. Curative resection is the only therapeutic option so far. In the palliative situation, evident data and clear guidelines for this rare tumor entity are missing. We report on a 44-year-old male with an unresectable IMT of the pancreatic head causing recurrent episodes of acute pancreatitis that resulted in a chronic obstructive course of the disease. The patient entered a palliative therapeutic regimen including radiation therapy and antiinflammatory medication. In a regular follow-up of 12 months, he presented with stable disease after initial progression. This case of local progressive IMT of the pancreatic head was managed with a palliative therapeutic regimen and is discussed based on the current literature.

Inflammatory myofibroblastic tumor of the pancreas: a case report of 2 pediatric cases--steroids or surgery?

Inflammatory pseudotumors also termed inflammatory myofibroblastic tumors (IMTs) are rare, benign, solid lesions of unclear etiology more usually found in the lung and very rarely in the pancreas. We report 2 cases and outline our management for each. The first case was treated surgically, whereas the second was treated with high-dose steroids. This represents the first reported case whereby steroid treatment has been successful in pancreatic IMT.

Inflammatory myofibroblastic tumor of mesentery: a case report

INTRODUCTION

Inflammatory myofibroblastic tumor occurring at intra-abdominal sites in children has rarely been described. In the abdomen, mesentery is a rare location for an inflammatory myofibroblastic tumor.

CASE REPORT

A case report of inflammatory myofibroblastic tumor of mesentery presenting as painless abdominal swelling is presented. Histopathological study of specimen documented the diagnosis. Complete resection of tumor was done with no recurrence seen in follow-up.

Case report: inflammatory myofibroblastic tumor of the duodenum

INTRODUCTION

We report a very rare case of inflammatory myofibroblastic tumor of the duodenum. A 16-year-old boy underwent esophagogastroduodenoscopy for intermittent epigastric pain, night sweats, and malaise.

CASE REPORT

An exophytic mass lesion was found in the first part of the duodenum, but biopsies were non-diagnostic. Computed tomography confirmed a 60-mm mass with no lymphadenopathy, and the patient underwent surgical resection. Histology revealed spindle cells with the morphological and immunophenotypical profile of myofibroblasts on a background of mixed inflammatory infiltrate, typical of inflammatory myofibroblastic tumor. Six months after surgery, the patient developed a recurrence, and this was successfully treated by immunosuppression. Currently, the patient is asymptomatic, and there is no radiological or pathological evidence of disease.

Rapid regression of duodenal inflammatory myofibroblastic tumor after intravenous ketorolac: case report and review of the literature

Inflammatory myofibroblastic tumors are known to sometimes regress spontaneously or in response to treatment with antiinflammatory drugs. We present the case of a 13-year-old boy with an inflammatory myofibroblastic tumor of the proximal duodenum, which regressed rapidly within days of an open surgical biopsy, resulting in perforation of the duodenum. Ketorolac was administered intravenously after the biopsy and is implicated as a potential cause of the rapid regression of the tumor. We discuss the surgical management of this patient and present a review of the literature.

Ovarian inflammatory myofibroblastic tumor in children

Inflammatory myofibroblastic tumors or inflammatory pseudotumors are uncommon solid tumors that are highly vascularized, have an intermediate prognosis, and are associated with local recurrence, and rare metastasis. Inflammatory myofibroblastic tumors (IMT) most often are seen in the lung of young adults, but there have been reports of these tumors occurring in children, in various sites. The authors report a case of an ovarian IMT arising in a six-year-old girl (third case reported in the literature), treated by a right adnexectomy with uneventful postoperative course, and discuss recent reports.

Mesenteric inflammatory myofibroblastic tumors in an elder patient with early recurrence: A case report

Inflammatory myofibroblastic tumor (IMT) of the alimentary tract often occurs in children or young adults, but may occur at any age. Symptoms are nonspecific and depend on the location of the tumor. The most often involved sites are small bowel mesentery especially the distal ileum, mesotransverse colon, or great omentum. Recurrence appears to be more frequent in the extrapulmonary lesion. Herein we demonstrate a 63-year-old male patient with mesenteric IMT, with an early recurrence after his first operation. We should be aware that if the tumor is larger than 8 cm, multinodular, omental, with ill-defined margin, with pathologically atypia, or ganglion-like cells, a close surveillence after primary surgery with image study might be necessary to detect the tumor recurrence early. Tumor recurrence may be asymptomatic, and it may act like a malignant tumor with a poor prognosis.

Lower abdominal inflammatory myofibroblastic tumor -an unusual presentation- a case report and brief literature review

A 9-year-old girl presented with lethargy, malaise & chest pain. Her blood counts confirmed hypochromic microcytic anemia. She was prescribed iron supplements. Subsequently she was admitted to our hospital with fever and increasing chest and abdominal pain. She was treated with antibiotics, and a diagnosis of "early chest infection" was made. Over the following 2 weeks she failed to improve, and her anemia worsened. She was readmitted, and found to have a mass in her lower abdomen with pressure symptoms on her bowel and bladder. A white-cell scan showed increased uptake in right lower quadrant. An ultrasound and a CT scan confirmed a mass adjacent to her bladder. Needle biopsy showed it to be an unusual localization of an inflammatory myofibroblastic tumor (IMT) of cecum. A presentation with chest pain, fever, anemia and pressure symptoms was highly unusual of a lower abdominal IMT mass. She had a successful excision of the tumor, with resolution of her symptoms.

Gastrointestinal stromal tumors: diagnostic challenges and practical approach to differential diagnosis

Over the last decade, gastrointestinal stromal tumors (GISTs) have evolved from histogenetically obscure gastrointestinal mesenchymal tumors to well-defined tumors with distinctive clinical, morphologic, ultrastructural, histogenetic, and molecular characteristics, for which targeted therapy is available. This is largely attributable to the discovery of CD117 overexpression and activating mutations in c-kit or platelet-derived growth factor alpha genes in most of GISTs. The availability of specific diagnostic tests and targeted therapy for GISTs has led to an increased awareness of these tumors. At the same time, the list of potential GIST mimics has lengthened considerably and it has become increasingly important that GISTs be distinguished from their mimics because correct diagnosis has implications for both treatment and prognosis. The purpose of this review is to provide an update of the expanding differential diagnosis of GISTS, to draw attention to unusual GIST variants, to provide a practical approach the differential diagnosis of GISTs and to highlight some of the challenges faced by pathologists in resolving this differential diagnosis.

Pancreatic malignant fibrous histiocytoma, inflammatory myofibroblastic tumor, and inflammatory pseudotumor related to autoimmune pancreatitis: characterization and differential diagnosis

Malignant fibrous histiocytoma (MFH) and inflammatory myofibroblastic tumor (IMT) are uncommon primary non-epithelial cell tumors of the pancreas. In addition, there are inflammatory pseudotumors (IPT) that may arise in the course of autoimmune pancreatitis (AIP). In the English language literature, only 24 cases of IMT and nine cases of MFH in the pancreas have been reported to date. We investigated three individual spindle cell tumors of the pancreas that were identified as MFH, IMT, and IPT, respectively, using immunohistochemical and molecular analysis. Both the MFH and the IMT, but not the IPT, showed nuclear p53 expression and mutations of the p53 gene. The MFH and the IMT also had higher mitotic and Ki-67 (MIB-1) indexes than the IPT. The IPT was found to be a tumor-like case of AIP. Many IgG4-positive plasma cells, which are considered to be a feature of AIP, were found in all three tumors. It is concluded that in this series of spindle cell tumors of the pancreas, apart from immunohistochemical features, the demonstration of p53 mutations may be helpful in distinguishing true neoplastic tumors from pseudotumors such as IPTs arising in the context of AIP.

Inflammatory myofibroblastic tumor of the distal bile duct associated with lymphoplasmacytic sclerosing pancreatitis. Case report and review of the literature

Inflammatory myofibroblastic tumor (IMT) or inflammatory pseudotumor has been described in various organs such as the liver, intestinal tract, spleen, kidney, bladder, lung, peritoneum and heart. However, its appearance in the periampullary region is uncommon and has rarely been reported in the literature. It is characterized histologically by myofibroblastic cell proliferation together with a mixed inflammatory infiltrate that clinically and radiologically mimics a malignant tumor. We report a case of IMT located in the distal common bile duct of a 51-year-old woman. She underwent Whipple resection with the initial diagnosis of cholangiocarcinoma; the pathologic diagnosis of the tumor was IMT of the distal bile duct associated with lymphoplasmacytic sclerosing pancreatitis. Referring to previously reported cases, suspected diagnosis of a malignant tumor made surgical excision the primary choice for symptom relief and in order to obtain a definitive diagnosis. IMT relationship with lymphoplasmacytic sclerosing pancreatitis is discussed.

Mesenteric inflammatory pseudotumor as a cause of abdominal pain in a teenager: presentation and literature review

Inflammatory pseudotumor (IP) is an unusual cause of chronic abdominal pain in children. The management of these lesions is complicated by controversies surrounding their appropriate classification and the numerous alternate names with which they are described. Successful treatment requires careful radiologic and pathologic evaluation to distinguish IPs from other lesions, along with complete surgical resection. We present the case of a 15-year-old boy with IP and review the literature in an attempt to simplify the description of these tumors.

Inflammatory myofibroblastic tumour of the gallbladder

BACKGROUND: Inflammatory myofibroblastic tumour (IMT) is a benign, nonmetastasizing proliferation of myofibroblasts with a potential for local infiltration, recurrence and persistent local growth. CASE REPORT: We report a case of a 51 year-old female, who had excision of a gallbladder tumour. Histopathology showed it to be IMT of the gallbladder. CONCLUSION: The approach to these tumours should be primarily surgical resection to obtain a definitive diagnosis and relieve symptoms. IMT has a potential for local infiltration, recurrence and persistent local growth.

Laparoscopic distal pancreatectomy for inflammatory pseudotumor of the pancreas

An 82-year-old woman presented with abdominal pain, nausea, emesis, and weight loss of ~25 lb over 6 months. A CT scan and MRI of the abdomen revealed a mass in the tail of the pancreas that was suspicious for malignancy. The patient underwent successful laparoscopic distal pancreatectomy and was discharged home on the 4th postoperative day after an uneventful course. Pathology revealed an inflammatory pseudotumor of the pancreas (IPT). Pancreatic IPT is a rare entity, and this case represents the first report of laparoscopic resection of this lesion. The presentation, diagnosis, histologic features, and therapy of IPT of the pancreas are reviewed.

Recurrent inflammatory pseudotumors in children

BACKGROUND/PURPOSE

pulmonary (PPT) and extrapulmonary pseudotumors (EPPT) are uncommon benign tumors, which, in general, do not recur after complete resection. Recurrence rates for both types of pseudotumors are undocumented in a large population of children, and the salient features of potential recurrences are unspecified.

METHODS

This is a report of 15 children with PPT and EPPT; 3 children had a recurrence. These pseudotumors recurred despite adequate primary resection of all gross disease at first presentation. The literature was reviewed to determine rate of recurrence for PPT and EPPT and also to document features common to recurrent pseudotumors.

RESULTS

Overall recurrence rate for pseudotumors was 14%. PPT and EPPT, which were not confined to a single organ, had a high chance of recurrence (46% and 30%, respectively) compared with PPT and EPPT, which were confined to a single organ (1.5% and 8%, respectively). Recurrences have appeared between 3 months and 7 years. Intraabdominal EPPT accounts for more than 75% of the EPPT recurrences.

CONCLUSIONS

PPT and EPPT recur more frequently than anticipated. All pseudotumors, which on initial presentation extend beyond the confines of a single organ, have a high chance of recurrence despite what appears to be adequate resection. Children with pseudotumors that extend beyond a single organ, require frequent postoperative evaluation for recurrence and may be candidates for chemotherapy or radiotherapy at the time of initial resection.

Successful treatment of inflammatory myofibroblastic tumor with malignant transformation by surgical resection and chemotherapy

Inflammatory myofibroblastic tumor (IMT) is a tumor composed of myofibroblasts and a mixed inflammatory infiltrate that rarely undergoes malignant transformation. The authors present the case of a 7-year-old boy with an abdominal mass diagnosed as IMT with malignant transformation. The tumor recurred twice after attempts at resection and was initially treated with vincristine and etoposide. After a third recurrence and incomplete resection, he was treated with cisplatin, Adriamycin, and methotrexate. He is disease-free after 2 years, representing successful combined surgery and chemotherapy in the treatment of malignant IMT. The use of chemotherapy for aggressive myofibroblastic tumors is reviewed.

Inflammatory myofibroblastic tumor

Inflammatory myofibroblastic tumors are well described in lung and upper respiratory tract of young adults and children. Intra-abdominal forms of the disease are reported to occur most frequently in the liver, followed by stomach, bowel and spleen. A 13-year-old girl who had intermittent fever ranging from 99-101 degrees F of three months period and significant weight loss was referred as a case of pyrexia of unknown origin. The patient was subjected to laparotomy. A solid mass was found arising from the mesentery, four feet from the iliocaecal junction and was adherent to the wall of ileum. The patient became afebrile after the removal of the mass and has gained weight and remained well during the ten months since discharge.

Regional pancreatectomy and transverse colectomy with mesenteric vascular reconstruction for inflammatory pseudotumour of the head of pancreas and mesenteric root

BACKGROUND

Inflammatory myofibroblastic pseudotumour is a rare pancreatic lesion.

CASE OUTLINE

A 32-year-old woman with such a tumour was treated by a radical operation comprising proximal pancreatic-duodenectomy (Whipple Procedure) and transverse colectomy with resection and reconstruction of the superior mesenteric artery and vein. She remains well 6 years later.

DISCUSSION

The importance of aggressive surgical clearance rather than chemotherapy is highlighted in the management of patients with these unusual tumours.

Liver tumors

Liver tumors in children are rare, potentially complex, and encompass a broad spectrum of disease processes. Any age group may be affected, including the fetus. Most present with abdominal distension and/or a mass. Accurate preoperative diagnosis is usually possible using a combination of ultrasound scanning and cross-sectional imaging techniques (CT and/or MR), supplemented by liver biopsy and measurement of tumor markers. The most common benign tumors are hemangiomas, but mesenchymal hamartoma, focal nodular hyperplasia, and adenoma also are found. In Western countries, hepatoblastoma is the most common primary malignant liver tumor; disease-free survival is now possible in more than 80% of affected patients because of advances in combination chemotherapy, improved techniques of surgical resection, and the selective use of liver transplantation. In contrast, there has been less progress in the management of hepatocellular cancer, which still poses many therapeutic challenges.

Inflammatory pseudotumor causing intestinal obstruction: diagnostic and therapeutic aspects

The authors report an unusual presentation of inflammatory pseudotumor (IPT) that caused intestinal obstruction in a 9-year-old boy, and discuss the clinicopathologic features of this rare entity with emphasis on diagnosis and treatment. There are no specific presumptive clinical and laboratory findings, including tumor markers and imaging techniques, that distinguish mesenteric IPT from other abdominal mass lesions. The most important diagnostic aid is to bear this entity in mind when a child presents with intestinal obstruction associated with an abdominal mass. Radical unnecessary surgical procedures or potentially harmful therapy should be avoided, and appropriate treatment is achieved by total excision of the lesion in most of the cases.

Abdominal inflammatory myofibroblastic tumors in children: report of an appendiceal case and review of the literature

Inflammatory myofibroblastic tumors (IMT) are rare, benign lesions. They mimic, clinically and radiologically, malignant tumors-especially sarcoma. IMT most often are seen in the lung of young adults, but there have been reports of these tumors occurring in children, in various sites. The authors report a case of appendiceal IMT arising in a 15-year-old boy previously treated for inherited distal renal tubular acidosis. He was admitted because of anorexia, weight loss, and a low-grade fever. The ultrasound study showed bilateral hydroureteronephrosis, with a poorly functioning right kidney noted on intravenous urography, and a retrovesical soft-tissue mass. Laboratory studies showed renal insufficiency, an elevated white blood cell count, anemia, thrombocytosis, and hypergammaglobulinemia. During laparotomy, a pelvic appendiceal mass was discovered, appendectomy was performed, and the pathological diagnosis of inflammatory myofibroblastic tumor was made. Three months later the boy was well, and the biological, sonographic, and urographic results had returned to normal. A review of 74 cases of abdominal IMT occurring in childhood emphasizes the importance of pathological differentiation of these lesions from malignancy, with early total excision whenever possible. Long-term follow-up is necessary to detect local recurrence, which may develop many years later, and to confirm the allegedly benign nature of these tumors.

Orthotopic liver transplantation for inflammatory myofibroblastic tumor of the liver hilum

Inflammatory myofibroblastic tumor is a rare gastrointestinal neoplasm. The authors report the case of a 5-year-old girl who initially presented with gastric outlet obstruction secondary to an inflammatory myofibroblastic tumor along the lesser gastric curvature. A subtotal gastrectomy and wedge resection of a left hepatic lobe nodule were performed. Obstructive jaundice developed one month postoperatively. Computerized tomography, percutaneous transhepatic cholangiography, and selective celiac and mesenteric arteriography showed a mass that involved the left hepatic lobe, with concomitant high-grade biliary obstruction and portal venous encasement. Percutaneous biliary drainage was performed. During laparotomy, the tumor was found to be unresectable, and the patient was referred to the Liver Transplant Service at The Children's Hospital of Philadelphia. A total hepatectomy with temporary portocaval shunt was performed, leaving the inferior vena cava in situ. At the back table, an ex vivo left trisegmentectomy was performed, followed by reimplantation of the posterior segment of the right hepatic lobe. The reimplanted liver segment functioned poorly, and completion hepatectomy with portocaval shunt was performed 24 hours postoperatively, because of severe coagulopathy, intraabdominal bleeding, and hemodynamic instability. The patient's condition stabilized, and she was listed for urgent liver transplantation. The anhepatic state was managed with intermittent plasmapheresis. She had transplantation 72 hours later, and was discharged from the hospital 3 weeks postoperatively after an uneventful recovery. She remains disease-free and has normal liver function 8 months after transplantation.

Myofibrosarcoma of the head and neck in children

We have identified a distinctive malignant soft tissue neoplasm that occurred in the head and neck region of six children. Histologically, these neoplasms presented an array of features ranging from low-grade spindle cell to high-grade fibrohistiocytic histologies and often had myoid characteristics. Ultrastructural and immunohistochemical studies indicated that they contained neoplastic myofibroblasts that were variably positive for vimentin (4 positive/4 tested), alpha-smooth muscle actin (4/5), muscle-specific actin (5/5), desmin (2/5), and v-src protein substrate p80/85 (4/5). Three patients died of rapidly progressive unresectable local disease, one died of metastatic and local disease, and two are alive 13 months and 8 years after wide resection. We conclude that these neoplasms form a distinctive subset of pediatric soft tissue sarcomas that display an aggressive clinical behavior, typically with local recurrence, and exhibit features of myofibroblastic differentiation.

Report of three gastric tumors in children

The literature concerning gastric tumors in children is mainly limited to case studies. The authors reviewed 1,403 histological reports of pediatric gastric pathology (covering 10 years) at their institution. There were three gastric tumors of benign histology and no malignant tumors. The first patient was a 9 1/2-year-old boy who presented with several months of symptomatic, pH-probe-confirmed gastroesophageal reflux. He underwent placement of a Toupet antireflux valve. During laparotomy, a submucosal mass was discovered incidentally, on the greater curvature of the stomach. The mass was excised. Pathological examination showed heterotopic pancreas. The second patient, a 15-month-old girl, presented with a short period of vomiting. Results of an upper gastrointestinal series showed gastric outlet obstruction. She underwent laparotomy and was found to have an intussusception of a gastric polyp into the proximal jejunum, and an associated malrotation. Ladd's procedure, gastroduoduodenostomy with reduction of the intussuscepted polyp, and excision of the polyp were performed. Histological examination of the tumor showed hamartoma with hyperplastic elements. The tumor was benign but was regarded as difficult to classify. The third patient, a 6-year-old boy, presented with microcytic anemia. Endoscopy showed multiple friable bleeding gastric masses. He underwent laparotomy, with partial gastrectomy and pyloroplasty. Histological examination showed the tumor to be plasma cell granuloma. The tumor recurred, and the patient required subsequent operative procedures. The authors confirm that gastric tumors in children are rare. Although the tumor histology may be benign, excision of the tumor may require major operative resection.