Inflammatory myofibroblastic tumor of the gallbladder: imaging aspects

Inflammatory Myo-Fibroblastic Tumor of the Gallbladder with Multivisceral Involvement: Successful Treatment with Radical Surgery

Inflammatory myo-fibroblastic tumor (IMT) of the gallbladder is an extremely rare condition. Only seven cases have been reported. All of these were presented either with polyp/mass inside the gallbladder or gallbladder wall thickening, involving just one adjacent organ. We herein present a case of IMT of gallbladder presenting with a huge mass replacing the gallbladder with multiple organ involvement, successfully treated by en bloc multivisceral resection. Moreover, we have compared it with the characteristics of all reported cases of IMT of the gallbladder.

Application of 18F-FDG PET/CT imaging in gallbladder inflammatory pseudotumor with elevated CA199: a case report and review of literature

Background

Gallbladder inflammatory pseudotumor (GIPT) is a nonspecific chronic proliferative inflammation of the gallbladder. At present, the pathogenesis is not clear, which may be related to bacterial and viral infections, congenital diseases, gallstones, chronic cholangitis and so on. GIPT is rare and the imaging examination has no obvious specificity. There are few reports on the ¹⁸F-FDG PET/CT imaging characteristics of GIPT. In this paper, ¹⁸F-FDG PET/CT findings of GIPT with elevated CA199 are reported and the literature is reviewed.

Case description

A 69-year-old female patient presented with recurrent intermittent right upper abdominal pain for more than 1 year, followed by nausea and vomiting for 3 hours, without fever, dizziness, chest tightness and other symptoms. Complete CT, MRI, PET/CT and related laboratory tests, CEA (-), AFP (-), Ca199 224.50U/mL ↑,¹⁸F-FDG PET/CT images showed uneven thickening at the bottom of the gallbladder, slightly increased gallbladder volume, eccentric and localized thickening of the gallbladder body wall, nodular soft tissue density shadow, clear boundary, smooth gallbladder wall, presence and smooth hepatobiliary interface, increased FDG radioactivity uptake, SUVmax was 10.2.The tumor was resected after operation and was diagnosed as gallbladder inflammatory pseudotumor by postoperative pathology.

Conclusion

¹⁸F-FDGPET/CT imaging has a certain significance for gallbladder inflammatory pseudotumor. In patients with chronic cholecystitis, when the CA199 increases, the gallbladder wall appears localized thickening, the hepatobiliary interface exists and is smooth, and the ¹⁸F-FDG metabolism is mildly to moderately increase. Gallbladder cancer cannot be diagnosed alone, and the possibility of gallbladder inflammatory pseudotumor should also be considered. However, it should be noted that the cases with unclear diagnosis should still be actively treated with surgery, so as not to delay the treatment opportunity.

Infant biliary cirrhosis secondary to a biliary inflammatory myofibroblastic tumor: A case report and review of literature

BACKGROUND

A biliary inflammatory myofibroblastic tumor (IMT) is a rare type of mesenchymoma that, although it has a broad age spectrum, usually occurs in adults. Diagnosis is difficult because biliary IMTs often exhibit nonspecific clinical symptoms and imaging features, resulting in delayed or inappropriate treatment. Although most IMTs are benign, some show malignant properties such as infiltration, recurrence, and metastasis.

CASE SUMMARY

Here, we retrospectively describe a 10-month-old infant who was admitted to our hospital due to stubborn jaundice. The patient responded poorly to routine medical treatment and his clinical manifestations and laboratory tests lacked specificity, so we turned to repeated ultrasound scans and other imaging examinations. As both hepatosplenic ultrasonography and diffusion-weighted magnetic resonance imaging demonstrated a space-occupying lesion, an exploratory laparotomy was performed. The final diagnosis made over two mo after the disease onset was infant biliary cirrhosis caused by a biliary IMT, which partially infiltrated into the liver. This infant is the youngest case of biliary IMTs that has been reported till now. The patient underwent an incomplete resection of the mass and Kasai Portoenterostomy. However, because of cirrhosis, he also received a paternal liver transplant. Since some IMTs show malignant properties, we proceeded with a three-year of follow-up; however, no recurrence or metastasis has been noted.

CONCLUSION

Neoplastic disease such as IMTs should be considered when routine medical treatment of obstructive jaundice is not successful. Observation of dynamic imaging changes is helpful for diagnosis. Periodic follow-up is necessary for IMTs.

A case of inflammatory pseudotumour of the gallbladder presenting as a big mass of uncertain behavior

Background

Inflammatory pseudotumour has been used to describe an inflammatory or fibrosing tumoral process of an undetermined cause that may involve a variety of organ systems, including the lungs, spleen, liver, lymph nodes, pancreas and extrahepatic bile duct with potential for recurrence and persistent local growth. In this article, we report a patient with a big mass of uncertain nature and behavior.

Case presentation

A 60-year-old woman presented with a 1-week history of abdominal pain, fever and jaundice. Six months before she had had right upper quadrant pain that was interpreted as biliary colic. A contrast-enhanced CT scan showed a big mass of soft tissue with diffuse infiltration of the gallbladder, displacement of the transverse colon, hepatic flexure and duodenum. For diagnostic distinction between a chronic inflammatory disease or a neoplasm, exploratory laparotomy was required. Intraoperative exploration disclosed a big mass of hard texture involving the gallbladder, with multiple concrements, hepatoduodenal ligament, right and transverse mesocolon, stomach and duodenum.

Cholecystectomy was performed, preserving adjacent organs with macroscopic desmoplastic reaction. Histopathologic examination of the gallbladder showed a spindle cell proliferation with diffuse chronic inflammatory infiltrate of lymphocytes, plasma cells and hyalinized fibrous stroma. No vascular invasion or cellular atypia were evident.

Conclusion

Inflammatory pseudotumour is a rare condition and diagnostic distinction from a chronic inflammatory disease or other neoplasm is only possible by histopathologic examination. There is a limited number of case reports in the literature indicating tumor location in the gallbladder.

Recurrent metastatic primary inflammatory myofibroblast tumour of the gallbladder following pancreaticoduodenectomy

Inflammatory myofibroblast tumour (IMT) is an uncommon soft tissue tumour with an unpredictable clinical course: mostly benign, occasionally locally aggressive and rarely capable of metastasis. Diagnosed mainly in the mesentery, omentum, retroperitoneum, pelvis and lungs, IMT is extremely rare as a primary gallbladder tumour. Despite improved radiographical capabilities, differentiating the tumour from other more common causes of gallbladder neoplasms necessitates histopathological and immunohistochemistry tests. Once diagnosed, malignant potential should be taken into consideration, striving for an en bloc R0 resection and postoperative long-term follow-up with routine ancillary imaging. The authors present the case of a recurrent primary IMT of the gallbladder, after two surgical treatments, including a pancreaticoduodenectomy. Now 3 years after initial diagnoses the patient is asymptomatic, but has developed local and distant metastases and is being treated with systemic corticosteroid.

Inflammatory myofibroblastic tumor of the gallbladder: a case report and literature review

A 50-year-old man had undergone chemotherapy and radiotherapy for malignant lymphoma 1 year earlier. Follow-up computed tomography revealed a gallbladder polyp. Transabdominal ultrasound demonstrated a 20-mm hypoechoic sessile polyp with basal waist in the gallbladder fundus; the surface was covered with a hyperechoic layer of non-uniform thickness. On contrast-enhanced computed tomography, the polyp showed an early uniform and sustained staining pattern. Magnetic resonance imaging revealed that the polyp had low and slightly high signal intensities on T1- and T2-weighted imaging, respectively. Gallbladder bed resection was performed with the diagnosis of special tumor. Histologically, the polyp comprised a proliferation of myofibroblast-like spindle cells with inflammatory cell infiltration, without muscularis propria or vascular invasion. Most of the polyp surface was covered with necrotic exudate, and part of the normal epithelium remained. Consequently, a diagnosis of inflammatory myofibroblastic tumor was made. The sessile shape with basal waist, epithelium shedding, and surface necrotic exudative matter may represent intraluminal expansive growth such as a subepithelial tumor. A surface with a hyperechoic layer of non-uniform thickness on gallbladder polyp can help in the diagnosis of a tumor with expansive growth directly under the epithelium with stretching/rupture of the epithelium.

Radiologic and Clinicopathologic Findings of Inflammatory Myofibroblastic Tumor

PURPOSE

The aim of the study was to describe the clinical, radiographic, and pathologic features of inflammatory myofibroblastic tumor (IMT) to enhance the recognition of this rare disease.

MATERIALS AND METHODS

The clinical, imaging, and pathologic findings were retrospectively reviewed in 54 patients with IMT lesions, which were conformed by biopsy or surgical pathology. Of 54 patients, 51 had preoperative computed tomography (CT) examination and 13 had preoperative magnetic resonance imaging records.

RESULTS

The clinical appearances of these 54 patients had some relationship with the locations of lesions. Of 54 IMT patients, 87.0% cases (47/54) had solitary lesion. The mean long diameter of the lesions located at the sites of chest, abdomen, and pelvic regions was bigger than that of other locations (F = 3.025, P = 0.038). On plain CT images, soft tissue mass was found in all IMT lesions, except for 3 lesions that arose in the intestine tract, appearing as focal or diffuse thickening in the bowel wall. After contrast administration, all lesions were persistently enhanced; 72.7% cases (24/33) demonstrated heterogeneous enhancement with various cystic regions. Comparing the CT features with different anatomic lesions, ill-defined margin on the plain CT images and calcification were seen more frequently in the lesions of the head and neck (P = 0.010 and 0.035); however, the other radiological findings had no significant differences (all P > 0.05). Twelve of 51 IMT patients showed invasion into adjacent structures. On magnetic resonance imaging, 92.3% lesions (12/13) showed soft tissue masses demonstrating isointense to hypointense contrast compared with skeletal muscle on T1-weighted images and heterogeneously high signals on T2-weighted images; 85.7%(6/7) of lesions were heterogeneously enhanced with cystic changes. Immunohistochemistry showed that the percentage of positive staining for SMA, vimentin, anaplastic lymphoma kinase, CD68, CD34, CD99, B-cell lymphoma/leukemia-2, cytokeratin, Desmin, and S-100 protein were 88.9%, 87.0%, 44.4%, 59.3%, 53.7%, 29.6%, 42.6%, 28.5%, 13.0%, and 24.1%, respectively.

CONCLUSIONS

Inflammatory myofibroblastic tumor can involve any part of the body, and the clinical and radiological appearances are various owing to different anatomic sites. An ill-defined soft tissue mass heterogeneous enhancement with or without invasion into adjacent structures on computed tomographic or magnetic resonance images and positive staining for SMA and vimentin on immunohistochemical examination could suggest the diagnosis.