Differentiation of Lymphoma Presenting as Retroperitoneal Mass and Retroperitoneal Fibrosis: Evaluation with Multidetector-row Computed Tomography

Multisystem diseases in the abdomen and pelvis: imaging manifestations and diagnostic roles of cross-sectional imaging

Systemic diseases, such as IgG4-related disease, sarcoidosis, and amyloidosis, usually involve multiple systems or organs simultaneously or sequentially. The gastrointestinal tract, hepatobiliary system, and genitourinary tract are commonly involved in many multisystem diseases and can also be the first sites with disease involvement. Cross-sectional imaging, such as CT and MR, plays an important role in the diagnosis and management of multisystem diseases by aiding in the evaluation of multiorgan involvement. Here, common imaging features of frequently affected organs are reviewed in multisystem diseases that we often encounter in the abdomen and pelvis, and the diagnostic roles of cross-sectional imaging for these diseases are also discussed.

Leiomyosarcomas of the inferior vena cava: diagnostic features on contrast-enhanced CT, ultrasonography and MRI

Purpose

To evaluate clinical presentation and imaging characteristics of leiomyosarcomas of the inferior vena cava (IVC LMS) using contrast-enhanced CT (CECT), ultrasonography (US), magnetic resonance imaging (MRI), and to identify features that facilitate early and accurate pre-operative diagnosis.

Materials and methods

Our study enrolled 21 patients with pathologically confirmed IVC LMS from October 2015 to June 2022. All participants underwent CECT, and additionally, 12 participants had US examinations and 3 had MRI. Images were independently reviewed by two experienced radiologists. The clinical presentations and diagnostic characteristics were recorded.

Results

The study involved 16 female and 5 male patients, with an average age of 55 ± 11 years (ranging from 34 to 80 years). Common clinical symptoms included abdominal pain, back pain, leg discomfort, abdominal distension, jaundice, and the presence of an abdominal mass. On CT scans, a large, lobulated, heterogeneous mass with progressive enhancement was typically seen in 13 of the 21 patients (61.9%). Ultrasonography revealed that IVC LMS typically presented as a lobulated, heterogeneous, hypoechoic mass. Color Doppler imaging evaluated lumen obstruction in 8 of the 12 patients (66.7%), and high velocity flow signals were detected by Pulsed wave Doppler in 4 of the 12 patients (33.3%). On MRI, IVC LMS presented as a heterogeneous mass that exhibited intermediate intensity on T1-weighted images, slightly high intensity on T2-weighted images and high intensity on diffusion-weighted images.

Conclusion

Several diagnostic characteristics on CECT, US and MRI could aid in the diagnosis of IVC LMS. The detection of a heterogeneous mass with progressive enhancement along the inferior vena cava on CECT was strongly indicative of IVC LMS. Both CT and US are effective in accurately indicating the location of the tumor within the IVC.

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Primary Bile Duct Diffuse Large B-cell Lymphoma Diagnosed by Repeated Endoscopic Ultrasound-guided Fine-needle Aspiration and Endoscopic Retrograde Cholangiopancreatography

A 54-year-old man was admitted with obstructive jaundice. Computed tomography showed common bile duct stricture and a tumor around the celiac artery. Repeated endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) as well as a laparotomic biopsy around the celiac artery were diagnostically unsuccessful. Since the bile duct stricture progressed, EUS-FNA and ERCP were performed a third time, finally leading to the diagnosis of diffuse large B-cell lymphoma. The treatment plan and prognosis of obstructive jaundice differ greatly depending on the disease. It is important to conduct careful follow-up and repeated histological examinations with appropriate modifications until a diagnosis is made.

Imaging manifestations of IgG4-related disease

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

New-onset retroperitoneal fibrosis following COVID-19 mRNA vaccination: Coincidental or vaccine-induced phenomenon?

The Pfizer-BioNTech mRNA vaccine is a US Food and Drug Administration-approved coronavirus disease 2019 (COVID-19) vaccine. Although it is reported to be safe and effective, immune dysregulation leading to autoimmunity has become an area of concern. Retroperitoneal fibrosis (RPF) is an immune-mediated fibroinflammatory disease characterized by the deposition of fibrous tissues, primarily around the abdominal aorta and iliac arteries. Herein, we report a case of RPF following Pfizer BioNTech COVID-19 mRNA vaccination. To the best of our knowledge, there have been no published reports on RPF after COVID-19 mRNA vaccination. A 58-year-old woman with no history of autoimmune diseases presented with acute onset of epigastric pain 5 weeks after the second dose of the Pfizer-BioNTech vaccine. She had been diagnosed with stage I breast cancer 9 years ago and was in complete remission on admission. Abdominal computed tomography showed preaortic soft-tissue infiltration around the origin of the superior mesenteric artery but no evidence of breast cancer recurrence. Considering the temporal relationship between current symptoms and vaccination and the absence of other possible causes, she was diagnosed with RPF secondary to Pfizer-BioNTech vaccine-induced autoimmunity. This case may raise awareness of the possibility of RPF development following COVID-19 mRNA vaccination.

A Case of Follicular Lymphoma Mimicking Idiopathic Retroperitoneal Fibrosis

Retroperitoneal fibrosis (RF) is a rare disease, which can be primary (idiopathic) or secondary. We present the case of a 56-year-old patient with symptomatic RF, in whom, after ineffective treatment with glucocorticoids, immunosuppressants, and non-steroidal anti-inflammatory drugs for one year and a progressive clinical course, a follicular lymphoma in the retroperitoneal space and several lymphoma nodes was identified. We also include a literature review on differential diagnosis through image inspection and case reports of lymphoma mimicking RF.

Renal Lymphoma Mimicking a Retroperitoneal Hematoma

We report the case of a 65-year-old female with an atypical presentation of renal lymphoma at computed tomography (CT), which was initially misinterpreted as a retroperitoneal hematoma. This case highlights the importance to keep a high level of suspicion in order to make a prompt diagnosis since treatment strategies differ significantly.

Validation of the diagnostic criteria for IgG4-related kidney disease (IgG4-RKD) 2011, and proposal of a new 2020 version

Background

In 2011, the IgG4-related kidney disease (IgG4-RKD) working group of the Japanese Society of Nephrology proposed diagnostic criteria for IgG4-RKD. The aim of the present study was to validate those criteria and develop a revised version.

Methods

Between April 2012 and May 2019, we retrospectively collected Japanese patients with kidney disease, for whom data on serum IgG4 values and/or immunohistological staining for IgG4 in renal biopsy samples were available. These patients were classified as IgG4-RKD or non-IgG4-RKD based on the diagnostic criteria for IgG4-RKD 2011, and the results were evaluated by expert opinion. Accordingly, we developed some revised versions of the criteria, and the version showing the best performance in the present cohort was proposed as the IgG4-RKD criteria for 2020.

Results

Of 105 included patients, the expert panel diagnosed 55 as having true IgG4-RKD and 50 as mimickers. The diagnostic criteria for IgG4-RKD 2011 had a sensitivity of 72.7% and a specificity of 90.0% in this cohort. Of the 15 patients with true IgG4-RKD who were classified as non-IgG4-RKD, all lacked biopsy-proven extra-renal lesions, although many had clinical findings highly suggestive of IgG4-RD. The revised version to which “bilateral lacrimal, submandibular or parotid swelling, imaging findings compatible with type 1 autoimmune pancreatitis or retroperitoneal fibrosis” was added as an item pertaining to extra-renal organ(s) improved the sensitivity to 90.9% while the specificity remained at 90.0%.

Conclusion

The revised version has considerably improved test performance after addition of the new extra-renal organ item (imaging and clinical findings).

Retroperitoneal Fibrosis and its Differential Diagnoses: The Role of Radiological Imaging

Background Retroperitoneal fibrosis is a rare disease with an incidence of 0–1/100 000 inhabitants per year and is associated with chronic inflammatory fibrosis of the retroperitoneum and the abdominal aorta. This article sheds light on the role of radiological imaging in retroperitoneal fibrosis, names various differential diagnoses and provides an overview of drug and surgical treatment options.

Methods A literature search for the keywords “retroperitoneal fibrosis” and “Ormond’s disease” was carried out in the PubMed database between January 1, 1995 and December 31, 2019 (n = 1806). Mainly original papers were selected, but also reviews, in English and German language, with a focus on publications in the last 10 years, without excluding older publications that the authors believe are relevant to the topic discussed in the review (n = 40).

Results and Conclusion Ormond’s disease is a rare but important differential diagnosis for nonspecific back and flank pain. Imaging diagnostics using CT or MRI show a retroperitoneal mass, which must be differentiated from lymphoma, sarcoma, multiple myeloma and Erdheim-Chester disease. Patients have an excellent prognosis under adequate therapy. FDG-PET/CT or FDG-PET/MRT should be considered as potential modalities, as hybrid imaging can evaluate both the morphological changes and the inflammation.

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Leiomyosarcoma of the Inferior Vena Cava with Hepatic and Pulmonary Metastases: Case Report

Sarcomas are connective tissue tumors accounting for only 1% of all adult malignancies. Leiomyosarcoma (LMS) is a sarcoma arising from smooth muscle cells, and accounts for 10-20% of all sarcomas. A subtype of LMS are those originating from the smooth muscle of blood vessels. Leiomyosarcoma of the inferior vena cava is a sarcomatous tumor, with less than 350 cases described in the literature. It carries a poor prognosis, with 5- and 10-year survival rates of 31.4% and 7.4%, respectively. We present a case of a 46-year-old female with no significant past medical history presented to the emergency department with mild abdominal pain and distention, early satiety, and weight loss for three weeks, found to have unresectable metastatic leiomyosarcoma of the inferior vena cava.

IgG4-related Retroperitoneal Fibrosis: An Emerging Masquerader With a Sinister Presentation

OBJECTIVE

Retroperitoneal fibrosis (RPF) is a rare proliferative fibro-inflammatory disease involving the soft tissues of the retroperitoneum. IgG4 related retroperitoneal fibrosis is an emerging entity which needs to be distinguished from idiopathic RPF. We describe a clinical case of IgG4 related RPF highlighting the importance of clinching this diagnosis.

METHODS

A 70 year old female was referred to the outpatient department of our institute with complaints of fatigue, bilateral flank pain and loss of appetite for the past 1 month. The CT and PET scan demonstrated a uniformly enhancing bulky retroperitoneal mass causing bilateral hydroureteronephrosis. The biopsy from the mass lesion revealed IgG4 related disease. The patient was started on corticosteroids after percutaneous nephrostomy placement.

RESULTS

Three months post induction of therapy, repeat PET-CT shows resolution of the mass with no FDG avid lesion. Serum IgG4 levels were reduced to normal (27 mg/dL) suggestive of response to treatment. The percutaneous nephrostomies were removed and the patient is doing well on maintenance dose of corticosteroids for her disease.

CONCLUSION

The availability of serum IgG4 levels for monitoring treatment response and follow-up can curtail the repeated radiological imaging and associated contrast exposure as compared to idiopathic RPF. Secondly, the diagnosis of IgG4-related RPF shall alert the clinician to look out for extra-retroperitoneal diseases on follow up of this multi-organ disease.