[A case of Sjögren's syndrome associated with inflammatory pseudotumor of the liver]

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.

Enlarging Liver Mass: Inflammatory Pseudotumor in a Patient With Polymyalgia Rheumatica

Inflammatory pseudotumors of the liver are rare, non-neoplastic liver tumors. Due to the nonspecific clinical presentation, imaging features, and histopathological findings, they can mimic malignant tumors requiring invasive diagnostics. We present a case of a 61-year-old female patient with a history of type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and polymyalgia rheumatica who had initially presented with abdominal pain for 3 weeks. Further workup showed normal liver chemistries and tumor markers: AFP and CA 19-9. Magnetic resonance imaging (MRI) of the abdomen showed a segment 6 lesion measuring 4.1 × 4.0 × 3.7 cm. A liver biopsy then confirmed the diagnosis of an inflammatory pseudotumor of the liver with negative IgG4. On follow-up imaging, a rapid growth of this liver lesion was noted. Laparoscopy was done but did not show any distinct liver lesion. Follow-up imaging confirmed a decrease in the size of the mass. Interestingly, the patient had been on a higher dose of steroids for her polymyalgia rheumatic leading up to the follow-up imaging. This is the first case of an inflammatory pseudotumor of the liver in a patient with polymyalgia rheumatica. With this case, we would like to increase the awareness for inflammatory pseudotumors of the liver as a differential diagnosis of liver lesions in patients with underlying autoimmune disorders.

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.

Inflammatory myofibroblastic tumor of the lung with unique histological pattern and association with Sjögren's disease and systemic lupus erythematosus

Inflammatory myofibroblastic tumor (IMT) of the lung is a rare condition. Radiological properties and clinical presentation of this disease can mimic malignant process. We present a case of IMT of the lung in a 58 year old female patient with a single lung nodule. Tumor was unencapsulated, firm, and well circumscribed. Microscopically tumor had multinodular structure with single or multiple small blood vessels in the center of each nodule surrounded in circular pattern by connective tissue containing spindle cells embedded into the thick layers of extracellular matrix. Extracellular matrix was identified as type I and type III collagen fibrils embedded into type IV collagen and laminin. The tumor was surrounded by T-, B-lymphocytes and polyclonal plasma cells. Histological organization of this lesion's stromal component was unique, but cell composition was similar to inflammatory pseudotumor of the lung. In addition, tumor tissue sections exhibited strong positivity for IgG, weak positivity for IgA, 1Cq, but were negative for IgM, and C3. Mutational analysis of the EGFR, KRAS genes and ALK locus rearrangement were performed and did not reveal any mutations. This is the first report of an IMT associated with Sjögren's disease, systemic lupus erythematosus and Non-Hodgkin lymphoma developing in the lungs. Patient was clinically followed up for 18 months and no recurrence of the tumor observed.

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.

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 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.