Inflammatory myofibroblastic tumor of the hepatobiliary system: report of MR imaging appearance in four patients

Hepatic Inflammatory Pseudotumor-Focusing on Its Heterogeneity

Hepatic inflammatory pseudotumors (IPTs) are defined as benign, non-malignant, non-metastasizing tumors characterized by the presence of myofibroblastic spindle cells, hetorogenous populations of inflammatory cells, particularly plasma cells, lymphocytes and macrophages, as well as locations of fibrosis and necrosis without cellular anaplasia or atypical mitoses. Despite subsequent reports in the references, hepatic IPT remains difficult to diagnose; while posing major issues specifically for its differential diagnosis compared with that of other various benign diseases and malignant hepatic tumors. Histopathological findings are always a requisite for confirming the diagnosis, particularly given that the pathogenesis of IPT remains ambiguous to date. Hepatic IPT is a heterogeneous entity in terms of its clinical features, pathological findings, and pathogenesis. Once the diagnosis is confirmed, however, needless surgery such as wedge resection and lobectomy should be avoided. Here, we discuss the heterogeneity of hepatic IPT, its clinical features, pathological findings, and pathogenesis, and describe its differential diagnosis.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

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.

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.

Radiologic and Clinicopathologic Findings of Inflammatory Myofibroblastic Tumor

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

MRI characteristics for the differential diagnosis of benign and malignant small solitary hypovascular hepatic nodules

PURPOSE

To compare the MRI findings of benign and malignant solitary hypovascular hepatic nodules and identify the differentiating features.

MATERIALS AND METHODS

A total of 135 patients with solitary hypovascular hepatic lesions up to 3 cm (mass forming intrahepatic cholangiocarcinoma, n=29; metastases, n=26; inflammatory pseudotumors and solitary necrotic nodule, n=48; and hemangioma, n=32) were assessed. MRI findings were analyzed, and lesions were scored for peripheral and intratumoral appearance and enhancement patterns.

RESULTS

Univariate and multivariate analyses showed that the most common findings for benign lesions were subcapsular, sharp margin, homogeneous, marked high signal on T2WI, mild hyperintensity on T2WI, increasing intensity of peripheral globular enhancement, and persistent central septum-like linear enhancement on delayed phase (P<0.05). An area under the curve of 0.955 was obtained for differentiating malignant from benign nodules using the combined imaging features of ill-defined margins, heterogeneity, decreasing intensity of peripheral rim-like enhancement, and central increasing intensity of patchy enhancement. Interobserver agreement was good, ranging from 0.72 to 1.00.

CONCLUSION

MRI may be a useful noninvasive method for determining whether hypovascular hepatic nodules are malignant or benign.

Follow-Up Imaging of Inflammatory Myofibroblastic Tumor of the Uterus and Its Spontaneous Regression

Inflammatory myofibroblastic tumor (IMT) is an aggressive benign mass that may arise from various tissues and organs with a great variability of histological and clinical appearances. Due to variable and nonspecific imaging findings, diagnosis of IMT is not obtained before surgery. The aim of this paper is to present CT and MRI findings during four-year follow-up of complete, spontaneous regression of IMT of the uterus. The diagnosis was made by histology and immunohistochemistry analysis of the open excisional biopsy specimen. At that time, the organ of origin was not specified. After analysis of the follow-up imaging findings and the mode of tumor regression, the uterus was proclaimed as the probable site of origin. IMT of the uterus is extremely rare and has been reported in ten cases up to now. The gradual, complete regression of uterine IMT documented by CT and MRI may contribute to understanding of its nature.

Diffusion-weighted magnetic resonance imaging for non-neoplastic conditions in the hepatobiliary and pancreatic regions: pearls and potential pitfalls in imaging interpretation

Potentially, diffusion-weighted magnetic resonance imaging (DWI) can assess the functional information on concerning the status of tissue cellularity, because increased cellularity is associated with impeded diffusion. DWI in the hepatobiliary and pancreatic regions has demonstrated the usefulness to detect malignant lesions and differentiate them from benign lesions. However, it has been shown more recently that there is some overlap in ADC values for benign and malignant neoplasms. Moreover, some non-neoplastic lesions in the hepatobiliary and pancreatic regions exhibit restricted diffusion on DWI, because of pus, inflammation, or high cellularity. Focal eosinophilic liver disease, hepatic inflammatory myofibroblastic tumor, granulomatous liver disease, acute cholecystitis, xanthogranulomatous cholecystitis, focal pancreatitis, or autoimmune pancreatitis frequently exhibit restricted diffusion on DWI, which may be confused with malignancy in the hepatobiliary and pancreatic regions. Thus, DWI should not be interpreted in isolation, but in conjunction with other conventional images, to avoid the diagnostic pitfalls of DWI. Nevertheless, the presence of diffusion restriction in the non-neoplastic lesions sometimes provides additional information regarding the diagnosis, in problematic patients where conventional images have yielded equivocal findings. DWI may help differentiate hepatic abscess from malignant necrotic tumors, gallbladder empyema from dense bile or sludge in the gallbladder, and pylephlebitis from bland thrombosis in the portal vein. Therefore, knowledge of DWI findings to conventional imaging findings of diffusion-restricted non-neoplastic conditions in the hepatobiliary and pancreatic regions helps establishing a correct diagnosis.

Uncommon hepatic tumors: iconographic essay - Part 2

In cases where typical aspects are shown, the diagnosis of most frequent hepatic lesions can be made with some safety by means of several imaging methods; on the other hand, uncommon lesions generally represent a diagnostic challenge for the radiologist. In the present second part of the study, the authors describe four rare hepatic lesions, as follows: primary hepatic lymphoma, myofibroblastic tumor, primary hepatic neuroendocrine tumor and desmoplastic small round cell tumor, approaching their main characteristics and imaging findings with emphasis on computed tomography and magnetic resonance imaging.

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.

Inflammatory myofibroblastic tumor of the liver mimicking an infiltrative malignancy in computed tomography and magnetic resonance imaging with Gd-EOB

Inflammatory myofibroblastic tumors (IMT) are a benign tumor entity, which rarely develop in the liver. Surgery is the most common treatment for these lesions as it is difficult to distinguish them from malignant liver tumors and local recurrent growth may occur. IMT is a diagnostic challenge for imaging. Only a limited number of reports of single cases or small number of patients described the imaging features on computed tomography. Reports on IMT appearance on magnetic resonance imaging are scarce. We present a case of IMT of the liver with infiltration of the abdominal wall treated with surgery and describe the imaging features with the use of the hepatobiliary contrast agent, gadoxetic acid (Gd-EOB).

Algorithmic approach to solid adnexal masses and their mimics: utilization of anatomic relationships and imaging features to facilitate diagnosis

Solid adnexal masses, while less common than their cystic counterparts, may present a challenge for radiologists given the wide range of histologic entities that occur in this region. Pelvic masses, especially when large, can seem overwhelming at first but application of an algorithmic approach allows for more confident assessment. This approach focuses first on the use of anatomic relationships and interactions of various pelvic structures to localize the mass' origin. For instance, the directionality of ureteral displacement can suggest if a mass is intra or extraperitoneal. Then, key discriminating imaging features, such as the presence of fat, hypervascularity, or low T2 signal on magnetic resonance imaging (MRI) can be applied to further narrow the list of diagnostic possibilities. Entities such as leiomyomas, nerve sheath tumors, congenital uterine anomalies, and vascular abnormalities (ovarian torsion or iliac vessel aneurysm) in particular are often accurately characterized with sonography and/or MRI. For solid adnexal masses in which a definitive diagnosis by imaging is not reached, information germane to clinicians regarding further management can still be provided, principally with regard to surgical vs. nonsurgical treatment.

Computed tomography and magnetic resonance imaging findings of inflammatory myofibroblastic tumors of the head and neck

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) is a rare tumor of mesenchymal origin that commonly occurs in the lung. Because of its non-specific clinical and imaging features, IMT is often misdiagnosed as a malignant tumor. There have been few imaging reports on IMT of the head and neck.

PURPOSE

To analyze the computed tomography (CT) and magnetic resonance imaging (MRI) findings of inflammatory myofibroblastic tumors (IMTs) of the head and neck.

MATERIAL AND METHODS

Six patients with IMTs of the head and neck confirmed by histopathologic examination were analyzed retrospectively.

RESULTS

The mean patient age was 40 years. The tumor locations in the six patients were as follows: left bridge of the nose (one), right infratemporal fossa (two), and left parotid gland (three). Three patients who underwent CT all had soft tissue masses or nodules and no calcification. Bridge of the nose tumor showed a homogeneous isodense nodule and mild homogeneous enhancement. Infratemporal fossa tumor showed a homogeneous low density mass and intermediate homogeneous enhancement. Left parotid gland tumor showed a heterogeneous, mostly low density mass, and intermediate heterogeneous enhancement. T1-weighted images of the parotid gland tumors were hypointense; the infratemporal fossa tumor was isointense. T2-weighted images were mildly hypointense and of mixed hypo- and isointensity in the two parotid gland tumors; the infratemporal fossa tumor was homogeneously mildly hypointense. Heterogeneous intermediate enhancement was demonstrated in one parotid gland and the infratemporal fossa patients and mild homogeneous enhancement in another parotid gland patient.

CONCLUSION

The imaging features of IMTs of the head and neck are non-specific. An ill-defined, aggressive mass and variable enhancement on CT and MRI may suggest the diagnosis of IMT. IMT should be included in the differential diagnosis of regional tumors.

Spectrum of multilocular cystic hepatic lesions: CT and MR imaging findings with pathologic correlation

A multilocular cystic hepatic lesion detected at computed tomography (CT) and magnetic resonance (MR) imaging is a common but nonspecific radiologic finding that can cause potential challenges for differential diagnosis. This imaging pattern may be observed in a wide spectrum of common and uncommon neoplastic or nonneoplastic entities. Neoplastic lesions include cystadenoma, cystadenocarcinoma, hepatocellular carcinoma (HCC), metastases, mesenchymal hamartoma, and inflammatory myofibroblastic tumor. Nonneoplastic lesions include hepatic abscess, echinococcal cyst, intrahepatic hematoma, and biloma. The multiple coalescent cysts seen in polycystic liver disease may exhibit an imaging pattern similar to that of a multilocular cystic lesion. Mural nodularity, irregular thickness of the septa, ragged inner surface, and typical enhancement pattern in the solid portion of the lesion are often indicative of malignancy, although multilocular primary or secondary malignant tumors are uncommon. Recognition of the more common necrosis or cystic change of HCC and metastases induced by locoregional or systemic treatment also is important. The nonenhanced cystic component may be composed of different types of fluids (eg, serous, mucinous, proteinaceous, hemorrhagic, bilious, or mixed) or spontaneous or treatment-related necrosis, whereas the septa may be formed by a wide range of tissues depending on the lesion type. An understanding of the CT and MR imaging findings of these lesions and their respective pathologic correlation aids in accurate diagnosis.

Inflammatory myofibroblastic tumour of the maxillary sinus: CT and MRI findings

AIM

To characterize the computed tomography (CT) and magnetic resonance imaging (MRI) findings of inflammatory myofibroblastic tumours (IMTs) of the maxillary sinus.

MATERIALS AND METHODS

The imaging findings of eight patients with IMTs of the maxillary sinus were reviewed retrospectively. Of the eight patients, four patients underwent unenhanced and contrast-enhanced CT, and one patient underwent unenhanced CT only; three patients underwent unenhanced and contrast-enhanced MRI.

RESULTS

Five cases of IMTs occurred in the left maxillary sinus, while three cases were right-sided. Four cases occupied the entire sinus, and the other four cases only partially occupied the sinus. Unenhanced CT images showed heterogeneous masses in four cases and a homogeneous mass in one case. One of the tumours showed some areas of calcification. T1-weighted MRI images showed isointense lesions. T2-weighted images showed mixed isointense and mild hyperintense lesions. All cases showed bone destruction and had infiltrated into the nasal fossa, orbit, infratemporal fossa, and other adjacent tissues. Seven cases showed mild to moderate heterogeneous enhancement on contrast-enhanced CT or T1-weighted MRI images.

CONCLUSION

IMTs of the maxillary sinus can be characterized as a soft-tissue mass with bony destruction and infiltration of the adjacent tissues, with mild to moderate enhancement after the injection of contrast medium. CT and MRI can help to diagnose IMTs, determine the extent of the lesion and its relationship with adjacent tissues, and thus facilitate the prediction of surgical resectability.

Magnetic resonance imaging findings in primary lymphoma of the liver: a case report

Introduction

Primary lymphoma of the liver is an extremely rare finding, with the few such cases reported in the literature to date describing indeterminate imaging findings, being focused more on computed tomography. To the best of our knowledge, there is no prior report describing magnetic resonance imaging scan findings with such a lesion. In the case reported here, magnetic resonance imaging gave us the opportunity to ascertain the correct diagnosis, confirmed by histopathology, thus avoiding unnecessary surgery or other treatments. Although this condition is rare, knowledge of magnetic resonance imaging findings will be invaluable for radiologists and other medical subspecialties that may face such cases in the future in helping to provide adequate management for affected patients.

Case presentation

A focal lesion was incidentally detected by ultrasound in a 75-year-old asymptomatic Albanian man being treated for benign hypertrophy of prostate. Chest and abdomen computed tomography scans did not reveal any abnormal findings besides a solid focal lesion on the right lobe of the liver and a mild homogenous enlargement of the prostate gland. Subsequently, magnetic resonance imaging of the upper abdomen was performed for better characterization of this lesion. Our patient was free of symptoms and his laboratory test results were normal.

Conclusions

The magnetic resonance imaging scan results showed some distinctive features that helped us to make the correct diagnosis, and were thus very important in helping us provide the correct treatment for our patient.

Aggressive hilar inflammatory myofibroblastic tumor with hilar bile duct carcinoma in situ

Inflammatory myofibroblastic tumor (IMT) of the biliary tree is extremely rare and is generally a benign condition, though malignant change is possible. Making a differential diagnosis between this lesion and other malignant conditions is very difficult on preoperative imaging studies. Hence, the final diagnosis of IMT may be made during or after operation depending on the pathologic examination. We treated a 63-year-old woman who received right hepatectomy with caudate lobectomy under the suspicion of hilar cholangiocarcinoma. Frozen biopsy during the operation showed carcinoma in situ and there were stromal cells in the bile duct's resection margins. The postoperative hospital course was uneventful except for minor bile leakage. At postoperative month 4, she developed jaundice, ascites and pleural effusion. Computed tomography images showed a mass-like lesion in the porta hepatis with portal vein thrombosis and a right chest wall mass. Excisional biopsy was done and the pathology report was malignant spindle cell tumor suggestive of an aggressive form of IMT. Her condition rapidly deteriorated regardless of the best supportive care and she expired at postoperative month 5. Further investigation is necessary to clarify the reasons for recurrence and infiltration of this disease.

Unusual case of pancreatic inflammatory myofibroblastic tumor associated with spontaneous splenic rupture

Background

Spontaneous splenic rupture considered a relatively rare but life threatening. The three commonest causes of spontaneous splenic rupture are malignant hematological diseases, viral infections and local inflammatory and neoplastic disorders. We describe a unique and unusual case of inflammatory myofibroblastic tumor of the tail of pancreas presented with massively enlarged spleen and spontaneous splenic rupture.

Case presentation

A 19 years old male patient with no significant past medical history presented to emergency room with abdominal pain and fatigue. Massively enlarged spleen was detected. Hypotension and rapid reduction of hemoglobin level necessitated urgent laparatomy. About 1.75 liters of blood were found in abdominal cavity. A large tumor arising from the tail of pancreas and local rupture of an enlarged spleen adjacent to the tumor were detected. Distal pancreatectomy and splenectomy were performed. To our knowledge, we report the first case of massively enlarged spleen that was complicated with spontaneous splenic rupture as a result of splenic congestion due to mechanical obstruction caused by an inflammatory myofibroblastic tumor of the tail of pancreas. A review of the literature is also presented.

Conclusion

Inflammatory myofibroblastic tumor of the tail of pancreas should be included in the differential diagnosis of the etiological causes of massively enlarged spleen and spontaneous splenic rupture.

Imaging of focal hepatic lesions: self-assessment module

Focal hepatic lesions are one of the diagnostic challenges in daily practice. This article focuses on the imaging features of focal hepatic lesions on different imaging modalities, including sonography, CT, and MRI.

Inflammatory myofibroblastic tumors in the liver: MRI of two immunohistochemically-verified cases

In immunohistochemically-proven hepatic inflammatory myofibroblastic tumors, MRI revealed layered patterns of contrast enhancement during dynamic imaging, consisting of outer hypovascular rind and inner hypervascular stroma and mimicking the imaging features of pyogenic organized abscess with deficient central necrosis in four lesions in two patients. For the outer hypovascular rind, T2-weighted images showed hyperintensity, suggesting immature fibrosis corresponding to the area of arterial hypovascularity and delayed contrast enhancement. The patients' favorable clinical course and imaging findings reflected the benign nature of these lesions, from an infectious origin, despite the phenotypic expression of myofibroblastic proliferation in the hypervascular stroma containing chronic inflammatory cells.

Inflammatory myofibroblastic tumor of the liver

Inflammatory myofibroblastic tumor is a rare benign entity formerly known as inflammatory pseudotumor. Involvement of the liver is extremely rare. There are controversies about the optimal treatment of this benign entity. Newer reports suggest an association with autoimmune sclerosing pancreatitis and primary sclerosing cholangitis. We present a case of an 18-year-old patient with biliary obstruction from a perihilar mass of the liver requiring hepatic resection. Division of the hepatic bile duct resulted in drainage of yellow, thick, gelatinous material in the presence of benign margins and absence of cholangitis. Histological examination showed a mass with fibroblastic and myofibroblastic cells set in a loose myxoid matrix containing scattered lymphocytes, consistent with an inflammatory myofibroblastic tumor. One-year recovery was uneventful. This report discusses the presentation, diagnosis, and controversies in management of this disease.

Recurrence of inflammatory pseudotumor in the distal bile duct: Lessons learned from a single case and reported cases

Inflammatory myofibroblastic tumors (IMTs) or inflammatory pseudotumors (IPs) have been extensively discussed in the literature. They are usually found in the lung and upper respiratory tract. However, reporting of cases involving the biliopancreatic region has increased over recent years. Immunohistochemical study of these lesions limited to the pancreatic head or distal bile duct seems to be compatible with those observed in a new entity called autoimmune pancreatitis, but usually intense fibrotic reaction (zonation) predominates producing a mass. When this condition is limited to the pancreatic head, the common bile duct might be involved by the inflammatory process and jaundice may occur often resembling adenocarcinoma of the pancreas. We have previously reported a case of IMT arising from the bile duct associated with autoimmune pancreatitis which is an extremely rare entity. Four years after Kaush-Whipple resection, radiological examination on routine follow-up revealed a tumor mass, suggesting local recurrence. Ultrasound-guided FNA confirmed our suspicious diagnosis. This present case, as others, suggests that persistent follow-up is necessary in order to prevent irreversible liver damage at this specific location.

Inflammatory myofibroblastic tumor of the orbit presenting as a subconjunctival mass

PURPOSE

To present a case of inflammatory myofibroblastic tumor in the anterior orbit and to describe its clinical features, diagnosis, and management.

METHODS

Case report and literature review.

RESULTS

A 10-year-old boy presented with diplopia and limited ocular motility in his right eye secondary to a subconjunctival mass in the right supranasal side. Incisional biopsy and debulking were performed. Histopathologic examination showed the proliferation of spindle-shaped myofibroblasts that were immunoreactive for smooth muscle actin and vimentin and infiltrate of inflammatory cells.

CONCLUSIONS

We believe this is the first case of an inflammatory myofibroblastic tumor found localized in the orbit.

Inflammatory myofibroblastic tumour of the gallbladder

BACKGROUND: Inflammatory myofibroblastic tumour (IMT) is a benign, nonmetastasizing proliferation of myofibroblasts with a potential for local infiltration, recurrence and persistent local growth. CASE REPORT: We report a case of a 51 year-old female, who had excision of a gallbladder tumour. Histopathology showed it to be IMT of the gallbladder. CONCLUSION: The approach to these tumours should be primarily surgical resection to obtain a definitive diagnosis and relieve symptoms. IMT has a potential for local infiltration, recurrence and persistent local growth.

Inflammatory pseudotumor of the liver: ferumoxide-enhanced MR imaging as a tiebreaker

We examined a 70-year-old male patient with an inflammatory pseudotumor of the liver mimicking a peripheral-type cholangiocellular carcinoma. Ferumoxide-enhanced magnetic resonance (MR) imaging revealed residual Kupffer cell function in liver parenchyma in and surrounding the inflammatory pseudotumor involvement, which suggested the diagnosis of inflammatory pseudotumor of the liver. We correlate the MR imaging and pathologic findings in this report.

Synchronous gastrointestinal and musculoskeletal manifestations of different subtypes of inflammatory myofibroblastic tumor: CT, MRI and pathological features

We describe a case of an unusual multicentric appearance of an inflammatory myofibroblastic tumor, consisting of multiple gastrointestinal masses with different growth patterns and simultaneous, distant, musculoskeletal manifestations. CT and MR imaging features demonstrated a different degree of lesion enhancement, which proved histologically to be related to an alternation of predominantly spindle cell areas with a myxoid-vascular IMT subtype. A clear separation of the imaging characteristics of this tumor's subtypes by correlation with the pathology was not possible because of the mixed histologic character of the tumor in all its locations. However, MRI signal in the T2-weighted sequence was lower in the spindle cell variant localized predominantly in the musculoskeletal system, while the gastrointestinal predominantly myxoid-vascular counterparts showed slightly higher signal in the T2-weighted sequence.