Inflammatory pseudotumor of the liver associated with Crohn's disease

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.

Inflammatory myofibroblastic tumor of the transverse colon with synchronous gastrointestinal stromal tumor in a patient with ulcerative colitis: a case report

INTRODUCTION

Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach.

PRESENTATION OF CASE

A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given.

DISCUSSION

Although the relationship between IMT and Crohn's disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described.

CONCLUSION

To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy.

Differentiation between inflammatory myofibroblastic tumor and cholangiocarcinoma manifesting as target appearance on gadoxetic acid-enhanced MRI

PURPOSE

To determine the differential features of inflammatory myofibroblastic tumor (IMT) and intrahepatic cholangiocarcinoma (ICC) manifesting as target appearance on gadoxetic acid-enhanced MRI.

METHODS

Twenty-seven patients with 36 IMTs (1.2-6.0 cm) and 34 patients with 34 ICCs (1.5-6.0 cm) who underwent gadoxetic acid-enhanced MRI were enrolled in this study. Two reviewers evaluated morphology, signal intensity, and enhancement features of tumors on T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and gadoxetic acid-enhanced imaging.

RESULTS

As for 32 IMTs with target appearance, IMTs most commonly demonstrated early target appearance characterized by a peripheral hypointense rim on unenhanced T1WI (n = 27, 84.4%), central enhanced area with a hypointense rim on arterial phase (AP) and portal venous phase (PVP) (n = 29, 90.6%), and transitional phase (TP) (n = 28, 87.5%). Meanwhile, most of the ICCs showed homogeneous hypointensity on T1WI (100%), a hyperenhancing rim on AP, late target appearance on TP (n = 32, 94.1%) and HBP (n = 32, 94.1%). Target appearance on DWI appearing as hyperintensity with central hypointense area was seen in 2 IMTs and 32 ICCs. On T2WI, 24 IMTs (n = 24, 75.0%) displayed central iso- and peripheral hyperintensity and 27 ICCs (84.4%) showed layered hyperintensity with either brighter or darker area in center. The remaining six IMTs with no target were observed as cystic appearing nodules (n = 3) or ill-defined hypovascular nodules (n = 2) and fibrotic mass (n = 1).

CONCLUSION

IMTs often show early target appearance on unenhanced T1WI, and early dynamic phases of gadoxetic acid-enhanced MRI. Target appearance on later phases, such as TP and HBP, and DWI target appearance were commonly in ICCs, but rare in IMTs.

Hepatogastric Inflammatory Pseudotumor Presumably Deriving from Prior Amebic Infection

Introduction

Inflammatory pseudotumor is a rare entity with a clinical and radiographic presentation that is difficult to differentiate from malignancy. This is a case report of a large hepatogastric inflammatory pseudotumor that presumably developed from a prior amebic pseudocyst.

Case Report

A 14-year-old boy presented with increasing vomiting, epigastric pain, dysphagia, asthenia and weight loss. The clinical history included an amebic infection at the age of 2 months. Instrumental investigations revealed an 8 x 6 cm left subdiaphragmatic mass inseparable from the gastric fundus, which appeared to infiltrate the left hepatic lobe. Surgery disclosed a bulky mass adhering to the gastric fundus and left hepatic lobe that prompted total gastrectomy, resection of the second and third hepatic segments, and Roux-en-Y esophagojejunal loop anastomosis. Histology subsequently confirmed that this was a pseudocyst with a large calcified nucleus surrounded by myofibroblastic proliferation associated with a diffuse lymphoplasmacytic infiltrate affecting the gastric wall and hepatic parenchyma, hence the final diagnosis of inflammatory pseudotumor, presumably in response to a prior amebic pseudocyst.

Conclusions

Inflammatory pseudotumor is a rare entity that is seldom found in the stomach. The particular interest of the present case lies in the fact that it developed in the stomach and liver, presumably deriving from a previous amebic pseudocyst.

Mass-forming renal Crohn's disease: a case report with multimodality imaging

The most common extraintestinal manifestations of Crohn’s disease involve the eyes, skin, hepatobiliary tract, and the musculoskeletal and respiratory systems. Mass-forming granulomatous inflammation in extraintestinal organs is extremely rare and there are only a few reports of patients with Crohn’s disease presenting with inflammatory pseudotumours of the liver, pancreas and kidneys. We present a case of a mass-forming renal granulomatous inflammation in an adult female with Crohn’s disease. The clinical, pathological and imaging features of this case illustrate that renal inflammatory pseudotumour is a rare but important differential diagnosis of a renal mass in patients with Crohn’s disease and that radiologists should be aware of its existence when considering other more common pathologies, such as focal pyelonephritis and renal tumours. Renal inflammatory pseudotumour may have relatively non-specific imaging features and a biopsy may be required to make the diagnosis.

Metastatic hepatocellular carcinoma in a patient with Crohn's disease treated with azathioprine and infliximab: a case report and literature review

Hepatocellular carcinoma most commonly occurs in patients with underlying liver disease or cirrhosis. We describe a case of hepatocellular carcinoma in a 34-year-old man with Crohn's disease treated with azathioprine and infliximab. The patient had no history of liver disease and a complete autoimmune and viral workup was unremarkable. Unfortunately, the patient developed widespread metastatic disease and passed away 5 months after his initial diagnosis. The mechanism of hepatocellular carcinoma in patients' with Crohn's disease is poorly understood and may include both autoimmunity and treatment-related complications. Previous case reports suggest the possibility of a concerning association between azathioprine therapy and the development of hepatocellular carcinoma in patients with Crohn's disease. Clinicians may consider early imaging in patients with Crohn's disease presenting with concerning symptomatology or abnormal liver enzymes, especially in those being treated with azathioprine alone or in combination with infliximab. Future research may help to uncover additional risk factors for this exceedingly rare diagnosis in this patient population.

Abnormal liver function induced by myofibroblastic sarcoma infiltrating the liver: A case report

Myofibroblastic sarcoma (MS) is a rare disease, which most frequently occurs in the head, neck and extremities. To the best of our knowledge, although a small number of studies have reported MS of the oral cavity, maxilla, tonsil, thyroid and tongue, MS of the liver and subsequent disabled liver function has not been previously reported. This study presents the case of a 38 year old female initially diagnosed and treated for a mass in the retroperitoneal region, who was subsequently diagnosed with MS of the liver three months following preliminary surgical treatment. The patient refused further treatment and was lost to follow-up three months after discharge from the hospital. Clinical, biochemical and imaging observations, as well as pathological manifestations of the patient in the present case are discussed with the aim of increasing the knowledge of MS of the liver.

Rare presentation of self-resolving multifocal inflammatory pseudo-tumour of liver

Inflammatory pseudo-tumour (IPT) of the liver is a rare condition with the appearance of a tumour-like space occupying lesion. Aetiology and natural history is not known for these benign lesions, as they are commonly diagnosed as malignant lesions and frequently undergo surgical resection since spontaneous resolution is very rare. Multifocal IPT involving both lobes of liver are rarely reported. Here we report a unique case of multifocal IPT of the liver which resolved spontaneously within 5 wk period.

Complete response to steroids in dural inflammatory pseudotumor associated with Still's disease

We report a unique case of a dural-based inflammatory pseudotumor (IPT) arising in the left cavernous sinus of a patient with a history of juvenile Still's disease. The patient presented with hemi-facial paresthesias, dull, constant headaches, and transient episodes of sharp pain along the temporalis region. Treatment with oral steroid therapy resulted in complete regression of the lesion and accompanied neuralgia symptoms. Because intracranial IPT can mimic meningiomas both clinically and radiographically and can be associated with systemic arthritic diseases, neurosurgeons should be familiar with this entity in order to avoid unnecessary radical surgery and alternatively consider a tapering course of steroid therapy.

Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature

Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.

Inflammatory myofibroblastic tumor of the liver following renal transplantation

Inflammatory myofibroblastic tumor (IMT), previously named inflammatory pseudotumor, is a benign lesion, the exact etiology of which remains obscure; immunosuppression and infections have been speculated to be responsible for the development of pseudotumor. IMT associated with transplantation is rarely reported; we report the first case of IMT of the liver in a renal transplantation patient, who presented with symptoms of abdominal pain. The findings of computed tomography suggested hepatocellular carcinoma or liver abscess, and surgical resection was performed. The lesion was pathologically diagnosed as IMT.

Renal involvement in Crohn's disease: granulomatous inflammation in the form of mass lesion

Extraintestinal manifestations of Crohn's disease (CD) are varied and concentrated mainly to the skin and eye. Urinary tract or renal involvement is extremely rare. Herein we report on a case of renal lesion of a 50-year-old woman with a 15-year history of CD. Abdominal computed tomography scan of the patient identified heterogeneous multinodular mass lesions in the left kidney. Histology proved classic granulomatous inflammatory nodules with multinucleated giant cells, eosinophils, plasma cells, epithelioid cells, and spindle-shaped myofibroblasts in the areas, where the computed tomography scan indicated. After the extensive PubMed search in the literature, this is the first macroscopically documented and histologically proved, mass-like renal involvement in CD. From now on, differential diagnostics of renal mass lesions in CD should include the tumor-like, Crohn's-type granulomatous inflammation as direct kidney manifestation of the disease.

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 myofibroblastic pseudotumour of the liver in association with gall stones - a rare case report and brief review

Inflammatory myofibroblastic pseudotumours of the liver are rare tumour-like lesions that can mimic malignant liver neoplasms. The symptoms and radiological findings of this rare tumour can pose diagnostic difficulties. We describe a 69-year-old gentleman who was admitted to our department with symptoms suggestive of acute cholecystitis. Ultrasonography and computed tomography of the liver raised the possibility of metastatic liver disease. A core biopsy of the liver was performed to confirm the diagnosis of liver metastasis. Unexpectedly it showed no evidence of malignancy but instead revealed an inflammatory myofibroblastic pseudotumour of the liver. This case report highlights the diagnostic dilemma that arose due to the similarity of appearances between the two pathological entities on imaging and this stresses the need for accurate histological diagnosis so as to avoid unnecessary surgical intervention. To the best of our knowledge, only a minority of cases are reported in the literature associating a hepatic inflammatory myofibroblastic pseudotumour with gall stones.

Inflammatory myofibroblastic pseudotumour of the liver in association with gall stones - a rare case report and brief review

Inflammatory myofibroblastic pseudotumours of the liver are rare tumour-like lesions that can mimic malignant liver neoplasms. The symptoms and radiological findings of this rare tumour can pose diagnostic difficulties. We describe a 69-year-old gentleman who was admitted to our department with symptoms suggestive of acute cholecystitis. Ultrasonography and computed tomography of the liver raised the possibility of metastatic liver disease. A core biopsy of the liver was performed to confirm the diagnosis of liver metastasis. Unexpectedly it showed no evidence of malignancy but instead revealed an inflammatory myofibroblastic pseudotumour of the liver. This case report highlights the diagnostic dilemma that arose due to the similarity of appearances between the two pathological entities on imaging and this stresses the need for accurate histological diagnosis so as to avoid unnecessary surgical intervention. To the best of our knowledge, only a minority of cases are reported in the literature associating a hepatic inflammatory myofibroblastic pseudotumour with gall stones.

Inflammatory pseudotumor of the liver successfully treated with nonsteroidal anti-inflammatory drugs: a challenge diagnosis for one not so rare entity

Inflammatory pseudotumor of the liver is a rare, benign lesion characterized by a well-circumscribed mass of chronic inflammatory cell infiltration and proliferating fibrous tissue. Its etiology remains unclear, although inflammatory processes have been proposed. It is often misdiagnosed as a malignant tumor, and the management has been traditionally surgical. We report the case of a 16-year-old boy who was referred from another hospital with a fever of >38 degrees C with rigor and right upper quadrant pain which he had suffered from for 5 days. The ultrasonographic computed tomography and MRI findings were not diagnostic, and we performed a needle biopsy from the lesion that was consistent with inflammatory pseudotumor (of liver, mixed fibrous tissue and chronic inflammatory cell infiltration). The patient was treated with nonsteroidal anti-inflammatory drugs and had an uneventful clinical course. During follow-up, the lesion subsequently shrank to completely vanish 1 year later.

Inflammatory pseudotumour of the liver: the residuum of a biliary cystadenoma?

Inflammatory pseudotumour is a rare form of a liver mass. We report the case of a 28-year-old man presenting with obstructive jaundice, in whom an inflammatory pseudotumour arose with the resolution of a mucus secreting cystic liver lesion. The initial features suggested an intrahepatic cystadenoma or cystadenocarcinoma, which on its involution left a solid mass. Histopathology showed an inflammatory pseudotumour with no evidence of malignancy. A similar case has been reported recently, with the development of an inflammatory pseudotumour following collapse of a liver cyst seen on imaging. These two cases may shed some light on the origins of these rare liver lesions.

Inflammatory pseudotumor of the liver masquerading as hepatocellular carcinoma after a hepatitis B virus infection: Report of a case

We report a rare case of hepatic inflammatory pseudotumor (IPT) after a hepatitis B virus (HBV) infection. Early contrast enhancement on computed tomography (CT) with a washout phenomenon at the delayed phase, and depleted Kupffer cell function on superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) suggested hepatocellular carcinoma (HCC). However, the lack of a tumor capsule, absence of liver cirrhosis, and normal serum levels of alpha-fetoprotein and PIVKA-II (protein induced by vitamin K absence; descarboxyprothrombin) contradicted this diagnosis. We excised the tumor to exclude malignancy, and the histopathological diagnosis was IPT. Recent evidence suggests that this entity has changed from an extremely rare pathology to an established disease. Thus, IPT should be considered in the differential diagnosis of a liver mass with an infectious-inflammatory antecedent. Although surgery is not mandatory, surgical removal is recommended if there is a possibility of malignancy. Further investigations are warranted to elucidate the mechanisms of IPT developing after an HBV infection.