Inflammatory pseudotumor in head and neck

Nonspecific inflammatory pseudotumor of the maxillary and temporal fossa: a study of seven cases

OBJECTIVE

Inflammatory pseudotumor (IPT) is a rare, locally aggressive, benign neoplasm of unknown etiology. Because of its aggressive clinical behavior and locally destructive or infiltrative features, it may be mistaken for a malignant tumor. Approximately 5%-44% of extrapulmonary IPT occur in the head and neck, primarily affecting the orbit.

STUDY DESIGN

Between 2008 and 2021, our hospital received referrals for seven patients (three men and four women, aged 42-73 years) with pain, swelling, mass, and trismus. Computed tomography, magnetic resonance imaging, and biopsy were performed on all patients to diagnose IPT.

RESULTS

Of the seven patients, four received low-dose prednisolone (PSL), one underwent surgery, and two were left untreated. The IPT disappeared in one of the two untreated cases, whereas it improved and later deteriorated in the other. The surgical patient had no recurrence. Low-dose PSL was effective in two patients; however, high-dose PSL and immunosuppressants were required in the remaining two cases owing to infiltration into each orbit or brain region.

CONCLUSIONS

Low-dose PSL treatment was applicable in IPT cases affecting the maxillary to temporal fossa region, wherein symptoms did not improve without treatment. However, when low-dose PSL was ineffective, high-dose PSL and immunosuppressants were required.

Inflammatory myofibroblastic disease of right petrous apex: A rare case with review of literature

ABSTRACT

Inflammatory myofibroblastic tumor (IMFT) is a rare tumor of unknown etiology. It can involve any part of the body. The IMFT involving the base of skull is rare with only 36 cases reported in the literature. We report a rare case of IMFT of temporal bone with review of literature. A 42 year old male presented with complaints of headache and double vision and MRI brain showed lesion in the right petrous apex region suggestive of a neurogenic mass. He had excision of lesion and histopathology was suggestive of IMFT with IgG4 and ALK positive. He had complete clinical response but a month later he presented with right eyelid ptosis and decreased rotation of eye medially with recurrent lesion on MRI. Patient received radiation by SRT technique and then started on Ceretinib with partial response. The IMFT is rare tumor of unknown etiology and tumors of temporal bone are more aggressive. It is benign but locally invasive tumor. Treatment of IMFT is controversial. Extensive surgery with complete excision has about 80% response rates and with intracranial extension, adjuvant radiation is need. In head and neck IMFT response rates are lower (30 to 40%). Monoclonal antibodies and steroids are used in IMFT at recurrence. In advanced or metastatic ALK positive tumors, Crizotinib is used with a response rate of 50%. Radiotherapy (25 to 30 Gy) induces remission and helps to taper the steroids. Temporal bone IMFT is a rare tumor with multimodality approach and variable response to treatment.

Corticodependent and recurrent inflammatory pseudo tumor. Analysis of cases and review

Inflammatory pseudo tumor (IP) is an infrequent process with benign evolution in most cases whose etiology and pathogenesis are unknown. It usually affects young men and children, in whom the macroscopic lesion can mimic a malignant process, which is ruled out after biopsy. Therefore, the diagnosis of certainty is histological and treatment consists of corticosteroids, leaving resection for cases in which biopsy is not possible or in which it produces local complications. We present a case of an inflammatory pseudo tumor with special corticodependence that began as a long-term periodic fever and splenic focal lesion that required splenectomy for its diagnosis and that, after decreasing the corticosteroid regimen, presented recurrences at the cerebellar and systemic level requiring the association of various immunosuppressants and rituximab to achieve remission. As a result of this case, we have performed an analysis of all the pseudo tumors diagnosed in adults in the hospitals of the province of Malaga, and it has been compared with that described in the bibliography.

Inflammatory Myofibroblastic Tumor of the Subglottis: A Rare Case Report

Inflammatory myofibroblastic tumor (IMT) is a very rare mesenchymal tumor that can behave as a locally benign or aggressive lesion. Here, we present an extremely rare case of IMT involving the subglottic of a middle-aged male. Steroid therapy treatment alleviated dyspnea, but the recurrence of dyspnea was reported two months later. Both sides of the subglottic tumor were excised following treatment, and the surgical specimens were subjected to histopathological evaluation and diagnosis for IMT. At 4 years after excision, follow-up laryngoscopy revealed symmetric vocal cords without evidence of any subglottic mass. Subglottic mass is often asymptomatic until it presents with hoarseness or dyspnea, and subglottic IMT is rare. Based on the successful treatment of our case, complete surgical excision is highly recommended for this rare tumor. However, further research is needed to discover a more effective and cost-effective treatment approach.

Case Report: Recurrence of Testicular Myofibroblastic Tumor After Surgery

Inflammatory myofibroblastic tumour (IMT), also known as plasma cell granuloma (PCG) or inflammatory pseudotumour (IPT), is a distinctive, rarely metastasizing neoplasm composed of myofibroblastic and fibroblastic spindle cells accompanied by inflammatory infiltration of plasma cells, lymphocytes and/or eosinophils. IMT predominantly affects children and young adults, and the age at presentation ranges from 3 to 89 years. We present a very rare case of recurrent testicular IMT without ALK rearrangement. This case highlights the clinical characteristics and diagnostic factors associated with primary and recurrent foci of this rare tumour, along with key therapeutic approaches.

Imaging features, therapies, and outcomes of fibrosing inflammatory pseudotumor of the nasopharynx: A systematic review

BACKGROUND AND PURPOSE

Fibrosing inflammatory pseudotumor (FIP) of the nasopharynx is a rare nonneoplastic inflammatory lesion that is frequently mistaken for malignancy or infection. It is often misdiagnosed by radiologists as nasopharyngeal carcinoma or lymphoma, resulting in multiple biopsies and delays in diagnosis. The purpose is to understand trends in clinical presentation, imaging findings, treatment modalities, and patient outcomes of nasopharyngeal FIP.

METHODS

MEDLINE and EMBASE databases were queried for articles related to FIP of the nasopharynx. Articles that described cases of FIP involving the nasopharynx were selected. Studies that described inflammatory pseudotumor of the nasopharynx associated with known distinct pathologic entities were excluded.

RESULTS

A total of 19 articles describing 37 patients were included. MRI findings were reported in 32 patients. All cases demonstrated avid gadolinium enhancement. T2-weighted imaging characteristics were described or displayed for 21 patients: 95% demonstrated hypointensity compared to surrounding mucosa. Fluorodeoxyglucose (FDG) PET/CT findings were reported for 6 patients, all demonstrating mild FDG avidity.

CONCLUSIONS

Nasopharyngeal FIP is a histological diagnosis of exclusion that presents with facial pain and, often, cranial neuropathies. Relatively low T2-weighted MRI signal should inform the interpreting neuroradiologist to include FIP as a differential consideration for both the ordering provider and pathologist. Corticosteroid therapy is the most frequently employed therapy and results in partial or complete response in most patients. Radiation therapy and anti-inflammatory medications have also been reported to have potential therapeutic roles.

Inflammatory Pseudotumor in the Parapharyngeal Space: Is It Possible to Diagnose by Exclusion?

Inflammatory pseudotumor (IP) is a rare pathologic condition that easily can be confounded with malignancy. The clinical presentation depends on the site of occurrence and the radiological or laboratory findings are not specific. Diagnosis can be established only with histology. We report a case of a 64-year-old woman with IP in an uncommon localization, the parapharyngeal space extending to skull base. Although the diagnosis was not certain after histopathological examination, broad diagnostic workup helped to exclude malignancy or bacterial infection and led to diagnosis of an IP by exclusion. We observed a good clinical and radiological regression of symptoms after administration of oral immunosuppressants, confirming the immunological mechanism of the disease.

Inflammatory Pseudotumor of the Temporal Bone Leading to Atypical Superior Semicircular Canal Dehiscence Syndrome: A Novel Case Report

OBJECTIVE

Inflammatory pseudotumor of the temporal bone is a benign idiopathic inflammatory process that is rarely encountered in clinical practice. We describe a novel case of a patient who developed superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone.

PATIENT

One female patient found to have inflammatory pseudotumor of the temporal bone. After treatment with mastoidectomy and steroids, she subsequently developed superior semicircular canal dehiscence syndrome.

INTERVENTIONS

The patient initially underwent myringotomy and pressure equalization tube placement for a unilateral effusion. Imaging with computed tomography and magnetic resonance imaging revealed a lytic mastoid mass. A complete mastoidectomy was diagnostic for inflammatory pseudotumor and the patient was treated with adjuvant long-term corticosteroids. After this procedure, she was discovered to have new development of symptomatic superior semicircular canal dehiscence syndrome. She eventually underwent a trans-mastoid repair of her superior semicircular canal dehiscence.

MAIN OUTCOME MEASURES

The patient's clinical course is described with emphasis on the development of superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone.

RESULTS

The patient's radiographic and clinical history were found to be consistent with inflammatory pseudotumor of the temporal bone. She underwent a therapeutic mastoidectomy with long-term post-operative corticosteroids. During her post-operative course, she developed symptoms of vertigo, hearing loss, and autophony. She was subsequently diagnosed with superior semicircular canal dehiscence and treated with a trans-mastoid repair of the dehiscence. Her symptoms satisfactorily resolved after this surgery.

CONCLUSIONS

Inflammatory pseudotumor of the temporal bone is a rare benign inflammatory process. We present what is to our knowledge the first description of superior semicircular canal dehiscence syndrome developing in the setting of inflammatory pseudotumor.

Immunoglobulin G4-related periodontitis: case report and review of the literature

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a chronic inflammatory systemic disease of unknown etiology that can affect one or multiple organs. The disease can mimic many infectious and inflammatory diseases, mainly causing organ enlargement or hyperplasia. Its diagnosis primarily relies on clinical, serologic, and histological features (lymphoplasmacytic infiltrates, storiform fibrosis, and obliterative phlebitis of IgG4 + plasma cells). Here, we report a rare case of IgG4-related periodontitis, and review the relevant literatures.

CASE PRESENTATION

A 38-year-old Chinese man visited the Department of Periodontics with gingival enlargement, loose teeth, and tooth loss. The patient had very poor oral hygiene and a large amount of calculus. Gingivae were edematous with deep periodontal pockets and attachment loss. Panoramic radiography showed alveolar bone loss. Serologic examination showed that IgG was 23.70 g/L and IgG4 concentration was 2.800 g/L. There was significant lymphoplasmacytic infiltration, a storiform pattern of fibrosis, and mitotic figures with hematoxylin and eosin staining; immunohistochemical staining showed 10 scattered IgG4-positive plasma cells in a high-power field. The patient was diagnosed as IgG4-related periodontitis. He received a course of corticosteroids with periodontal therapy, and the enlargement was significantly improved without recurrence.

CONCLUSION

IgG4-RD in the oral and maxillofacial region mainly involves salivary glands, but this rare case was characterized by enlarged gingivae. The differential diagnosis of IgG4-RD should be based on the clinical features and serologic (IgG4) and histopathological examinations. Corticosteroid therapy is effective for most IgG4-RD patients. Taken together, we hope this case report and the literature review can help dentists to improve their understanding of the IgG4-RD.

Intracranial Inflammatory Pseudotumor: A Case Report

: Primary inflammatory pseudotumor of the central nervous system is extremely rare. These lesions may be intra-axial, extra-axial, or a mix of them. We report a case of intracranial inflammatory pseudotumor involving both brain parenchyma and dura.

Laryngeal Myofibroblastic Tumor: A New Therapeutic Approach. A Case Report

Myofibroblastic tumors are rare lesions which can affect any part of the body. Although benign, their mass effect causes symptoms that can become life-threatening. Supraglottic laryngeal involvement is extremely rare, with only 4 cases described in the English literature. Because the pathophysiology is unknown and the incidence is so low, there is no standardized therapeutic management, although for laryngeal tumors surgery has traditionally been the preferred initial option. Another less common option is intravenous and oral corticosteroid therapy, but this is usually reserved for myofibroblastic tumors in other head and neck sites that are more difficult to access surgically, or patients who cannot undergo surgery. These lesions have a very high tendency to recur, and morbidity rates are therefore also high. We present a case of supraglottic myofibroblastic tumor in which we elected high-dose corticosteroid therapy as the only form of treatment. With this new therapeutic approach, we avoided the undesirable effects of the usual type of surgery. At the 12-month follow-up, the patient is in complete remission.

IgG4-related disease with pseudotumor formation in the larynx

Mikulicz's disease, an immunoglobulin G4-related disease (IgG4-RD) occurs frequently in the head and neck region but rarely in the larynx. We report a case of IgG4-RD with pseudotumor formation in the larynx. A 50-year-old man presented at our facility for a complete physical examination and diagnostic testing of a left arytenoid tumor. On examination, a large supraglottic mass was noted with signs of dyspnea. Movement disorder of the vocal fold was absent. The patient underwent surgery with general anesthesia to improve respiratory symptoms and a resected specimen was submitted for diagnosis. The pathology findings revealed lymph follicle formation, interstitial follicular fibrosis, angiogenesis, and inflammatory cell infiltration with plasmacytosis. Immunohistologic staining at high magnification revealed one hundred or more IgG4-positive plasma cells and fifty percent IgG4/IgG. In addition, obliterative phlebitis was observed. Medical history was positive for retroperitoneal fibrosis with serum IgG4 levels below the diagnostic criteria of IgG4-RD, but histological characteristics of IgG4-RD were met. The diagnosis of IgG4-RD was established, oral treatment with prednisolone (0.6 mg/kg/day) was initiated, and the tumor reduced in size. IgG4-RD may cause irreversible functional impairment. Early diagnosis and treatment are important in reducing the risk of permanent impairment of vocal fold mobility.

Ureteral inflammatory myofibroblastic tumor: A case report and literature review

RATIONALE

Inflammatory myofibroblastic tumor (IMT) is a rare soft-tissue neoplasm which has been described in a variety of locations. In the urogenital system, IMT predominantly occurs in the bladder and the kidney. IMT arising from the ureter is exceedingly rare and has been sporadically reported before.

PATIENT CONCERNS

We reported an extremely exceptional case of IMT arising from the ureteral submucosa in a 54-year-old man. The patient was hospitalized with the main complaint of intermittent and moderate left abdominal pain for 2 months.

DIAGNOSES AND INTERVENTIONS

Computed tomography scan revealed a nearly circular mass in the left upper ureter. Ureteroscopy showed that the ureteral lumen mucosa was smooth. However, the upper ureter was compressed and narrow. Renal dynamic imaging was performed and the measured glomerular filtration rate was 46.98 mL/min (right renal) and 9.77 mL/min (left renal), respectively. A retroperitoneoscopic radical nephroureterectomy was performed. The histopathologic examination revealed that the soft-tissue neoplasm was mainly composed of myofibroblastic spindle cells proliferation with mixed inflammatory infiltrate, containing lymphocytes, neutrophils, and eosinophils. On immunohistochemical staining, the tumor was positive for smooth muscle actin and Ki-67 (<1%+), indicating a confirmed diagnosis of ureteral IMT.

OUTCOMES

The patient recovered well with no occurrence of complications. At 3-year follow-up, there was no radiologic evidence of tumor recurrence or metastasis and the man was well.

LESSONS

Ureteral IMT is extremely rare and often asymptomatic, resulting in delayed diagnosis. Radiologic evidences may be suggestive of the diagnosis of IMT. However, it is necessary to make an accurate diagnosis in terms of histopathologic assessment. Complete lesion excision is the best therapeutic approach with rare recurrences and excellent survival.

Treatment-refractory ALK-positive inflammatory myofibroblastic tumour of the oral cavity

We present a challenging case of a previously healthy 23-year-old man who developed an inflammatory myofibroblastic tumour of the hard palate, harbouring a rearrangement of the anaplastic lymphoma kinase (ALK) locus. Despite surgical intervention, radiotherapy and ALK-inhibition therapy, the tumour recurred locally and metastasised to regional lymph nodes, and the patient passed away roughly 9 months after diagnosis from local progression. The rapid progression of this patient's disease and its resistance to treatment demonstrate the potentially aggressive clinical course of inflammatory myofibroblastic tumours. ALK-inhibition therapy was unsuccessful in this ALK-positive tumour, highlighting the need for further investigation of markers predictive of disease progression and treatment response.

Crizotinib in ALK+ inflammatory myofibroblastic tumors-Current experience and future perspectives

Inflammatory myofibroblastic tumor (IMT) and its subtype epithelioid inflammatory myofibroblastic sarcoma (EIMS) are rare soft-tissue tumors. As about 50% of IMT and 100% of EIMS contain activating rearrangements of the anaplastic lymphoma kinase (ALK) gene, targeted kinase inhibition of ALK by compounds such as crizotinib is a potential treatment option. We performed a literature review and analyzed a total of 30 patients with IMT/EIMS treated with crizotinib. A total of 12 patients achieved complete or partial remission. As preliminary data are promising, a prospective study evaluating crizotinib treatment in patients with unresectable/multifocal ALK⁺ IMT/EIMS is warranted.

Inflammatory Myofibroblastic Tumor: Rare Manifestation in Face

Inflammatory myofibroblastic tumor, also known as inflammatory pseudotumor and plasma cell granuloma, is a tumor that occurs most often in the lungs, abdomen, skin, soft tissue, genital system, and mediastinal. Before surgery, the diagnosis is difficult to establish because of its diverse manifestations. In the head and neck, manifestation is rare and may occur in the upper respiratory tract, soft tissues, orbits, and skull base. This article aims to report a rare manifestation of the disease in the face, highlighting the importance of a correct diagnosis to determine the most appropriate form of treatment, in male patient, leucoderma, 22 years old, with complain of a painless unilateral growth in the left cheek, beginning 2 months before and with progressive growth.

Laryngeal paralysis associated with a muscle pseudotumour in a young dog

An 18-month-old male entire Bloodhound dog was presented with a six-week history of progressive inspiratory dyspnoea, stridor, dysphonia and exercise intolerance. CT scan performed elsewhere had revealed the presence of an unencapsulated nodular mass (3x1x5 cm) dorsal to the larynx and first tracheal rings. Laryngoscopy demonstrated the presence of bilateral laryngeal paralysis and distorted laryngeal architecture suggestive of extraluminal compression. Histopathology results of incisional biopsies from the mass were suggestive of a benign non-neoplastic muscular lesion. Surgery was performed to manage laryngeal paralysis and attempt mass excision. A second histopathology examination confirmed an inflammatory and dysplastic lesion suggestive of a pseudotumour. All clinical signs resolved after surgery and at the 13 months follow-up the dog remains asymptomatic. To the authors’ knowledge, this is the first report of a case of laryngeal paralysis caused by a muscle pseudotumour in a young dog.

Inflammatory Pseudotumor of the Temporal Bone: A Case Series

OBJECTIVE

Inflammatory pseudotumor of the temporal bone is a benign, idiopathic inflammatory process that is locally invasive and a cause of significant morbidity. This study reviews our experience with seven patients and is currently the largest series to date.

STUDY DESIGN

Retrospective review from January 1, 2014 to January 1, 2016.

SETTING

Single tertiary medical center.

PATIENTS

There were five male and two female (n = 7) subjects with a diagnosis of temporal bone inflammatory pseudotumor. The mean age at presentation was 41 years old. The most common presenting symptoms were hearing loss (7/7) and headache (4/7). Four patients demonstrated an inflammatory aural polyp. Two patients experienced facial nerve paralysis.

INTERVENTION(S)

Seven patients underwent computed tomography and six underwent magnetic resonance imaging. Corticosteroids and antibiotics were the initial treatment of choice. Five patients also underwent surgery. As adjuvant therapy, two patients received Rituximab, one patient received radiation, and one received mycophenolate mofetil.

MAIN OUTCOME MEASURE(S)

Clinical courses were followed with focus on symptoms, disease recurrence, duration, and treatment. Mean follow-up was 17.8 months.

RESULTS

The primary lesions demonstrated T2 hypo-intensity and enhancement as well as diffuse dural thickening on magnetic resonance imaging in five of six patients. Histopathology demonstrated chronic inflammation in the setting of hyalinized fibrosis (7/7). All the patients are currently symptomatically stable.

CONCLUSION

Inflammatory pseudotumor of the temporal bone can cause devastating effects on neurological function and quality of life. Recognition of characteristic imaging and histopathology can expedite appropriate treatment. Patients may require chronic steroid therapy. Adjunctive therapy with radiation and immuno-modulation are currently being explored.

A rare case of inflammatory myofibroblastic tumor of the mandible mimicking a malignant tumor

Inflammatory myofibroblastic tumor (IMT) of the head and neck is a rare benign proliferative lesion of unknown etiology that mimics malignant lesions clinically and radiographically. I report the case of a 27-year-old woman who presented with a mass in her left mandible associated with restricted mouth opening that had developed over the preceding 7 months. The mass was resected completely with 5 mm margin under general anesthesia. The mass was extending to the floor of the mouth and impinging on the masseter and temporalis muscles. Given its characteristics of being localized and aggressive, complete surgical resection is the best treatment modality for IMT.

IgG4-related disease causing facial nerve and optic nerve palsies: Case report and literature review

IgG4-related disease (IgG4-RD) is increasingly being recognized as an entity effecting the head and neck region. Although most commonly seen with salivary gland or paranasal sinus involvement, IgG4-RD may also involve the temporal bone and skull base. We report a rare care of a 61-year-old female with IgG4-RD presenting as synchronous lesions of the middle ear and middle cranial fossa with polyneuropathy of cranial nerves II, VI, and VII. Initial histopathological evaluation of her resected ear mass suggested a benign inflammatory process but no specific diagnosis. Her symptoms progressed over 10months prompting re-evaluation of the specimen and consideration of the IgG4-RD diagnosis. Key pathologic features included prominent lymphoplasmacytic population, storiform fibrosis, obliterative phlebitis, and IgG4 specific staining. The patient was treated with high-dose intravenous and oral steroids but was transitioned to azathioprine secondary to steroid-induced myopathy. Radiographic studies before and after treatment reveal marked improvement of the intracranial and extracranial disease. Correspondingly, her cranial neuropathies resolved. A high degree of clinical suspicion is necessary to diagnosis IgG4-RD. The diagnosis can be supported by elevated serum IgG, elevated IgG index, and pathognomonic histopathological findings. Primary treatment is with corticosteroids. However, immunotherapy using azathioprine or rituximab can be utilized in recurrent disease or patients with steroid intolerance.

Killian's polyp mimicking malignant tumor

Killian polyp is predominantly found in children and any sinonasal tumor in elderly presenting with epistaxis and pain usually indicates malignant growth until proved otherwise. We present an unusual case of Killian polyp in an elderly patient that behaved as a malignant tumor. This case report reminded us that paranasal sinuses are still dark hollow mysterious cavities, and we should take utmost clinical acumen in managing such cases.

The great mimicker: a rare case of head and neck inflammatory pseudotumour in the presence of human immunodeficiency virus

BACKGROUND

Inflammatory pseudotumours of the head and neck are rare. A connection has been made between inflammatory pseudotumours and human immunodeficiency virus positivity.

CASE REPORT

This paper reports a case of an inflammatory pseudotumour presenting with a lesion in the left tonsil and left cervical lymph node in a 49-year-old human immunodeficiency virus positive patient. A histological diagnosis was obtained after biopsy and serial radiological imaging.

CONCLUSION

Diagnostic uncertainties can lead to unnecessary surgery. It is important to recognise the clinical, radiological and histological indicators of an inflammatory pseudotumour to enable a timely diagnosis and arrange appropriate treatment. In patients with co-morbidities causing immunocompromise, the potential diagnosis of an inflammatory pseudotumour should be considered. This is especially the case in human immunodeficiency virus patients, as inflammatory pseudotumours have been associated with immune reconstitution inflammatory syndrome, which can manifest up to several years after the initiation of, or change in, antiretroviral therapies.

Bilateral inflammatory myofibroblastic tumor mastoiditis

BACKGROUND

Inflammatory myoblastic tumors (IMTs) are rare, mesenchymal neoplasms most commonly located in areas of previous inflammation. In the temporal bone, these tumors typically present as solitary, space-occupying lesions that clinically resemble chronic otitis media.

METHODS

We present a case of bilateral IMTs with facial nerve involvement, sigmoid sinus thrombosis, leptomeningeal enhancement, and seizures.

RESULTS/CONCLUSION

This case demonstrates the need for a high index of suspicion of IMT when imaging reveals bilateral mastoid opacification. These tumors are more aggressive than their orbital counterparts and require multimodality therapy to prevent recurrence and alleviate severe neurotologic symptoms.