Inflammatory pseudotumor in the liver associated with intrahepatic bile duct stones mimicking malignancy

Magnetic resonance imaging of inflammatory pseudotumor of the liver: a 2021 systematic literature update and series presentation

PURPOSE

Inflammatory pseudotumors of the liver (IPTL) are not exceptional benign lesions with various etiologies, histology, and imaging appearances. The incomplete knowledge of this pathology and the wide polymorphism sometimes resembling malignancy often induce long and expensive diagnostic flow, biopsy and occasionally unnecessary surgery. We propose a systematic revision of MRI literature data (2000-2021) with some narrative inserts and 10 new complete MRI cases, with the aim of organizing the data about IPTL and identifying some typical features able to improve its diagnosis from imaging.

METHODS

We performed a systematic revision of literature from 2000 to 2021 to obtain MRI features, epidemiological, and clinical data of IPTL. The basic online search algorithm on the PubMed database was "(pseudotumor) AND (liver) AND (imaging)." Quality assessment was performed using both scales by Moola for case report studies and by Munn for cross-sectional studies reporting prevalence data. A case-based retrospective study by collecting patients diagnosed with IPTL from three different university hospitals from 2015 to 2021 was done as well. Only cases with MR examinations complete with T1/T2/contrast-enhanced T1/Diffusion-Weighted (W) images and pathology-proven IPTL were selected.

RESULTS

After screening/selection 38 articles were included for a total of 114 patients. In our experience we selected 10 cases for a total of 16 IPTLs; 8 out of 10 patients underwent at least 1 MRI follow-up. Some reproducible and rather typical imaging findings for IPTL were found. The targetoid aspect of IPTL is very frequent in our experience (75% on T1W, 44% on T2W, 81% on contrast-enhanced T1W (at least one phase), 100% on Diffusion-W images) but is also recurrent in the literature (6% on T1W, 31% on T2W, 51% on CE-T1W (at least one phase), 18% on Diffusion-W images, and 67% on hepatobiliary phase). In our experience, Apparent Diffusion Coefficient map values were always equal to or higher than those of the surrounding parenchyma, and at MRI follow-up, nodule/s disappeared at first/second control, in six patients, while in the remaining 2, lesions persisted with tendency to dehydration.

CONCLUSION

A targetoid-like aspect of a focal liver lesion must raise diagnostic suspicion, especially if IgG4-positive plasma is detected. MRI follow-up mainly shows the disappearance of the lesion or its reduction with dehydration.

Inflammatory myofibroblastic tumor of the liver: A case report and review of literature

BACKGROUND

Inflammatory myofibroblastic tumors of the liver (IMTL) are extremely rare neoplasms and very little is known about their clinical presentation, pathogenesis, and biological behavior. Due to their absolute rarity, it is almost impossible to obtain a definite diagnosis without histological examination. Because of their intermediate biological behavior with the risk for local recurrence and metastases, surgical resection is recommend whenever IMTL is suspect.

CASE SUMMARY

We herein present a case of an otherwise healthy 32-year-old woman who presented with intermittent fever, unclear anemia, malaise and right flank pain 4 mo postpartum. The liver mass in segment IVa/b was highly FDG avid in the positron emission tomography-computed tomography. Hepatic resection was performed achieving a negative resection margin and an immediate resolution of all clinical symptoms. Histological analysis diagnosed the rare finding of an inflammatory myofibroblastic tumor of the liver and revealed cytoplasmic anaplastic lymphoma kinase expression by immunohistochemistry. Twelve months follow-up magnetic resonance imaging showed no recurrence and no metastases in the fully recovered patient.

CONCLUSION

IMTLs are extremely rare and difficult to diagnose. Due to their intermediate biological behavior, surgical resection should be perform whenever feasible and patients should be followed-up in order to detect recurrence and metastasis as early as possible.

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.

The Prevalence of Hyperechoic Rim in Solid Focal Liver Lesions and Its Implication

The objective of this study was to investigate the prevalence and clinical implications of the hyperechoic rim of liver focal solid lesions. A retrospective review was conducted of sonograms of focal liver lesions with a hyperechoic rim, as well as relative examinations such as computed tomography, magnetic resonance imaging, biopsy, resection, and histopathology reports. A cohort of 10 232 patients was found to have solid focal liver lesions (2030 malignant, 8202 benign). A hyperechoic rim was determined in 182 hemangiomas, 2 granulomas, 2 hepatocellular carcinomas (HCCs), and 4 other malignancies. There were significant differences between malignant and benign lesions ( P < .001), between HCCs and hemangiomas ( P < .001), between malignancies and hemangiomas ( P < .001), between HCCs and granulomas ( P = .044), and between other malignancies and granulomas ( P = .005). There was no significant difference between liver granulomas and hemangiomas ( P = .656). In this study, a hyperechoic rim in solid focal liver lesions appeared mainly in hemangiomas, granulomas, and rarely in malignant lesions.

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 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.

Recurring multicystic inflammatory pseudotumor of the liver: a case report

Inflammatory pseudotumor (IPT) of the liver is a rare benign lesion for which imaging diagnosis remains a challenge. We report the case of a 39-year-old Algerian woman, who presented epigastric pains combined with fever and jaundice. Ultrasound, CT scan and MRI showed the presence of a 10 cm-long multi-septated cystic mass of the left lobe, with peripheral enhancement. A left-hepatectomy was performed and histopathology revealed an IPT of the liver. During the 4 following years, the patient had three other recurrences of liver IPT at various locations distinct from the original, revealed by the same clinical symptoms. During these relapses, the lesions did regress thanks to a medical treatment. This observation underlines the difficulty of the diagnosis and treatment of liver IPT.

(18)F-FDG PET/CT in inflammatory pseudotumor of the colon causing intussusception

Inflammatory pseudotumor is a rare benign lesion mimicking malignancy both clinically and radiologically. An accurate diagnosis is still difficult and is based on the histological examination. Since inflammatory pseudotumor is exceptionally rare in the colon, this unexpected lesion can be mistaken for malignancy. We report the first case of inflammatory pseudotumor in the colon that showed (18)F-fluorodeoxyglucose (FDG) uptake and acted as the lead point causing colocolic intussusception.

Inflammatory Pseudotumor of the Liver Complicated by Lung Necrosis and Pleural Empyema: A Case Report

Inflammatory pseudotumor of the liver (IPTL) is a rare condition, but an important differential diagnosis of hepatic space-occupying lesions. It may regress spontaneously and mimic other liver tumors. Complications are usually intrahepatic. Herein, we present a case of IPTL which developed pleural empyema and lung necrosis as an uncommon complication.

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.