Inflammatory Pseudotumor of the Liver: Report of two Cases

Inflammatory pseudotumor of the Liver. A Report of Two Cases with Unusual Histologic Picture

Two cases of inflammatory pseudotumor (IPT) of the liver are reported. Clinical presentation was vague and aspecific. Laboratory tests and data from imaging techniques provided no specific information on the actual nature of the lesions and were misleading, suggesting a malignant lesion in one patient and a complicated hydatid cyst in the other. On gross examination, the tumors appeared yellowish ore grey-yellow in color, with a firm cut surface and well circumscribed from the surrounding parenchyma, although a true capsule was not evident. Variability in the histological pattern was also observed, even though the major finding was in both cases an admixture of lymphocytes, plasmacells, granulocytes and monocytes. Lymphocytes were immunohistochemically heterogeneous; monocytes showed in one case large hyperchromic atypical nuclei, confirming the previously, reported possibility that some cases of IPT may be mistaken for sarcomas. Further evidence is added in support of the hypothesis that some liver IPT may result from the evolution of cholangitic abscesses.

Inflammatory Pseudotumor of the Liver: Report of Two Cases

Inflammatory pseudotumor of the liver is a very rare lesion. Herein we describe two cases of this entity which occurred in two women aged 22 and 49 years, respectively. Both cases were considered to be clinically malignant and only the histopathologic examination revealed the non-neoplastic nature of the disease. Ultrastructural and immunohistochemical studies further supported the evidence of a reactive disease.

So-called inflammatory myofibroblastic tumour: a proliferative lesion of fibroblastic reticulum cells?

The term inflammatory pseudotumour was originally used in a generic fashion for any lesion which simulated a neoplastic condition at a clinical, macroscopic and microscopic level but which was thought to have an inflammatory/reactive pathogenesis. In more recent times, the term has been employed in a more restrictive sense for a mass lesion characterized microscopically by the proliferation of a spindle cell component against a heavy inflammatory infiltrate of mixed composition but usually with a predominance of mature lymphocyte and plasma cells. The spindle cell component has generally been regarded as being of mesenchymal nature and having morphological and phenotypical features consistent with fibroblasts or myofibroblasts, the latter cell being clearly preferred over the former in the more resent reports. The term inflammatory myofibroblastic tumour (IMFT) is the one currently favoured, which proposes the myofibroblastic nature of the process. It is the purpose of this review to bring forth some evidence that the neoplastic spindle cell component of IMFT may be instead derived from the subtype of cells of the accessory immune system that have been variously called fibroblastic reticulum cells, myoid cells, and dictyocytes.

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.

Inflammatory pseudotumour of the liver--evidence for malignant transformation

A case of inflammatory pseudotumour of the liver is reported, and evidence is presented for its subsequent evolution into malignant non-Hodgkin's lymphoma. Such postulated malignant transformation challenges the assumption that hepatic inflammatory tumours are entirely benign lesions.

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

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.

Inflammatory pseudotumor of the retroperitoneum in a child

Inflammatory pseudotumor is a rare, benign lesion of various organs and tissues that occurs in children and young adults. A case is reported in a 12-year-old boy in a retroperitoneal location with involvement of the left ureter and a thrombosis of left iliac vein. He underwent surgical resection. A local recurrence 6 months later was surgically cured.

Inflammatory pseudotumour of the liver: antecedent causes and clinical experience

We present a case in which inflammatory pseudotumour of the liver which appears to complicate Caroli's disease. We have reviewed the literature in hepatic inflammatory pseudotumour with particular emphasis on underlying causes. We were able to find 45 reported cases, with adequate clinical data in 42; in these only 7 showed a probable antecedent cause. There were gallstones in another 5, giving a prevalence not significantly different to that within the general population. Hepatic inflammatory pseudotumour typically presents with a history of fever, anorexia, loss of weight, hepatic pain, jaundice and a detectable liver mass (or masses). The diagnosis of inflammatory pseudotumour should be particularly considered when there is a history of previous inflammatory hepato-biliary disease. Preoperative or intra-operative diagnosis might then avoid major hepatic surgery.