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Endo S, Watanabe Y, Abe Y, Shinkawa T, Tamiya S, Nishihara K, Nakano T. Hepatic inflammatory pseudotumor associated with primary biliary cholangitis and elevated alpha-fetoprotein lectin 3 fraction mimicking hepatocellular carcinoma. Surg Case Rep 2018; 4:114. [PMID: 30203247 PMCID: PMC6134473 DOI: 10.1186/s40792-018-0523-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/03/2018] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Sho Endo
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan.
| | - Yusuke Watanabe
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
| | - Yuji Abe
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
| | - Tomohiko Shinkawa
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
| | - Sadafumi Tamiya
- Department of Pathology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
| | - Kazuyoshi Nishihara
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
| | - Toru Nakano
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, 802-0077, Japan
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Blanton C, Kalarickal J, Joshi V. Biliary obstruction from a bile duct mass. Gastroenterology 2011; 141:812-3, 1129. [PMID: 21802419 DOI: 10.1053/j.gastro.2010.06.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 06/07/2010] [Indexed: 12/02/2022]
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Ueda J, Yoshida H, Taniai N, Onda M, Hayashi H, Tajiri T. Inflammatory pseudotumor in the liver associated with intrahepatic bile duct stones mimicking malignancy. J NIPPON MED SCH 2009; 76:154-9. [PMID: 19602822 DOI: 10.1272/jnms.76.154] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe a 71-year-old man with an inflammatory tumor arising in segment 5 of the liver. The patient was admitted because of acute pain in the right upper quadrant of the abdomen and fever. Initial laboratory tests revealed the following: serum alkaline phosphatase concentration, 634 IU/L; serum gamma glutamic transpeptidase concentration, 1,378 IU/L; serum C-reactive protein concentration, 0.89 mg/dL; and total bilirubin concentration, 8.9 mg/dL. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging showed a mass, 3 cm in diameter, in segment 5 of the liver. Magnetic resonance cholangiopancreatography showed a lesion of moderate-to-high signal intensity on T2-weighted images of segment 5. Endoscopic retrograde cholangiopancreatography revealed a common bile duct stone. The intrahepatic bile ducts of segment 5 could not be visualized after the use of contrast material. Endoscopic sphincterotomy was performed to remove the common bile duct stone. Antibiotics were administered soon after stone removal, and fever gradually resolved. Positron emission tomography revealed hot spots in segment 5 of the liver. Three weeks after discharge, the patient was readmitted with an acute pain in the right upper quadrant of the abdomen. Abdominal ultrasonography, CT, and magnetic resonance imaging showed enlargement of this area. Inflammatory changes of segment 5 due to cholangitis with intrahepatic bile duct stones was diagnosed. Because malignant disease could not be completely ruled out, segment 5 of the liver was resected. Macroscopic examination of the resected specimen revealed a gray, fibrotic, solid tumor associated with intrahepatic bile duct stones. Microscopic examination of the tumor showed proliferation of spindle-shaped myofibroblastic cells in a mixed myxoedematous, dense fibrotic stroma, associated with infiltration by various acute and chronic inflammatory cells. The postoperative course was uneventful, and the patient was discharged on postoperative day 16.
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Affiliation(s)
- Junji Ueda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Tublin ME, Moser AJ, Marsh JW, Gamblin TC. Biliary Inflammatory Pseudotumor: Imaging Features in Seven Patients. AJR Am J Roentgenol 2007; 188:W44-8. [PMID: 17179326 DOI: 10.2214/ajr.05.0985] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Hepatic biliary pseudotumor is a benign, rare, and poorly understood tumor that is typically diagnosed after aggressive surgical intervention. The purpose of this report is to describe the clinical and imaging features of this tumor in seven patients. CONCLUSION Although secondary clinical features may rarely suggest inflammatory pseudotumor, the typical presenting symptom--painless obstructive jaundice--is indicative of malignancy. The imaging appearance of hepatic hilar biliary pseudotumor is also indistinguishable from that of cholangiocarcinoma.
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Affiliation(s)
- Mitchell E Tublin
- Department of Radiology (AI), University of Pittsburgh Medical Center, Presbyterian-Shadyside (Presbyterian Campus), 200 Lothrop St., Pittsburgh, PA 15213, USA.
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Neild GH, Rodriguez-Justo M, Wall C, Connolly JO. Hyper-IgG4 disease: report and characterisation of a new disease. BMC Med 2006; 4:23. [PMID: 17026742 PMCID: PMC1618394 DOI: 10.1186/1741-7015-4-23] [Citation(s) in RCA: 190] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Accepted: 10/06/2006] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis. METHODS We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis. RESULTS Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment. CONCLUSION We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good.
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Affiliation(s)
- Guy H Neild
- UCL Centre for Nephrology, Royal Free Hospital, London NW3 2QG, UK
- Institute of Urology and Nephrology, Middlesex Hospital, London W1T 3AA, UK
| | - Manuel Rodriguez-Justo
- Department of Histopathology, Royal Free and University College Medical School, University College Hospital, Rockefeller Building, London WC1E 6JJ, UK
| | - Catherine Wall
- UCL Centre for Nephrology, Royal Free Hospital, London NW3 2QG, UK
| | - John O Connolly
- UCL Centre for Nephrology, Royal Free Hospital, London NW3 2QG, UK
- Institute of Urology and Nephrology, Middlesex Hospital, London W1T 3AA, UK
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Koide H, Sato K, Fukusato T, Kashiwabara K, Sunaga N, Tsuchiya T, Morino S, Sohara N, Kakizaki S, Takagi H, Mori M. Spontaneous regression of hepatic inflammatory pseudotumor with primary biliary cirrhosis: Case report and literature review. World J Gastroenterol 2006; 12:1645-8. [PMID: 16570364 PMCID: PMC4124304 DOI: 10.3748/wjg.v12.i10.1645] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hiroshi Koide
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Teranishi N, Yoshida H, Mamada Y, Taniai N, Mizuguchi Y, Shimizu T, Takahashi T, Akimaru K, Naito Z, Tajiri T. Inflammatory pseudotumor in the Spiegel lobe of the liver of an elderly woman. J NIPPON MED SCH 2005; 72:121-6. [PMID: 15940020 DOI: 10.1272/jnms.72.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe an inflammatory tumor in the Spiegel lobe of the liver of an 81-year-old woman. The patient was referred to our hospital for evaluation of a fever of over 39 degrees C and upper abdominal pain. Both conditions had persisted for five days in spite of antibiotic treatment. Initial laboratory tests revealed a serum C-reactive protein concentration of 20.9 mg/dL and white blood cell count of 15,500/microL. Abdominal ultrasound showed a hypoechoic lesion measuring 4 cm in diameter in the Spiegel lobe of the liver. A follow-up abdominal ultrasound revealed that the hypoechoic lesion was not decreased in size. Computed tomography showed a moderate-to-high-density area in the arterial phase and a low-density area in the Spiegel lobe on delayed phase. Magnetic resonance imaging showed a faint low-intensity lesion on T1-weighted imaging and moderate-to-high-intensity lesion on T2-weighted imaging in the Spiegel lobe. Angiography showed a slight hypervascularity in the area of the Spiegel lobe. Antibiotics and nu-globulin were commenced soon after admission and the fever gradually improved. Ultrasound-guided liver biopsy revealed that the hepatic parenchyma was almost completely replaced by dense hyalinized fibrous tissue and inflammatory cells. These findings were construed to indicate a benign lesion, but the tumor remained unchanged. Malignant disease could not be completely ruled out. Segment 1 of the liver was resected. Macroscopic examination of the resected specimen revealed a gray, fibrotic, solid tumor. The border of the tumor was well-circumscribed but not encapsulated. Microscopically, the tumor showed a marked fibrotic background with infiltration by a mixed population of lymphocytes, plasma cells, histiocytes, and reactive, plump spindle cells. The postoperative course was uneventful. The patient has remained well in the 10 months since the resection without recurrence.
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Affiliation(s)
- Nobuhisa Teranishi
- Surgery for Organ Function and Biological Regulation, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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Germanidis G, Xanthakis I, Tsitouridis I, Zaramboukas T, Kiskinis D, Konstantaras C, Miliaras S, Sirakos T, Pagkalos E. Regression of inflammatory myofibroblastic tumor of the gastrointestinal tract under infliximab treatment. Dig Dis Sci 2005; 50:262-5. [PMID: 15745083 DOI: 10.1007/s10620-005-1593-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Georgios Germanidis
- First Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece.
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Kalil AN, Franco TB, Furian R. Pseudotumor inflamatório do fígado: diagnóstico diferencial de carcinoma hepatocelular. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000200010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Antonio Nocchi Kalil
- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre; Santa Casa de Porto Alegre
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10
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Abstract
A case of inflammatory pseudotumour of the liver is presented. The clinical, radiological and pathological findings are described and a brief discussion of this rare but important condition is presented.
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Affiliation(s)
- M Baillie
- Department of Radiology, Auckland Hospital, Auckland, New Zealand
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11
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Lévy S, Sauvanet A, Diebold MD, Marcus C, Da Costa N, Thiéfin G. Spontaneous regression of an inflammatory pseudotumor of the liver presenting as an obstructing malignant biliary tumor. Gastrointest Endosc 2001; 53:371-4. [PMID: 11231407 DOI: 10.1016/s0016-5107(01)70422-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S Lévy
- Service d'Hépato-Gastroentérologie, Service d'Anatomopathologie, and Service de Radiologie, CHU Reims, and Service de Chirurgie Digestive, Hôpital Beaujon, Clichy, France
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12
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Ogawa T, Yokoi H, Kawarada Y. A case of inflammatory pseudotumor of the liver causing elevated serum CA19-9 levels. Am J Gastroenterol 1998; 93:2551-5. [PMID: 9860425 DOI: 10.1111/j.1572-0241.1998.00717.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inflammatory pseudotumor of the liver is a rare lesion characterized by proliferating fibrovascular tissue admixed with inflammatory cells. A 50-yr-old Japanese man was hospitalized because of upper abdominal pain and high fever. Computed tomography revealed a poorly demarcated, low density mass in the left lobe of the liver, and abnormal laboratory findings included WBC 9340/mm3, CRP 10.5 mg/dl, and marked elevation of CA19-9 to 1167.9 U/ml. Endoscopic retrograde cholangiography showed irregularity of the intrahepatic bile duct of the left lateral segment, and the lateral segmental branches of the portal vein were not visualized on the venous phase of abdominal angiography. Ultrasound-guided liver biopsy was performed, but malignant disease, including intrahepatic cholangiocarcinoma, could not be completely ruled out. The patient underwent left hepatic lobectomy with lymph node dissection. Histopathological examination yielded a definitive diagnosis of inflammatory pseudotumor. The lesion was immunohistochemically stained for CA19-9 by the ABC method, and the biliary epithelium in severely inflamed portal canals was found to be positive. The markedly elevated preoperative level of CA 19-9 decreased to almost within the normal range and the patient remains well 2 yr 9 months after surgery, without any complications.
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Affiliation(s)
- T Ogawa
- First Department of Surgery, Mie University School of Medicine, Tsu, Japan
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Abstract
Follicular dendritic cell tumour of the liver is a recently recognized entity. To date, only two cases have been described, both in the pathology literature. Histologically, it resembles an inflammatory pseudotumour and immunohistochemical and ultrastructural studies are required for its diagnosis. The ultrasound, computed tomography and angiographic features of two cases of follicular dendritic cell tumour of the liver are described in detail. One of the patients had multiple recurrences of this tumour. The imaging features are very similar to those of hepatocellular carcinoma. As follicular dendritic cell tumour is considered to be of low-grade malignant potential, in contrast to the dismal prognosis for hepatocellular carcinoma, it is important to be able to accurately distinguish between the two types of tumour prior to initiating definitive therapy.
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Affiliation(s)
- W C Peh
- Department of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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