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

Significantly Elevated CA 19-9 after COVID-19 Vaccination and Literature Review of Non-Cancerous Cases with CA 19-9 > 1000 U/mL

BACKGROUND

CA 19-9 is a commonly assessed tumor marker, considered characteristic of pancreatic ductal adenocarcinoma (PDAC) and biliary tract cancers; however, the positive predictive value of CA 19.9 is too low, and the usage of CA 19.9 as a screening tool in the healthy population remains controversial.

METHODS

The presented case illustrates a reversed diagnosis of highly elevated serum CA 19-9 levels in a 54-year-old female complaining of pain in the epigastric region, shortly after COVID-19 vaccination. Laboratory tests showed a significantly elevated level of the CA 19-9 marker (>12,000 U/mL, reference value: <37 U/mL) with normal pancreatic enzyme activity. The patient underwent imaging examination, which showed no abnormalities, except for increased pancreatic dimension and areas of fluid signal in the pancreas in magnetic resonance imaging (MRI), which may correspond to autoimmune pancreatitis (AIP). The patient remains asymptomatic with a recommendation for a follow-up MRI in 12 months.

RESULTS

A literature review conducted revealed multi-causal CA 19-9 increases above 1000 U/mL, including non-cancerous diseases of the lung, pancreas, liver, ovary, kidney, and others. The median concentration of CA 19-9 regardless of the cause of disease was 2810 U/mL (IQR ± 6895). The median CA 19-9 values in men and women were 3500 (IQR ± 10,050) and 2455 (IQR ± 3927), respectively, and differ significantly between the compared groups (p < 0.05). There was no difference between CA 19-9 values and the categorized cause of the increase.

CONCLUSIONS

Conducting differential diagnosis, it should not be forgotten that most international guidelines recommend the use of CA 19-9 only in conjunction with pathology of pancreas in radiological imaging; however, even such a combination can point the diagnostic pathway in the wrong direction. A highly elevated CA 19-9 level, typically associated with PDAC, may be the result of benign disease including AIP related to COVID-19 vaccination.

Borderline Brenner tumor with abnormally high serum level of carbohydrate antigen 199: a rare case report and literature review

Ovarian Brenner tumor with abnormally increased serum carbohydrate antigen 19-9 (CA19-9) level is extremely rare. A 70-year-old woman with abnormally elevated serum CA199 (1289 U/ml) found in routine physical examination. Pelvic CT and MRI scan revealed a large mass with large patches of calcification in the right adnexal area, and the patient achieved total hysterectomy and bilateral adnexectomy. Grossly, the right ovary had a solid enlargement of about 7.0 cm × 6.0 cm × 5.0 cm with irregular nodules and smooth surface and the cut surface of the mass showed that the tumor is cystic and solid. Microscopically, the tumor showed a background of fibrous tissue hyperplasia with nested and adenoid cell clusters with uniform cell size and clear boundaries. The cells were translucent with eosinophilic cytoplasm and calcification. Immunohistochemical staining showed CK7, CA125, and P63 presented diffusely strongly positive staining, while negativity for CK20, GATA3, AR, P53, and CgA. Ki-67 showed weak positive staining, about 1%. The serum CA199 level decreased significantly on the 5th day after surgery. Postoperative pathology and immunohistochemistry confirmed borderline Brenner tumor. This is the first to report a case of borderline Brenner tumor with an abnormally high serum level of CA199 before surgery. In clinical practice, the possibility of ovarian Brenner tumor should be considered when abnormal elevation of serum CA199 level cannot be reasonably explained.

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.

[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.

Complicated course of biliary inflammatory myofibroblastic tumor mimicking hilar cholangiocarcinoma: A case report and literature review

BACKGROUND

The inflammatory myofibroblastic tumor (IMT) is a rare, idiopathic, usually benign, mass-forming disease with myofibroblastic proliferation and a varying amount of inflammatory cells. Although it can affect various organs, the biliary tract is a rare localization of primary IMT, clinically, endoscopically and radiologically imitating cholangiocarcinoma. The treatment options are based only on clinical practice experience.

CASE SUMMARY

A 70-year-old woman was referred to our center due to progressive fatigue, weight loss, abdominal pain, night sweats, and elevated liver enzymes. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed proximal common hepatic duct and hilar biliary strictures extending bilaterally to lobular bile ducts. Although initial clinical, endoscopic and radiological signs were typical for hilar cholangiocarcinoma, histological examination showed no signs of malignancy. In total, 8 biopsies using different approaches were performed (several biopsies from dominant stricture during ERCP and direct cholangioscopy; ultrasound-guided liver biopsy; diagnostic laparoscopy with liver and lymph node biopsies). Histological examination revealed signs of IMT, and the final diagnosis of biliary IMT was stated. Although IMT is usually a benign disease, in our case, it was complicated. All pharmacological treatment measures were ineffective. The patient still needs permanent stenting, suffers from recurrent infections and mechanical jaundice. Despite that, the patient already survived 24 mo.

CONCLUSION

IMT presenting with hilar biliary strictures is a unique diagnostic and clinical challenge as it is indistinguishable from cholangiocarcinoma, and there are no evidence-based treatment options. Our goal is to increase the understanding of this rare disease and its possible course.

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 associated with primary biliary cholangitis and elevated alpha-fetoprotein lectin 3 fraction mimicking hepatocellular carcinoma

Background

Hepatic inflammatory pseudotumor (IPT) is a rare benign lesion. Because there is no specific laboratory marker or radiographic appearance, the majority of reported cases of hepatic IPT have been diagnosed after surgery or at autopsy. The etiology of hepatic IPT remains unclear but several mechanisms have been postulated such as infection or immune reaction.

Case presentation

A 79-year-old woman had been seeing her family doctor for hypertension, and she had been diagnosed with liver dysfunction for about 10 years. She continued attending follow-ups because of her drinking habit. Two months before her visiting our institution, further elevation of hepatobiliary enzymes was noted, and abdominal ultrasonography showed a hepatic tumor 4 cm in diameter in the lateral segment, so she was referred to our hospital. Hepatocellular carcinoma (HCC) was suspected because alpha-fetoprotein (102 ng/ml) (AFP) and lectin 3 (L3) fraction (85.4%) were elevated and the appearance on enhanced computed tomography was not inconsistent with HCC. Thus, we performed laparoscopic hepatectomy. She recovered uneventfully and was discharged on postoperative day 7. Pathological diagnosis revealed that the tumor was hepatic IPT and that the background liver condition was primary biliary cholangitis (PBC). AFP and L3 fraction decreased to normal ranges after surgery.

Conclusions

In 7 of 29 patients (24.1%) with reported cases of tumor markers in liver IPT, carbohydrate antigen 19-9 was elevated and AFP was elevated in 2 of 58 patients (3.4%). AFP is also frequently elevated in benign liver diseases such as hepatitis and liver cirrhosis, and L3 fraction has been used as a tumor marker for HCC with high specificity. To our knowledge, this is the first report of a case diagnosed with liver IPT in which AFP and L3 fraction increased before surgery and decreased to the normal range after resection. This confirms the rarity of hepatic IPT associated with PBC and elevated AFP and L3 fraction.

Fascioliasis simulating an intrahepatic cholangiocarcinoma-Case report with imaging and pathology correlation

Human fascioliasis is a rare zoonosis in Chile. Clinically it presents with a highly polymorphous group of symptoms that evolve in two periods. The first, acute or a result of hepatic invasion, lasts 2 weeks to 4 months and is characterized essentially by pain in the right hypochondrium and/or epigastrium, continuous fever and painful hepatomegaly. This clinical picture, associated with eosinophilia and a history of raw watercress consumption, corresponds to the classic presentation of the disease in its initial stage. We report the case of a 57-year-old female patient with no risk factors for and no clinical signs of fascioliasis, with a lesion in the right hepatic lobe compatible with intrahepatic cholangiocarcinoma, studied with computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET-CT). With the clinical suspicion of intrahepatic cholangiocarcinoma, a regulated right hepatectomy was performed, the pathological study of which revealed cholangitis and granulomatous pericholangitis resulting from trematode eggs, compatible with Fasciola hepatica.

Inflammatory pseudotumors of the liver: experience of 114 cases

Hepatic inflammatory pseudotumors (HIPT) are rare benign neoplasms with unknown etiology and a great potential for mimicry, challenging diagnostics, and treatment features. The aim of the study was to retrospectively analyze the imaging, pathological, and clinical features of HIPT in our large cohort of patients in order to increase the understanding and suggest a scoring system for treatment approaches. Retrospective study analyzed 114 HIPT cases recorded from July 2006 to July 2012, when surgery was performed. Data were compared with chi-square test. In our study population, the mean age was 53.14 ± 10.98 years, with 69 male and 45 female patients. Most presented symptoms were abdominal pain (59/144, 41.0 %), fever (48/114, 42.1 %), abdominal distension (35/144, 24.3 %), and weight loss (12/144, 8.3 %). Laboratory examinations were normal. Sixteen cases were HBsAg positive and 8 had liver cirrhosis. Most of the tumors were located in the right lobe (79/114, 69.3 %), 33 in the left lobe, and 2 in the caudal lobe. Three imaging modalities, such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), were compared and showed significant differences in sensitivity and sensibility. HIPT diagnostics are challenging, and conservative treatment should be prioritized as soon as the diagnosis is made. CT and MRI seem to have comparable diagnostic sensitivity. We propose a guideline for consideration of operative approach.

A Giant Simple Liver Cyst That Caused Increases in Serum CA 19-9 and CA 15-3 Levels

Simple cysts (SCs) of the liver are not associated with the biliary malformations in intrahepatic bile duct biliary. Seen in 0.1% to 7% of adult population, biliary malformations are more common in women. The levels of glycoprotein-like tumor markers (carbohydrate antigen (CA) 19-9) in the cysts and serum could be high. Although studies regarding CA 19-9 exist, sufficient data on cancer antigen (CA) 15-3 are not available. This case is about a 76-year-old woman who complained of painless intra-abdominal mass. The patient with a giant simple cyst extending from the gallbladder to the pelvis had preoparative CA 19-9 and CA 15-3 serum levels of 87.3 IU/L and 37 IU/L respectively. It was observed that CA 19-9 levels had decreased to 36 IU/L and CA 15-3 to 28.1 IU/L in blood samples taken in the third month after the surgery. There is a need for comprehensive studies to investigate the relationship between the size of the cyst and biomarkers (including markers such as CA 15-3) in the assesment of liver SC.

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.

Hepatic and pulmonary nodular lesions in pediatric urinary tract infections

One of the major goals in investigating children with urinary tract infection (UTI) is to recognize patients at risk of further UTI-related problems. This study reports the clinical features of 19 pediatric patients with UTIs in whom associated hepatic and/or pulmonary nodules were incidentally diagnosed by the imaging tests performed for the UTI. Hepatic nodules in five patients were detected on ultrasound scans, and pulmonary nodules and both hepatic and pulmonary nodules were detected in 12 and two children by dimercaptosuccinic acid scintigraphy. The mean age of the patients was 24.5 months. Vesicoureteral reflux (VUR) was detected in nine of 17 patients (52.9%), acute pyelonephritis was identified in nine of 18 patients, and renal scarring was found in 57.1% patients with pyelonephritis. On follow-up, the hepatic and/or pulmonary nodules regressed in all patients. About 85.7% of patients experienced a recurrence of UTI within 1 year. In comparison with age- and sex-matched controls with UTIs without pulmonary or hepatic nodules, the presence of VUR and the recurrence of UTI within 1 year were higher in patients with UTIs and nodules (P<0.05). The hepatic and/or pulmonary nodules identified on the ultrasound scan and by dimercaptosuccinic acid scintigraphy may provide a valuable diagnostic marker for the proper management of patients with an UTI.

A simple hepatic cyst with elevated serum and cyst fluid CA19-9 levels: a case report

Introduction

Simple hepatic cysts rarely cause symptoms, however, occasionally they become symptomatic due to mass effect, rupture, hemorrhage, and infection. We report a patient with a large hepatic cyst with elevated serum and cyst fluid CA19-9 levels. We studied serum and cyst fluid CA19-9 levels in this patient, before and after the intracystic instillation of minocycline hydrochloride.

Case presentation

A 76-year-old Japanese woman was diagnosed as having an infected hepatic cyst, by physical examination and enhanced abdominal computed tomography. Serum (170 U/ml; reference: < 37 U/ml) and hepatic cyst fluid (371 U/ml) CA19-9 levels were elevated. After the intracystic instillation of minocycline hydrochloride, necrotic cells in the cyst were drained, and it totally collapsed after 1 week. Cyst fluid CA19-9 levels increased remarkably after the intracystic instillation of minocycline hydrochloride, while serum CA19-9 levels decreased significantly.

Conclusion

Our study is the first report to reveal the influence of intracystic instillation of minocycline hydrochloride on serum and cyst fluid CA19-9 levels in a patient with a simple hepatic cyst.

Inflammatory pseudotumor of the liver: report of eight cases, including three unusual cases, and a literature review

BACKGROUND

Inflammatory pseudotumor (IPT) of the liver is a rare but increasingly recognized tumor-like lesion. This condition is becoming an important differential diagnosis in patients with hepatic space-occupying lesions. This study reports the clinical features of eight cases of IPT of the liver, including the first report of three cases with an unusual associated disease or clinical course.

METHODS

The study sample included cases of IPT diagnosed based on the histopathology in our institution from 1995 to 2004. Clinical events were reported and compared with reports in the literature.

RESULTS

The age of the patients ranged from 28 to 78 years. The most common symptoms were abdominal pain, fever and bodyweight loss. Three patients were diagnosed incidentally. The initial clinical diagnoses were hepatocellular carcinoma in three cases, liver abscess in two cases, metastasis in one case and uncertain nature in two cases. Two cases were associated with preceding endophthalmitis and cholangiocarcinoma, respectively. Two patients had spontaneous lesion regression, but one of these had possible recurrence 10 months later. The other two patients experienced resolution of their lesions following antibiotic treatment. Four patients underwent surgical resection with subsequent recovery.

CONCLUSIONS

The clinical and imaging features of IPT in this small series were found to sometimes mimic those of malignant liver tumors or abscess. Surgical resection was performed in half of the cases. However, IPT of the liver could resolve spontaneously or following antibiotics treatment.

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.

Multiple inflammatory pseudotumor of the liver, mimicking cholangiocarcinoma with tumor embolus in the hepatic vein: report of a case

A 68-year-old Japanese woman complaining of general fatigue and intermittent high fever was admitted to our hospital. Abdominal ultrasonography showed two tumors in the lateral segment of the liver, with soft tissue in the left hepatic vein that was considered to be a tumor embolus. A diagnosis of cholangiocarcinoma was made based on various radiological and laboratory examinations and therefore a surgical resection was performed. Microscopically, the tumor consisted of inflammatory cells, which had aggressively invaded the hepatic vein and Arantius' duct. The pathological diagnosis was inflammatory pseudotumor (IPT) that had invaded the hepatic vein. Although many cases of hepatic IPT have been previously reported, cases of hepatic IPT massively invading the hepatic vein are very rare as far as we could determine, based on a literature search. We herein report this case and discuss the diagnosis and treatment regarding hepatic IPT with massive venous invasion.

Spontaneous regression of hepatic inflammatory pseudotumor with primary biliary cirrhosis: Case report and literature review

Hepatic inflammatory pseudotumor (IPT) is a rare benign non-neoplastic lesion characterized by proliferating fibrous tissue infiltrated by inflammatory cells. The exact etiology of IPT remains unclear. Although the association of IPT with systemic inflammatory disorders has been well established, a specific relationship with cholangitis is distinctly rare. We report a case of spontaneous regression of hepatic IPT with primary biliary cirrhosis (PBC). To date, only two cases of IPT with PBC have been reported. In our case, however, IPT developed during the course of improvement of cholangitis of PBC induced by effective treatment, differing from two previously reported cases. Our case indicates that the development of IPT does not also relate to the activity of cholangitis and/or hyper gamma-globulinemia, since our case was confirmed radiologically to be free of IPT when biliary enzymes and immunoglobulins were much higher than the corresponding values on admission. Comparison of our case with the two previously reported cases suggests that IPT occurring with PBC does not represent the same disease entity or be a bystander for PBC.

Inflammatory pseudotumor of the liver revealing gynecological Corynebacterium infection

Inflammatory pseudotumor (IPL) of the liver is a rare benign clinicopathologic entity, which has been associated with infectious conditions, including alimentary, digestive tract and mouth infections. We report a new case, where a patient developed hepatic IPL that revealed endometritis related to Corynebacterium infection; the patient had a favorable outcome of hepatic IPL after appropriate antibiotic therapy initiation. Our findings therefore confirm that antibiotic therapy may be effective in patients with hepatic IPL associated with underlying infections, avoiding unnecessary surgery. Our data also indicate that when hepatic IPL is observed, a complete clinical evaluation, including gynecological evaluation, should be systematically performed.

Inflammatory pseudotumor of the liver associated with Crohn's disease

Inflammatory pseudotumor (IPT) of the liver is a rare, benign lesion that is characterized by proliferating fibrous tissue infiltrated by inflammatory cells. The exact etiology of IPT remains unclear. Although the association of IPT with systemic inflammatory disorders has been established, a specific link with Crohn's disease is rare. We report two cases of IPT associated with Crohn's disease. Both patients were elderly males who presented with abdominal pain and jaundice. At the time of presentation, both had active Crohn's disease that was undiagnosed. Computed tomography demonstrated a liver mass, and endoscopic retrograde cholangiography revealed biliary strictures in both patients. Given their symptomatic jaundice and concern for cholangiocarcinoma, they underwent abdominal surgical exploration and pathology results revealed IPT. They were subsequently diagnosed with Crohn's disease. Following treatment of Crohn's disease, there was significant improvement in their overall clinical status. An underlying diagnosis of inflammatory bowel disease should be considered in patients with IPT.

Utility of serum CA19-9 in diagnosis of cholangiocarcinoma: In comparison with CEA

AIM: The diagnosis of cholangiocarcinoma is often difficult, making management approaches problematic. A reliable serum marker for cholangiocarcinoma would be a useful diagnostic test. The aims of our study were to evaluate the usefulness of a serum CA19-9 determination in the diagnosis of cholangiocarcinoma.

METHODS: We prospectively measured serum CA19-9 and CEA concentrations in patients with cholangiocarcinoma (n = 35), benign biliary diseases (n = 92), and healthy individuals (n = 15). Serum CA19-9 and CEA concentrations were measured by an immunoradiometric assay without knowledge of the clinical diagnosis.

RESULTS: The sensitivity of a CA19-9 value > 37 KU·L^-1 and a CEA value > 22 μg·L^-1 in diagnosing cholangiocarcinoma were 77.14% and 68.57%, respectively. When compared with the benign biliary diseases group, the true negative rates of serum CA19-9 and CEA were 84.78% and 81.52%, respectively. The false positive rates of serum CA19-9 and CEA were 15.22% and 18.48%, whereas the accuracy of serum CA19-9 and CEA were 82.68% and 77.95%, respectively. Serum CA19-9 and CEA concentrations were significantly elevated (P < 0.001 and P < 0.05) in patients with cholangiocarcinoma (290.31 ± 5.34 KU·L^-1 and 36.46 ± 18.03 μg·L^-1) compared with patients with benign biliary diseases (13.38 ± 2.59 KU·L^-1 and 13.84 ± 3.85 μg·L^-1) and healthy individuals (12.78 ± 3.69 KU·L^-1 and 11.48 ± 3.37 μg·L^-1). In 15 patients undergoing curative resection of cholangiocarcinoma, the mean serum CA19-9 concentration was decreased from a preoperative level of 286.41 ± 4.36 KU·L^-1 to a postoperative level of 62.01 ± 17.43 KU·L^-1 (P < 0.001), and the mean serum CEA concentration from 39.41 ± 24.35 μg·L^-1 to 28.69 ± 11.03 μg·L^-1(P < 0.05). In patients with cholangiocarcinoma, however, no correlation was found between serum CEA and CA19-9 concentrations (r = 0.036).

CONCLUSION: These data suggest that the serum CA19-9 determination is a useful addition to the available tests for the differential diagnosis of cholangiocarcinoma. Serum CA19-9 is an effective tumor marker in diagnosing cholangiocarcinoma, deciding whether the tumor has been radically resected and monitoring effect of treatment.

Supra-elevated CA 19-9 in a benign hepatic cyst adenoma

BACKGROUND

Elevated CA 19-9 may be found in both cystadenomas and cystadenocarcinomas of the liver.

CASE OUTLINE

A 59-year-old woman presented with right upper quadrant abdominal pain, malaise and weight loss. Physical examination and laboratory evaluation revealed a mass in the right upper quadrant and a CA 19-9 level of 68 661 U/ml. CT scan demonstrated a cystic liver mass. She underwent a right hepatectomy, and her CA 19-9 returned to normal. Pathologic analysis revealed no malignancy.

DISCUSSION

In hepatic cystic neoplasms, an elevated CA 19-9 should not be used to establish the diagnosis of malignancy nor should it preclude resection.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

High CA 19-9 levels in benign biliary tract diseases. Report of four cases and review of the literature

For years, CA 19-9 has been proposed as a marker for epithelial-type gastrointestinal cancers, even though it is well known that its diagnostic specificity is low. Here we describe cases of extremely high CA 19-9 levels in benign biliary tract diseases. The first case involved a 77-year-old male patient with choledocholithiasis and jaundice who was found to have CA 19-9 levels of 98,628 UI/ml. The second case was a 63-year-old male patient with autoimmune cholangitis and a CA 19-9 level of 250 IU/ml. The third case was a 74-year-old male patient with cholelithiasis and choledocholithiasis who developed acute cholangitis. CA 19-9 levels were elevated to 14,950 UI/ml during the episode. The fourth case involved a 73-year-old man with biliary colic and jaundice following an acute open cholecystectomy procedure who had a transient 100-fold increase in CA 19-9 (2230 IU/ml).

Benign tumors of the liver

Benign tumors of the liver, less commonly encountered than metastatic or primary liver tumors, may present clinically with symptoms due to mass effect, or may be discovered incidentally during radiographic evaluation or surgical exploration for other clinical indications. Many of the lesions that result in a benign liver mass are true neoplasms, while others result from reactive proliferation of hepatocytes, biliary cells, mesenchymal or inflammatory cells. The premalignant nature or potential for malignant transformation is of concern in some of the benign tumors or tumor-like masses of the liver. In this article, benign tumors and tumor-like masses involving the adult liver are discussed with a focus on histopathology, histogenesis, and clinical significance of these interesting and unusual lesions.