Inflammatory pseudotumours of the liver: a spectrum of presentation and management options. Eur J Surg Oncol. 2009;35:1295-1298. [PMID: 19515527 DOI: 10.1016/j.ejso.2009.04.003]

Hepatic pseudotumor: A diagnostic challenge

Hepatic pseudotumors are rare lesions of unknown origin, characterized by the proliferation of fibrous connective tissue and inflammatory cell infiltrates. They mimic malignant lesions clinically, and radiologically, given their non-specific clinical and imaging features. The pathophysiology of hepatic pseudotumor is incompletely understood and there are no standardized criteria for diagnosis. Pseudotumors have been reported to develop in various organs in the body with the lung and liver being the most common site. Hepatic pseudotumors develop in patients with underlying triggers of liver inflammation and injury, including infections, autoimmune liver diseases, bile duct injury, or surgery. Hepatic pseudotumors respond well to conservative treatment with antibiotics, and steroids and some may regress spontaneously, thus avoiding unnecessary resection. This condition is rewarding to treat. It is important to recognize pseudotumor as a distinct clinical entity and include it in the differential of liver masses with atypical imaging features.

Inflammatory Pseudotumor of the Liver

Hepatic inflammatory pseudotumor (IPT) describes a mass lesion composed of fibroblasts or myofibroblasts with a dense inflammatory infiltrate comprising lymphocyte, plasma cells, and histiocytes. These lesions are presumed to be an exuberant response to an infectious organism, although in most cases the causative agent is unknown. In specific circumstances, pathologists should consider ancillary techniques to exclude specific infections, such as mycobacteria, Candida, or syphilis. IgG4-related disease may cause a plasma-cell rich IPT. Finally, true neoplasms can mimic IPTs and must be excluded with appropriate ancillary studies, including inflammatory myofibroblastic tumor, follicular dendritic cell tumor, inflammatory angiomyolipoma, Hodgkin lymphoma, and inflammatory hepatocellular carcinoma.

IgG4-related inflammatory pseudotumor of the liver presenting as an incidental solitary liver mass

Inflammatory pseudotumor is increasingly being recognized as a definitive pathological entity affecting many organ systems and often difficult to distinguish from malignancy. We report a case of a 48-year-old female who presented with right hypochondrial pain associated with nausea and vomiting and recent weight loss. An ultrasound scan demonstrated gallstones without evidence of cholecystitis and an incidental 1.5 cm mass in the left liver lobe. A computed tomography (CT) and a magnetic resonance imaging (MRI) scan described the mass suspicious of a malignant tumour. An ultrasound-guided biopsy confirmed a benign inflammatory mass with lymphoplasmacytic infiltration staining for IgG4 and no evidence of malignancy. The patient had an elevated serum IgG4 levels. The patient was kept under surveillance. She underwent a laparoscopic cholecystectomy and at 18 months following the initial presentation the patient remains asymptomatic with stable liver lesion on ultrasound scan.

[Inflammatory Myofibroblastic Tumor Misdiagnosed as Intrahepatic Cholangiocarcinoma]

An inflammatory myofibroblastic tumor (IMT) is a rare tumor that is currently classified as an intermediate cancer according to the World Health Organization classification system. The pathophysiology of its occurrence is still unknown. Imaging tests, such as CT or MRI, can be helpful in diagnosis, but the final diagnosis is confirmed by a pathological examination through a biopsy and immunohistochemistry stain. The patient, in this case, presented an asymptomatic intrahepatic mass discovered incidentally on an imaging examination. Initially, intrahepatic cholangiocarcinoma was suspected, but she was finally diagnosed with IMT through a histological examination after a liver resection.

Clinical and pathological characteristics of patients with pulmonary inflammatory pseudotumors: An 18-year retrospective study of 31 cases

To investigate the clinical and pathological characteristics in patients with pulmonary inflammatory pseudotumors (PIP).This retrospective study included 31 patients with PIP from 2001 to 2019. Preoperative computed tomography scan was performed in all patients. Clinical and pathological characteristics were collected and analyzed.Thirty-one patients (16 female and 15 male) were recruited, with a median age of 57 years (range, 11-72 years). Eight (25.8%) patients were asymptomatic, and the others had symptoms characterized by cough with sputum, chest and back pain, dry cough, fever and blood in sputum, or hemoptysis. All cases were single lesions, including 23 cases in the right lung, and 8 cases in the left lung. Computed tomography scan demonstrated irregular lobulated nodules or masses in 14 patients, and regular round or oval nodules or masses in 11 cases. The blurred edge of tumors and spiculation was found in 12 cases. Microscopic results were characterized by the collection of inflammatory mesenchymal cells. Immunohistochemical examination showed vimentin, smooth muscle actin, and anaplastic lymphoma kinase positive. Complete tumor resection was obtained in all cases. No recurrence or metastasis was observed during the follow-up period.PIP has a variety of manifestations. Preoperative diagnosis is difficult to reach. The final diagnosis still depends on the pathological and immunohistochemical examination. Complete surgical resection is the main treatment at present, and the overall prognosis is good.

Fibrohistiocytic Variant of Hepatic Pseudotumor: An Antibiotic Responsive Tumefactive Lesion

Inflammatory pseudotumor is a term used to designate inflammation-rich tumefactive lesions. Following the exclusion of specific entities such as IgG4-related disease and other neoplastic entities previously included in this entity, the majority of hepatic pseudotumors show a prominent fibrohistiocytic inflammatory reaction and have been previously categorized as fibrohistiocytic variant of hepatic pseudotumor (FHVHPT). The goal of this study was to examine the clinical, radiologic, histologic, and etiologic aspects of this entity. After excluding neoplastic diseases, we identified 30 patients with FHVHPT from 3 institutions between 2009 and 2019. We extracted demographic and clinical data, liver function tests as well as culture results and radiologic information. Hematoxylin and eosin-stained slides were reviewed for pattern of inflammation as well as its cellular composition. Immunohistochemistry for IgG4 and IgG was performed in all cases. The mean age of the 30 lesions characterized as FHVHPT was 56 years (range: 23 to 79 y). Nineteen patients showed solitary lesions; 11 were multiple. The mean size of the lesion was 3.8 cm (range: 1 to 7.5 cm). On imaging, a neoplastic process or metastasis was the leading diagnostic consideration (n=15, 50%). The most common symptom was abdominal pain (n=14/30); 8 patients presented with symptoms compatible with an infectious process, including fever. The inflammatory infiltrate was dominated by lymphocytes and plasma cells, and in most cases, a prominent histiocytic infiltrate (22/30). Neutrophils were identified in 12 cases, with microabscess noted in 8. Storiform pattern of fibrosis was seen in 14/30 cases; obliterative phlebitis was not identified. Culture identified a microorganism in 4 of 9 cases evaluated. The mean IgG4 count was 9.3 per HPF (range: 0 to 51) with 9 of the 26 (35%) biopsies showing >10 IgG4 positive plasma cells per HPF. The mean IgG4 to IgG ratio was 8% (range: 8% to 46%). A hepatectomy was performed in 4 cases. On broad spectrum antibiotics (n=14) the lesions either resolved or decreased in size. Eight patients did not receive specific therapy, nevertheless, the lesion(s) resolved spontaneously in 6 cases, remained stable or decreased in size in 2 cases. Notably, none of these patients showed evidence of a hepatic recurrence. FHVHPT, a tumefactive lesion that mimics hepatic neoplasia, is histologically characterized by a fibrohistiocytic infiltrate. In the majority of patients FHVHPT represents the organizing phase of hepatic abscess and can be successfully managed with antibiotic therapy.

Inflammatory pseudotumors of the liver: Importance of a multimodal approach with the insistance of needle biopsy

CONTEXT:

Inflammatory pseudotumor (IPT) of the liver is a rare, tumor-like lesion that is considered to be biologically benign but often mimics malignancy.

AIMS:

The aim of the study was construe clinicopathological features, imaging findings, differential diagnosis, management, and follow-up of IPT involving the liver.

SETTINGS AND DESIGN:

It is a retrospective study.

SUBJECTS AND METHODS:

Cases included were of IPT, diagnosed on histopathology, at our center from June 2009 to December 2016. Details studied were clinical presentation, imaging studies, laboratory investigations, pathological features, treatment, and follow-up of the cases and compared with reports in the literature.

RESULTS:

A total of cases of IPT included were 17. The age of the patients ranged from 21 to 62 years. Common presenting features were intermittent fever, upper abdominal pain, and weight loss. Radiological diagnosis varied from neoplastic (13) to infectious etiologies (4), with hepatocellular carcinoma being the most common differential (7/17). Laboratory investigations revealed leukocytosis, hyperbilirubinemia, raised transaminases, and raised serum alkaline phosphatase. Core biopsy of a tumor conceded increased fibrosis along with mixed inflammatory cell infiltrates. Eleven cases were managed conservatively and showed regression or complete recovery. Six patients underwent surgical resection. None of these had any recurrence in median follow-up of 22 months.

CONCLUSIONS:

IPT of the liver can masquerade as a fatality, either primary or metastatic. It will be well managed with conservative modalities and can avoid redundant hepatectomy, reserved for complicated cases. For this intent, accurate preoperative diagnosis is the requisite, and needle biopsy with or without fine-needle aspiration cytology plays as a significant rescuer in this field.

Hepatic Inflammatory Pseudotumor Protruding from the Liver Surface and Directly Penetrating the Colon

A 69-year-old man was diagnosed with a liver abscess and received antibiotics at a local hospital. He was referred to our hospital due to a persistent fever. He had hepatic masses protruding from the liver surface toward the transverse colon. We reached a diagnosis of inflammatory pseudotumor (IPT) by a percutaneous liver biopsy. Colonoscopy showed direct invasion of IPT to the colon. His condition improved by the intravenous administration of antibiotics. Hepatic IPT is often misdiagnosed as a malignant tumor. We should consider IPT when we encounter hepatic tumors, and a percutaneous liver biopsy is useful for avoiding unnecessary excessive treatments.

A Pancreatic Inflammatory Myofibroblastic Tumor with Spontaneous Remission: A Case Report with a Literature Review

The inflammatory myofibroblastic tumor (IMT) is a rare tumor that can develop in any systemic organ. Its features are generally benign, but it often resembles malignancies and is treated surgically. Our patient was an 82-year-old female complaining of abdominal discomfort. Computed tomography demonstrated a 5 cm, ill-enhanced mass at the pancreas head. Upper gastrointestinal endoscopy revealed a duodenal submucosal tumor with apical erosion. Endoscopic ultrasonography (EUS) demonstrated a heterogeneous, low-echoic pancreas mass without clear margins. Fine-needle aspiration biopsy (FNAB) demonstrated spindle myofibroblastic tissues with lymphoplasmacyte and eosinophil infiltration, confirming an IMT diagnosis. Surprisingly, the tumor spontaneously regressed in one month without medication. Histological diagnosis using EUS-FNAB is essential for the rare pancreatic solid tumor like IMT.

Inflammatory Pseudotumor of the Liver Presented in a Patient with Cholelithiasis

An inflammatory pseudotumor of the liver is a rare tumor-like lesion consisting of an inflammatory infiltrate that often can mimic a malignant liver neoplasm. The cause of an inflammatory pseudotumor of the liver is unknown, but it has been reported to be associated with different comorbid conditions most likely inflammatory or infectious in origin. We present an 83-year-old female who presented with a symptomatic gallstones disease and an incidental finding of inflammatory pseudotumor mimicking intrahepatic cholangiocarcinoma in preoperative liver imaging. Differentiating a pseudotumor from hepatic space-occupying neoplasms is crucial since it is one of the most important tumor-mimicking lesions. The imaging findings of this rare tumor can pose diagnostic difficulties because of the amount of fibrosis and cellular infiltration. If malignancy has been excluded, patients can be treated conservatively with steroids and non-steroidal anti-inflammatory drugs. However, complete surgical resection has been the modality of treatment for most of the cases with an indeterminate diagnosis.

Role of MR in the differentiation of IgG4-related from non-IgG4-related hepatic inflammatory pseudotumor

BACKGROUND

Hepatic inflammatory pseudotumor (IPT) is classified into 2 types based on IgG4 stain: IgG4-related and non-IgG4-related; the two types differ not only in their pathological characteristics, but also in the clinical features. This study aimed to investigate the MR character of hepatic IPT, and differentiate the IgG4-related IPT from the non-IgG4-related IPT.

METHODS

Twenty-five patients with 27 histologically proven hepatic IPTs were retrospectively analyzed. Ten lesions were diagnosed as IgG4-related IPT, and the other 17 as non-IgG4-related IPT. The MR signal features on T1, T2-weighted, dynamic-enhanced, and diffusion-weighted imaging were evaluated and compared.

RESULTS

The dominant lesions were subcapsularly distributed (n=17, 63.0%) with clear boundary (n=20, 74.1%), and showed progressive enhancement pattern (n=21, 77.8%) with diffuse homogeneous (n=12, 44.4%) or heterogeneous (n=8, 29.6%) hyperintensity, accompanied by delayed capsule-like enhancement (n=17, 63.0%) and central nonenhanced areas (n=18, 66.7%). Morphological features (P>0.05) were not sufficient to differentiate IgG4-related IPT from non-IgG4-related IPT; the wash-out pattern was only found in 2 IgG4-related IPT, while the progressive enhancement pattern was more common in the non-IgG4-related lesions (n=16) (P=0.022). During portal and delayed phases, iso-/hypoenhanced lesions were only seen in 3 IgG4-related IPT, and circular-enhanced lesions (n=5) existed exceptionally in the non-IgG4-related group with significant differences (P=0.029 and 0.027). Most IgG4-related IPTs had lower apparent diffusion coefficient compared with the liver parenchyma (n=6), while most non-IgG4-related IPTs had higher apparent diffusion coefficient value (n=13) (P=0.046).

CONCLUSIONS

Although MR images of hepatic IPT have certain characteristics, they are not enough to differentiate IgG4-related IPT from non-IgG4-related IPT. The enhancement pattern, signal features on portal and delayed phases, and the apparent diffusion coefficient value of the lesion may be helpful for the diagnosis.

Primary benign liver lesions

Benign focal liver lesions can origin from all kind of liver cells: hepatocytes, mesenchymal and cholangiocellular line. Their features at imaging may sometimes pose difficulties in differential diagnosis with malignant primary and secondary lesions. In particular, the use of MDCT and MRI with extracellular and hepatobiliary Contrast Agents may non invasively help in correct interpretation and definition of hepatocellular or mesenchymal and inflammatory nature, allowing to choose the best treatment option. The peculiarities of main benign liver lesions at US, CT and MRI are described, with special attention to differential diagnosis and diagnostic clues.

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.

A caecal pseoudotumour with an incidental adenomatoid testicular tumour in a man with right undescended testis: a case report

BACKGROUND

Inflammatory pseudotumour refers to a non-malignant tumour-like mass resulting from an inflammatory reaction that is composed of granulation tissue with leukocyte infiltration that commonly occurs in the paediatric or young adult population. These tumours occur more commonly in the lungs and the orbit but rarely does it affect the gastrointestinal tract. It poses a clinical diagnostic challenge since it is a benign condition than can mimic the malignant counterpart. Our case is a rare presentation of the caecal pseudotumour in the presence of a right undescended abdominal testis evaluated as a caecal tumour with a differential diagnosis of a testicular malignancy.

CASE PRESENTATION

We report a 53-year-old male who presented with clinical signs suggestive of right colon tumour and undescended right testis. Intra-operatively, a caecal mass was found with no clearly discernable appendix and extensive adhesion of the right colon to the retroperitoneum, to the liver and gall bladder. A testis was found adherent to the posterior aspect of the caecum and terminal ileum. A right hemicolectomy was performed. Histopathology findings revealed an inflammatory mass with abundant fibroblast proliferation and chronic inflammatory cells infiltrate, involving bowel wall and periceacal adipose tissue; no malignant cells were identified. The testis had within it an adenomatoid tumour nodule. He had uneventful recovery and was discharged home 7 days post-operatively. At the moment, he is symptoms free.

CONCLUSIONS

The occurrence of right colonic inflammatory pseudotumour and co-existent adenomatoid testicular tumour arising from a cryptorchid testis is very unusual. This would make one incline towards a malignant testicular lesion in the presence of cryptorchidism. Testicular adenomatoid tumour is a rare benign neoplasm, mostly affecting fully descended testis and usually does not warrant orchidectomy for purposes of preserving testicular function. On the other hand, surgical resection remains the only safe and curative treatment option available for inflammatory pseudotumours.

Inflammatory myofibroblastic tumors in children

BACKGROUND

Inflammatory myofibroblastic tumor (IMFT) is an uncommon neoplasm in children.

METHODS

Retrospective review from 1993 to 2014 of patients ≤18years of age with a histopathologic diagnosis of IMFT treated at two tertiary centers.

RESULTS

Thirty-two patients were diagnosed with IMFT. Mean (±SD) age was 9.3±5.7years at diagnosis. Tumor location was variable: abdomen/pelvis (28%), head/neck region (22%), intrathoracic (22%), genitourinary (9%), bowel (6%) liver (6%), and musculoskeletal (6%). Median follow-up was 2.6±4.6years, with 3 recurrences and 2 deaths, which occurred only after recurrence. Positive microscopic margin after resection was associated with recurrence, compared to those that had a negative margin (40% vs. 0%, p=0.04). Recurrence was associated with increased mortality (67% vs 0%, p=0.01). Time from first symptoms to resection was shorter in those with recurrence (25.8±22 vs. 179±275days, p=0.01) and in nonsurvivors (44.0±8.0 vs. 194.3±53.4days, p=0.02). Adjuvant chemotherapy, not including steroid monotherapy, either given before or after resection, was administered more often to nonsurvivors (100% vs 4%, p=0.009), and use of corticosteroids was also higher in the nonsurvivors (100% vs. 15%, p=0.04).

CONCLUSIONS

IMFT is a rare pediatric neoplasm with variable locations. Complete excision is critical for cure. Proposed guidelines for diagnosis, treatment and surveillance of theses tumors in children are reported.

Inflammatory Myofibroblastic Tumors: Current Update

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate biological potential with a predilection for the lung and abdominopelvic region. IMT represents the neoplastic subset of the family of inflammatory pseudotumors, an umbrella term for spindle cell proliferations of uncertain histogenesis with a variable inflammatory component. IMTs show characteristic fasciitis-like, compact spindle cell and hypocellular fibrous histologic patterns and distinctive molecular features. Imaging findings reflect pathologic features and vary from an ill-defined, infiltrating lesion to a wellcircumscribed, soft tissue mass owing to variable inflammatory, stromal, and myofibroblastic components.

Inflammatory pseudotumor of the liver occurring during the course of hepatitis C virus-related hepatocellular carcinoma treatment: A case report

•

Occurrence of IPT of the liver during the course of HCC treatment is rare.

•

IPT of the liver may resemble moderately differentiated HCC on dynamic enhanced CT.

•

Hepatic IPT may be associated with latent inflammatory reactions to HCV activity despite negative HCV-RNA.

•

Hepatectomy should be considered for a hepatic lesion suspected as HCC but may be IPT.

Introduction

Inflammatory pseudotumor (IPT) of the liver is a rare and benign disease that has a good prognosis. It is often difficult to distinguish IPT from hepatic malignancies, such as hepatocellular carcinoma (HCC), because specific clinical symptoms are absent and the diseases’ radiological findings can be similar. IPT is particularly difficult to distinguish from HCC in livers with hepatitis C virus (HCV)-related cirrhosis. We report a case of IPT of the liver that mimicked HCV-related HCC recurrence.

Presentation of case

A 78-year-old asymptomatic Japanese man who had undergone hepatectomy for HCV-related HCCs (moderately differentiated type) in segments 7 and 5 four and a half years previously was referred to our hospital for treatment of a 30-mm enhanced tumor in segment 5 (a typical HCC pattern). The tumor was identified via abdominal dynamic computed tomography (CT) and CT with hepatic arteriography and arterial portography. Thereafter, liver segmentectomy 5 was performed, and the histopathological diagnosis was a 10-mm IPT of the liver. After 1.5 years, magnetic resonance imaging revealed two new enhanced lesions in segment 8, which showed the typical pattern of HCC. Because these lesions grew in size for 3 months, liver segmentectomy 8 was performed for HCC recurrence. Histopathological examination showed that both lesions were HCCs.

Conclusion

HCV-related HCC has a high rate of multicentric recurrence. Our experience suggests that, when a hepatic lesion is suspected to be HCC, surgical resection should be considered for curative treatment and to rule out malignancy, even if the lesion may be an IPT.

Inflammatory Pseudotumor (IPT) and Inflammatory Myofibroblastic Tumor (IMT): A Representative Literature Review Occasioned by a Rare IMT of the Transverse Colon in a 9-year-old Child

Aims and Background

Inflammatory pseudotumor (IPT) and inflammatory myofibroblastic tumor (IMT) represent different entities. However, it is only in recent years that this has been taken into increasing consideration. Some authors still use both terms synonymously or interchangeably. Inflammatory myofibroblastic tumor is a real neoplasm because of the proliferation of myofibroblastic cells. Inflammatory pseudotumor is a more inflammatory reactive or regenerative entity and shows an overlapping with immunoglobulin G4-related disease.

Methods and Study Design

To analyze the current situation, 443 publications from the last 5 years (2009 to February 2014) were included. Reports involved 938 patients and 956 organ sites. The age distribution is twin peaked with one maximum in childhood and the other between 50 and 60 years of age. This distribution is questionable due to the more frequent occurrence of IPT in the liver and of IMT in the lung. Inflammatory pseudotumors mainly occur in older patients; IMTs in children and young adults.

Results and Conclusions

The liver and biliary tract were the most commonly affected of all body regions, at 32%. This was followed by the lung, including the respiratory tract, at 27%, and by the gastrointestinal tract, at 10%. Lesions of the large bowel, as in the present case of a 9-year-old boy, are very rare. There were organ-related as well as nonspecific clinical symptoms, such as fever, weight loss, and fatigue. Laboratory test results revealed anemia and elevated inflammation-dependent parameters. The patterns in medical imaging are variable and nonspecific. Morphology often suggests a malignant process. For this reason, therapy in most cases is surgical, but this is required more often in IMTs. Many IPTs could be treated conservatively.

IgG4-related inflammatory pseudotumour mimicking a hepatic abscess impending rupture

A 50-year-old man presenting with sudden onset right upper quadrant pain and no constitutional symptoms was found to have two necrotic liver masses on imaging, consistent with hepatic abscesses unresponsive to systemic antibiotics and percutaneous drainage. The patient deteriorated and developed symptoms consistent with impending rupture. He therefore subsequently underwent right hepatic segmentectomy. All cultures were negative and histopathology confirmed IgG4 related disease/inflammatory pseudotumour of the liver. Postoperatively, the patient was asymptomatic with no IgG4 disease activity in other organs.

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

Reported here is the case of a 55-year-old man who had tarry stools for 3 days before he was seen at this Department. The man had weight loss and an intermittent fever for 3 months prior. Histopathology revealed an inflammatory pseudotumor of the liver. This case is reported here along with a review of the literature. Nine days after surgery, the patient passed bright red blood (150 mL) in the stool with no clear trigger. A colonoscopy a month later revealed no abnormalities. This is a rare report of an inflammatory pseudotumor featuring intractable bleeding. An inflammatory pseudotumor of the liver is a rare condition, and differentiating this pseudotumor from hepatic space-occupying lesions is crucial. An inflammatory pseudotumor of the liver may spontaneously regress and mimic other liver tumors. The treatment of choice for this pseudotumor is still surgical resection, and this is especially true for patients with severe symptoms or an indeterminate diagnosis.

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.

Two pseudotumor cases mimicking liver malignancy

Inflammatory pseudotumor of the liver is a rare benign tumor that can be confused with malignant tumors of the liver. It is usually diagnosed after pathologic evaluation of the resected lesion. If a mass lesion in the liver is suspicious for malignancy on radiologic evaluation then surgical resection is planned for suitable patients rather than a biopsy. Inflammatory pseudotumors are similar to malignant tumors on macroscopic assessment, but microscopically they are characterized by the presence of inflammatory cells. In case of clinical or radiologic suspicion, the lesion is biopsied and once the diagnosis of inflammatory pseudotumor is made the lesion is managed by conservative-medical treatment. It must be kept in mind as part of differential diagnosis to avoid unnecessary surgery.

Inflammatory Myofibroblastic Tumor of Liver Masquerading as Focal Nodular Hyperplasia in a Patient with Non-Cirrhotic Portal Hypertension and Biliary Pancreatitis

Inflammatory myofibroblastic tumor (IMT) is a rare lesion of undetermined pathogenesis characterized by proliferation of spindled myofibroblast cells in a collagenized inflammatory background. It is usually benign but may show local infiltration or, in rare cases, metastasis. IMT has been observed in almost all solid organs; however, involvement of liver is exceptional. Its symptoms and radiological findings can mimic malignancy and pose diagnostic difficulties. The authors report the case of a 43-year-old woman with non-cirrhotic portal hypertension and gall stone induced acute pancreatitis having a mass in the right lobe of the liver which was initially diagnosed as focal nodular hyperplasia on imaging but proved to be inflammatory myofibroblastic tumor on pathological and immunohistochemical examination. The lesion resolved with conservative management without the need for surgical intervention.

Inflammatory pseudotumor of the colon causing intussusception: A case report and literature review

Inflammatory pseudotumor (IPT) is a rare space-occupying lesion of unknown etiology that can mimic malignancy on clinic-radiological and pathological examination. We describe a rare case of ileocecal intussusception from clinically suspected malignancy of the right colon where the patient underwent right hemicolectomy. Histopathology of the resected specimen confirmed IPT of the colon. This patient was observed to have abnormally elevated total leukocyte count and platelets before and after surgery. In an adult with intussusception associated with an abdominal mass, the possibility of IPT of the colon should be considered. Considering the abnormally high total leukocyte and platelet counts and colonic IPT, it is necessary to prevent postoperative adverse effects due to these changes. Although IPT of the colon is usually a benign process, controversy regarding its management still exists. We consider hemicolectomy as a safe treatment approach for colonic IPT and review the existing literature.

Diagnosis and management of solid benign liver lesions

More and more asymptomatic benign liver tumours are discovered incidentally and can be divided into regenerative lesions and true neoplastic lesions. The most common regenerative lesions include hemangioma, focal nodular hyperplasia and inflammatory pseudotumours of the liver. Neoplastic lesions include hepatocellular adenomas and angiomyolipomas. Regenerative lesions rarely increase in volume, do not yield a higher risk of complications and usually do not require treatment. By contrast, hepatocellular adenomas and angiomyolipomas can increase in volume and are associated with a risk of complications. Large hepatocellular adenomas (>5 cm in diameter) are undoubtedly associated with a risk of bleeding and malignant transformation, particularly the inflammatory (also known as telangiectatic) and β-catenin mutated subtypes. Accurate diagnosis needs to be obtained to select patients eligible for surgical resection. MRI has markedly improved diagnosis and can identify the major hepatocellular adenomas subtypes. The use of biopsy results to inform the indication for resection remains questionable. However, when diagnosis remains uncertain after imaging, percutaneous biopsy could help improve diagnostic accuracy.

Intra-abdominal inflammatory myofibroblastic tumor: Spontaneous regression

Inflammatory myofibroblastic tumors are usually treated by surgical resection. We herein report two cases of intra-abdominal inflammatory myofibroblastic tumors that were unresectable and underwent spontaneous regression without any treatment. Our case report and literature review show that regression is more common in the middle-aged and older male populations. Abdominal discomfort and fever were the most common symptoms, but the majority of patients had no obvious physical signs. There was no specific indicator for diagnosis. The majority of the lesions regressed within 3 mo and nearly all of the masses completely resolved within 1 year. We conclude that the clinical characteristics of inflammatory myofibroblastic tumors are variable and, accordingly, the disease needs to be subdivided and treated on an individual basis. Surgery is always the first-line treatment; however, for those masses assessed as unresectable, conservative therapy with intense follow-up should be considered.

Inflammatory Myofibroblastic Tumor of the Liver: A Diagnostic Challenge

Inflammatory myofibroblastic tumor (IMT) is an uncommon myofibroblastic neoplasm that was formerly included within the broad category of inflammatory pseudotumor (IPT). IMT is rarely encountered in the liver. Similar to IMT of other organs, the interchangeable use of the terms IMT and IPT in liver has made the analysis of these lesions difficult. In this review, clinical and pathological features of IMT of the liver are reviewed and the differential diagnosis of IMT is discussed, with emphasis on IPT and the other entities included in this large category. IMT can mimic malignant tumors. There are no known unique diagnostic clinical, laboratory, or radiological features. The definitive diagnosis of IMT depends on careful pathological examination. The histopathological evaluation of hepatic IMT reveals that, the myxoid/vascular pattern is the most frequently observed, followed by, in decreasing frequency, fibrous histiocytoma-like pattern and hypocellular fibrous pattern. In IMT of the liver, anaplastic lymphoma kinase (ALK) expression reliably predicts the presence of an ALK gene rearrangement. The diagnosis of hepatic IMT depends on the dominant histopathological pattern, and the management of the disease is still controversial. IMT of the liver is a distinctive neoplasm of intermediate biological potential, and should be distinguished from the variety of lesions that are included under the broad category of IPT. Therefore, to avoid confusion regarding the true incidence and behavior of hepatic IMT, the term IPT should not be used interchangeably with IMT. The rarity of IMT in liver should not minimize its consideration in the differential diagnosis of liver tumors, especially in patients with tumor markers in normal range.

Inflammatory pseudotumor of the liver: a rare case of recurrence following surgical resection

Inflammatory pseudotumor (IPT) of the liver is a rare, benign lesion that may be mistaken for malignancy. IPTs are difficult to diagnose due to non-specific clinical, laboratory and imaging features. We report the case of a 38-year old Asian male who presented with fatigue, weight loss and hepatomegaly. He was found to have a large hepatic IPT and underwent surgical resection; approximately two and a half years later, he developed acute cholangitis secondary to IPT recurrence. We present the imaging features of hepatic IPT using ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). We also review the literature on the diagnosis and management of this disease. The unique features of this case include the IPT's recurrence following surgical resection, large size and multiple modalities presented.

Two rare manifestations of Q fever: splenic and hepatic abscesses and cerebral venous thrombosis, with literature review ma non troppo

Q fever is a zoonosis caused by Coxiella burnetii. It often manifests as a flu-like syndrome; other common manifestations are pneumonia, hepatitis and endocarditis. Its course may be acute or chronic. The authors present two clinical cases of Q fever with rare manifestations. Case 1: A 55-year-old man admitted due to abdominal pain, diarrhoea and fever. Blood tests showed elevated transaminases, low platelets and elevated C reactive protein, with normal white cell counts; abdominal ultrasound showed splenic and hepatic abscesses. Serologies to C burnetii were positive (1:640), leading to the diagnosis of Q fever with splenic and hepatic abscesses. Case 2: A 47-year-old man admitted due to headache after sneezing, with unstable gait and vertigo. A brain tomography showed cerebral venous thrombosis. After an exhaustive investigation, antibodies to C burnetii were found and were undoubtedly positive (1:5120), leading to the diagnosis of Q fever. Both patients were treated with oral doxycycline.

Benign inflammatory pseudotumour mimicking extrahepatic bile duct cholangiocarcinoma in an adult man presenting with painless obstructive jaundice

Inflammatory pseudotumours (IPTs) of the biliary tract are extremely rare and heterogeneous by aetiology and clinical presentation. They might cause biliary obstruction and mimic cholangiocarcinomas and their final diagnosis is usually achieved only after surgical excision. The most characteristic feature of IPT is the presence of chronic inflammatory cell infiltrates with variable degree of proliferating fibrous tissue. IPTs have the potential for recurrence even after resection and if untreated they can grow causing a variety of symptoms due to compression of the surrounding structures and organs. Despite the significant improvement of modern imaging techniques, preoperative distinction between IPTs of the biliary system and malignancies is extremely difficult. Histological diagnosis poses a clinical challenge because sampling is often suboptimal. Although rare, IPTs should be in the differential diagnosis of patients who present with painless jaundice and no other clinical symptoms or signs characteristics of cholangiocarcinomas.

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

Introduction

Inflammatory pseudotumor of the liver represents a fairly uncommon pathology. Although it is a benign tumor, the correct diagnosis can be missed.

Case presentation

We report the case of a 55-year-old Caucasian man, who presented with a one-month history of abdominal pain and weight loss. He was diagnosed with a primary liver tumor by computed tomography and magnetic resonance imaging. Alpha-fetoprotein levels ranged within normal limits. A right posterior sectorectomy was performed. Histopathology revealed an inflammatory pseudotumor of the liver. Our patient remains in good condition one year later.

Conclusion

Although inflammatory pseudotumor of the liver is usually a benign process, controversy regarding its management still exists. With this case report we review the existing literature and consider hepatectomy as a safe treatment approach.

“Pseudotumoral” hepatic pattern in acute alcoholic hepatitis: A case report

In acute alcoholic hepatitis (AAH), a “pseudotumoral” appearance of the liver parenchyma on computed tomography (CT) scan has been reported. The main findings are hypervascularized areas closely similar to those observed in large hepatocellular carcinomas. We report a case of a patient affected by AAH with an unusual appearance of these “pseudotumoral” areas on CT scan, close resembling a metastatic cancer rather than a primary hepatocellular carcinoma. In fact, in contrast with previous reports, the picture was characterized by the presence of many inhomogeneous, hypoattenuated areas highlighted during both pre- and post-contrast phases. Moreover, we report the first description of “pseudotumoral” lesions on ultrasound scan. This patient was successfully treated with corticosteroids, even if many controversies still exist regarding their efficacy in this setting.