Inflammatory pseudotumor of the liver

Case report: An inflammatory pseudotumor of the caudate lobe of the liver caused by a foreign body

This case report explores a rare foreign body-induced inflammatory pseudotumor in the caudate lobe of a 47-year-old male. The patient was admitted to the hospital due to epigastric pain and fever. Radiological examinations led to the diagnosis of a malignant tumor, and a resection of the caudate lobe lesion was performed. The excised tumor specimen revealed a fishbone-like foreign body. Immunohistochemistry suggested that this was an inflammatory pseudotumor rather than a malignant tumor. This prompted us to contemplate the origin of the foreign body and the mechanisms by which it led to the formation of the inflammatory pseudotumor.

Laparoscopic treatment of inflammatory myofibroblastic tumor in liver: A case report

BACKGROUND

Inflammatory myofibroblastic tumor in the liver (IMTL) is a rare borderline mesenchymal tumor. Neither clinical symptoms nor laboratory tests have absolute specificity for the diagnosis of IMTL, and imaging also lacks obvious specificity. Although there are sporadic reports of recurrence after surgical treatment, surgical resection is the mainstay of treatment.

CASE SUMMARY

A 29-year-old man complained of general weakness, slight discomfort in the upper abdomen, with a history of upper respiratory tract infection for 1 wk before admission. Plain and enhanced upper abdominal magnetic resonance imaging showed a mass in liver segments II and III (48 mm × 53 mm). He was treated by laparoscopic left lateral segmentectomy. Postoperative pathological examination with hematoxylin and eosin staining suggested that the mass in liver segments II and III was IMTL. During 21 mo postoperative follow-up, no obvious residual or recurrent lesions were observed.

CONCLUSION

There is a risk of malignant degeneration in IMTL. The principal choice of treatment is laparoscopic left lateral segmentectomy.

Diagnosis of hepatic inflammatory pseudotumor by fine-needle biopsy

Hepatic inflammatory pseudotumor (IPT) is a benign lesion characterized by chronic infiltration of inflammatory cells and fibrosis that clinically, radiologically, and pathologically mimics malignancy. However, the epidemiology of IPTs remains unclear. IPTs are often misdiagnosed as malignant lesions because of the lack of characteristic features. We present the case of a 32-year-old man that was misdiagnosed as intrahepatic cholangiocarcinoma by CECT, CEMRI, and CEUS, which was finally confirmed as IPT by fine-needle liver biopsy. In this report, the key factor in the diagnosis of liver inflammatory masses was the presence of hepatic perfusion disorder.

Inflammatory pseudotumor of the Liver. A Report of Two Cases with Unusual Histologic Picture

Two cases of inflammatory pseudotumor (IPT) of the liver are reported. Clinical presentation was vague and aspecific. Laboratory tests and data from imaging techniques provided no specific information on the actual nature of the lesions and were misleading, suggesting a malignant lesion in one patient and a complicated hydatid cyst in the other. On gross examination, the tumors appeared yellowish ore grey-yellow in color, with a firm cut surface and well circumscribed from the surrounding parenchyma, although a true capsule was not evident. Variability in the histological pattern was also observed, even though the major finding was in both cases an admixture of lymphocytes, plasmacells, granulocytes and monocytes. Lymphocytes were immunohistochemically heterogeneous; monocytes showed in one case large hyperchromic atypical nuclei, confirming the previously, reported possibility that some cases of IPT may be mistaken for sarcomas. Further evidence is added in support of the hypothesis that some liver IPT may result from the evolution of cholangitic abscesses.

Hepatic inflammatory pseudotumor presenting in an 8-year-old boy: A case report and review of literature

Hepatic inflammatory pseudotumors are uncommon benign lesions. Accurately diagnosing hepatic inflammatory pseudotumor can be very challenging because the clinical presentation and radiological appearances are nonspecific and cannot be certainly distinguished from malignant neoplastic processes. Herein, we present a case of hepatic IPT in an 8-year-old boy who presented to clinic with a 3-mo history of a tender hepatic mass, fever of unknown origin, and 9-kg weight loss. The physical examination was notable for tender hepatomegaly. Laboratory investigations were notable for a normal hepatic profile and elevated erythrocyte sedimentation rate and C-reactive protein. A T2-attenuated magnetic resonance imaging scan of the abdomen showed a 4.7 cm × 4.7 cm × 6.6 cm, contrast-enhancing, hyper-intense, well-defined lesion involving the right hepatic lobe. In view of the unremitting symptoms, tender hepatomegaly, thrombosed right hepatic vein, nonspecific radiological findings, and high suspicion of a deep-seated underlying infection or malignancy, a right hepatic lobectomy was recommended. Microscopically, the hepatic lesion exhibited a mixture of inflammatory cells (histiocytes, plasma cells, mature lymphocytes, and occasional multinucleated giant cells) in a background of dense fibrous tissue. Immunohistochemically, the cells stained negative for SMA, ALK-1, CD-21 and CD-23, diffusely positive for CD-68, and focally positive for IgG4. The final histopathological diagnosis was consistent with hepatic IPT. At the postoperative 4-mo follow-up, the patient was asymptomatic without radiological evidence of recurrence.

Necrotic hepatocellular carcinoma occurring within an inflammatory pseudotumor-like nodule

Hepatocellular carcinoma (HCC) and inflammatory pseudotumor of the liver (IPL) are often difficult to differentiate before surgery. To date, colocalization of IPL and HCC has not been reported. We experienced a case of necrotic HCC surrounded by IPL-like tissue. The raised levels of alpha-fetoprotein and PIVKA-II declined to within the normal ranges after resection of the tumor. The IPL-like nodule most likely developed as a process of an inflammatory reaction such as abscess formation after the spontaneous destruction of the HCC. Our case is a warning that the presence of a 'pseudotumor' does not rule out the possible simultaneous presence of carcinoma.

Inflammatory pseudo-tumor of the liver: a rare pathological entity

Inflammatory pseudo-tumor (IPT) of the liver is a rare benign neoplasm and is often mistaken as a malignant entity. Few cases have been reported in the literature and the precise etiology of inflammatory pseudotumor remains unknown. Patients usually present with fever, abdominal pain and jaundice. The proliferation of spindled myofibroblast cells mixed with variable amounts of reactive inflammatory cells is characteristics of IPT. We reviewed the literature regarding possible etiology for IPT with a possible suggested etiology.

Inflammatory pseudotumours of the liver: a spectrum of presentation and management options

PURPOSE

To review the current management options in inflammatory pseudotumours via analysis of ten cases from this unit the largest experience of this pathology in a Western series. To assess the medical and operative options available for this condition and the varying outcomes and the lessons learned in this unit over the time period.

RESULTS

Data from the ten cases were analysed and a comprehensive review of the published literature to date has detailed 128 case reports with 215 cases of inflammatory pseudotumour of the liver. Data analysed included patient demographics, diagnostic modalities, details of treatment and eventual outcome. The data was tabulated using an Excel spreadsheet (Microsoft Excel 2004 for Mac 2004.Version 11.0). Categorical variables were compared using Pearson's chi(2) test and p values <0.05 were defined as statistically significant. Statistical analysis was performed using SPSS for Windows (Version 9.0, SPSS Inc., Chicago, IL).

CONCLUSION

Emphasis is placed on a preferred medical management initially for this tumour with a good prognosis coupled with regular follow up. There may be a need for surgical resection cases where diagnosis is unclear or the patient is not responding to medical treatment with progression of disease or symptoms.

Inflammatory pseudotumor of the liver: demographics, diagnosis, and the case for nonoperative management

BACKGROUND

Inflammatory pseudotumor of the liver (IPL) is an unusual tumor-like condition that is becoming recognized as an important differential diagnosis in the patient presenting with liver masses. This report describes six cases of IPL.

STUDY DESIGN

Clinical, diagnostic, pathologic, and followup data were collected prospectively on six patients presenting to a specialist hepatobiliary unit.

RESULTS

Six patients with IPL presented over a 2-year period. Median age was 35 years (range 2 to 79 years) and five patients were men. Three patients were Polynesian (Tongan and Samoan) and one was New Zealand Maori. Five patients presented with nonspecific symptoms (fever, arthralgia, myalgia) and IPL was an incidental finding in one patient. At presentation, four patients had elevated white cell counts, and five patients had abnormal liver function tests with elevations in alkaline phosphotase and gamma-glutamyl transferase the most commonly seen. Carcinogenic embryonic antigen and alpha fetoprotein were normal in all patients, although one was a known hepatitis B carrier. In all cases of IPL, diagnosis was made on core biopsy of the liver lesions and all patients were managed nonoperatively with complete resolution of the tumors. Two patients had marked reduction in systemic symptoms (fever and pain) from a short course of oral steroids.

CONCLUSIONS

IPL appears to be a relatively common problem in Maori and Polynesians. Recognition and differentiation of this condition from malignant liver lesions are important to avoid unnecessary surgery.

Inflammatory pseudotumour of the liver--evidence for malignant transformation

A case of inflammatory pseudotumour of the liver is reported, and evidence is presented for its subsequent evolution into malignant non-Hodgkin's lymphoma. Such postulated malignant transformation challenges the assumption that hepatic inflammatory tumours are entirely benign lesions.

A case of inflammatory pseudotumor of the liver causing elevated serum CA19-9 levels

Inflammatory pseudotumor of the liver is a rare lesion characterized by proliferating fibrovascular tissue admixed with inflammatory cells. A 50-yr-old Japanese man was hospitalized because of upper abdominal pain and high fever. Computed tomography revealed a poorly demarcated, low density mass in the left lobe of the liver, and abnormal laboratory findings included WBC 9340/mm3, CRP 10.5 mg/dl, and marked elevation of CA19-9 to 1167.9 U/ml. Endoscopic retrograde cholangiography showed irregularity of the intrahepatic bile duct of the left lateral segment, and the lateral segmental branches of the portal vein were not visualized on the venous phase of abdominal angiography. Ultrasound-guided liver biopsy was performed, but malignant disease, including intrahepatic cholangiocarcinoma, could not be completely ruled out. The patient underwent left hepatic lobectomy with lymph node dissection. Histopathological examination yielded a definitive diagnosis of inflammatory pseudotumor. The lesion was immunohistochemically stained for CA19-9 by the ABC method, and the biliary epithelium in severely inflamed portal canals was found to be positive. The markedly elevated preoperative level of CA 19-9 decreased to almost within the normal range and the patient remains well 2 yr 9 months after surgery, without any complications.

Hepatic actinomycosis: case report and review of the literature in Japan

Hepatic actinomycosis is rare. We report an 86-year-old Japanese man with a 3-day history of high fever and anorexia who had an actinomycotic liver abscess complicated by disseminated intravascular coagulation (DIC). A definitive diagnosis was made when an Actinomyces species was cultured from aspirated pus. The clinical course was satisfactory. Treatment included prompt percutaneous drainage coupled with long-term intravenous administration of high-dose minocycline and piperacillin, combined with therapy for DIC. We reviewed 11 cases in Japan of Actinomyces involving the liver, including the case reported here. In most patients, there were no predisposing factors. Common symptoms and laboratory findings included fever, abdominal pain, leukocytosis, and elevated C-reactive protein. In 6 of the 11 patients a partial hepatectomy was performed because hepatic tumor was suspected. Five patients presented with a liver abscess. Hepatic actinomycosis should be considered in the differential diagnoses of pyogenic liver abscess and space-occupying lesions of the liver.

Solitary fibrous tumor involving the renal capsule

Solitary fibrous tumors are spindle-cell neoplasms that originally were described in the pleura but that can occur in a large variety of sites. We report a well-circumscribed tumor, apparently involving the renal capsule, clinically thought to be a renal-cell carcinoma or oncocytoma. It was composed of bland spindle-shaped cells with a patchy lymphoplasmacytic infiltrate, suggesting sarcomatoid renal-cell carcinoma, inflammatory myofibroblastic tumor, or solitary fibrous tumor; however, immunohistochemical stains were negative for keratin, alpha-smooth-muscle actin, and desmin but strongly positive for CD34. Ultrastructural examination revealed fibroblast-like cells without myofibroblastic or epithelial differentiation. The combined findings favor a diagnosis of a solitary fibrous tumor involving the renal capsule. To our knowledge, this lesion has not been reported in this location.

Inflammatory pseudotumor of the liver: report of a case and review of the literature

Only 56 cases of inflammatory pseudotumor of the liver have been reported in the world literature since its first documentation in 1953. We report herein the case of a 68-year-old man incidentally found to have a lesion in the right lobe of the liver which closely resembled a neoplasm on imaging studies. Thus, partial hepatic resection was performed and histological examination of the resected specimen revealed a diagnosis of inflammatory pseudotumor. Surgical resection is the preferred treatment for inflammatory pseudotumor of the liver, especially in patients for whom a definite histologic diagnosis cannot be made preoperatively or by intraoperative frozen sections. In fact, most of the patients reported in the literature recovered uneventfully after local resection without any postoperative complications, as did our patient.

Inflammatory pseudotumour of the liver: antecedent causes and clinical experience

We present a case in which inflammatory pseudotumour of the liver which appears to complicate Caroli's disease. We have reviewed the literature in hepatic inflammatory pseudotumour with particular emphasis on underlying causes. We were able to find 45 reported cases, with adequate clinical data in 42; in these only 7 showed a probable antecedent cause. There were gallstones in another 5, giving a prevalence not significantly different to that within the general population. Hepatic inflammatory pseudotumour typically presents with a history of fever, anorexia, loss of weight, hepatic pain, jaundice and a detectable liver mass (or masses). The diagnosis of inflammatory pseudotumour should be particularly considered when there is a history of previous inflammatory hepato-biliary disease. Preoperative or intra-operative diagnosis might then avoid major hepatic surgery.

Vascular invasion by hepatic inflammatory pseudotumor. A clinicopathologic study

BACKGROUND

Unusual lesions composed of fibrous tissue, lymphocytes, histiocytes, and plasma cells, called inflammatory pseudotumors (IPT), are being increasingly recognized in many organs and tissues. A hepatic IPT extending into the inferior vena cava has never been reported before to the authors' knowledge. The patient in this study underwent liver resection with cardiopulmonary bypass and circulatory arrest to excise the IPT.

METHODS

The tissue was studied extensively using histologic, immunohistologic, flow cytometric, and gene rearrangement analysis and electron microscopic methods.

RESULTS

On gross examination, the large hepatic tumor resembled a malignancy invading the vena cava. Microscopically, a mixture of T-lymphocytes, B-lymphocytes, and plasma cells were scattered throughout the tumor. DNA flow cytometry did not reveal aneuploidy suggestive of neoplasia. Genetic analysis of the immunoglobulin and T-cell receptor genes did not detect evidence of clonal expansion of B-cells or T-lymphocytes.

CONCLUSIONS

This experience with the vascular invasive and biliary obstructive nature of IPT and the difficulty in diagnosing it before or during surgery underscores the potentially adverse impact of this lesion on patients. The authors believe that an aggressive approach should be taken when evaluating and treating hepatic masses, even though they may later be confirmed as being IPT.