Hepatic pseudotumor:A diagnostic challenge

Hepatic pseudotumors are rare lesions of unknown origin,characterized by the proliferation of fibrous connective tissue and inflammatory cell infiltrates.They mimic malignant lesions clinically,and radiologically,given their non-specific clinical and imaging features.The pathophysiology of hepatic pseudotumor is incompletely understood and there are no standardized criteria for diagnosis.Pseudotumors have been reported to develop in various organs in the body with the lung and liver being the most common site.Hepatic pseudotumors develop in patients with underlying triggers of liver inflammation and injury,including infections,autoimmune liver diseases,bile duct injury,or surgery.Hepatic pse-udotumors respond well to conservative treatment with antibiotics,and steroids and some may regress spontaneously,thus avoiding unnecessary resection.This condition is rewarding to treat.It is important to recognize pseudotumor as a distinct clinical entity and include it in the differential of liver masses with atypical imaging features.

Multiple inflammatory pseudotumor formation after craniopharyngioma resection via an extended nasal endoscopic approach:A case report

BACKGROUND This report describes a case of intracranial multiple inflammatory pseudotumors(IP)after endoscopic resection of a craniopharyngioma,which is relatively rarely reported in the literature,and neurosurgeons should be aware of its existence.CASE SUMMARY Herein,we report the case of a 56-year-old man who developed decreased visual acuity and blurred vision without obvious cause or inducement on April 27,2020.To seek further treatment,he went to the Department of Neurosurgery,Clinical Medical College,Yangzhou University.After falling ill,there was no nausea,vomiting,limb convulsions,obvious disturbance of consciousness,speech disorders,cough,or persistent fever.The neurological examination findings were normal,and pituitary magnetic resonance imaging(MRI)revealed multiple nodules with abnormal signals in the sellar region.The diagnosis was craniopharyngioma.We performed total resection of the tumor via transnasal endoscopy,and the postoperative pathology suggested that the type of tumor was craniopharyngioma.Six months after the operation,the patient experienced sudden hearing loss in the right ear,tinnitus in both ears,and numbness on the right side of the face and head.Meanwhile,cranial MRI showed multiple IP.After steroid hormone and anti-inflammatory therapy,the above symptoms did not significantly improve.Finally,the patient's symptoms were well improved by surgery,and the postoperative pathological diagnosis was multiple IP.CONCLUSION Intracranial inflammatory pseudotumor is a benign disease with slow progression,but the clinical symptoms and imaging findings are not typical,there are no pathological findings,and the diagnosis is relatively difficult.Most of the cases are treated by surgical resection,and the prognosis is good after surgery.

Inflammatory pseudotumors in the liver associated with influenza:A case report

BACKGROUND Inflammatory pseudotumor(IPT)is a rare and benign lesion that mimics malignancy and can develop in any part of the body.The pathophysiology and etiology of these quasineoplastic lesions remain unclear.CASE SUMMARY We report a case of a 65-year-old male who presented with fevers,night sweats,and unintentional weight loss following an influenza infection and was found to have multiple hepatic IPT’s following an extensive work up.CONCLUSION Our case highlights the importance of considering hepatic IPT’s in the differential in a patient who presents with symptoms and imaging findings mimicking malignancy shortly following a viral infection.

Coexistence of Pseudotumor Cerebri and Chiari Malformation Type 1

Objective:To identify different radiological markers for the diagnosis of the coexistence of pseudotumor cerebri and Chiari malformation type 1.Method:Patients who were clinically suspected to have Chiari malformation type 1 and were referred to the Department of Radiology between 2007 and 2020,and whose diagnosis was radiologically confirmed through magnetic resonance imaging(MRI),were retrospectively evaluated.A total of 49 Chiari malformation type 1 patients with both cervical and cerebral examinations and 49 control subjects of the same age and gender without a diagnosis of Chiari malformation type 1 were included in the study.In Chiari malformation type 1 diagnosed patients,the presence of pseudotumor cerebri,the presence of syringomyelia in cervical spinal MRI images,and the distance of cerebellar tonsils and obex according to McRae line were evaluated in millimeters.Result:In Chiari malformation type 1 clinically and radiologically diagnosed cases,the cerebellar tonsils and obex were located lower in patients with a radiological diagnosis of pseudotumor cerebri compared to those without,and the rate of accompanying syringomyelia appeared to be higher.However,no statistically significant difference was observed between the two groups.Conclusion:The coexistence of pseudotumor cerebri and Chiari malformation type 1 is more common than previously estimated.Different treatment protocols in the coexistence of pseudotumor cerebri and Chiari malformation type 1 emphasize the importance of making this diagnosis.Further radiological imaging studies are needed to identify different radiological markers for the diagnosis of the coexistence of pseudotumor cerebri and Chiari malformation type 1.

Pseudotumor recurrence in a post-revision total hip arthroplasty with stem neck modularity: A case report

BACKGROUND This unique presentation of hip swelling is only the seventh reported case of pseudotumor recurrence in a non-metal-on-metal total hip arthroplasty(THA)construct.The constellation of patient symptoms and laboratory findings contradict the expected elevated serum metal ion levels associated with the formation of pseudotumor.The presentation,lab trends,and imaging findings contribute to the growing base of knowledge surrounding the effects of corrosion in arthroplasty constructs with stem-neck modularity.CASE SUMMARY A 74-year-old man status post primary THA presented with left hip swelling and elevated serum metal ions five years after implantation of a modular stem-neck prosthesis.The swelling was diagnosed as pseudotumor based on laboratory trends and imaging findings and was treated with revision arthroplasty that completely resolved the initial hip swelling.The patient presented with recurrent hip swelling and recurrent pseudotumor findings on imaging in the same hip four months later.Non-operative management with ultrasound-guided hip aspiration resulted in symptom relief and resolution of the recurrent swelling.After one year of follow-up,the patient had no further recurrences of hip swelling.CONCLUSION This case of post-revision pseudotumor recurrence elucidates attributable patient,surgical,and implant factors with a discussion of diagnostics,management,and prognosis for patients with pseudotumor in non-metal-on-metal arthroplasty constructs.

Inflammatory pseudotumor of the liver and spleen diagnosed by percutaneous needle biopsy

An inflammatory pseudotumor (IPT) is a relatively rare lesion characterized by chronic inf iltration of inflammatory cells and areas of f ibrosis. IPTs are diff icult to diagnose because of the absence of specif ic symptoms or of characteristic hematological or radiological f indings. In this study, a case of a woman aged over 70 years was reported, who presented with a general malaise lasting more than two months. A computed tomography scan demonstrated a diffusely spread lesion of the liver with a portal vein occlusion and a splenic lesion surrounded by a soft density layer. Since the percutaneous liver biopsy showed f indings that suggested an IPT, although the radiological f indings did not exclude the possibility of a malignancy, we performed a percutaneous spleen biopsy to enable a more defi nitive diagnosis. The microscopic f indings from the spleen specimen lead us to a diagnosis of IPT involving the liver and spleen. Sub-sequent steroid pulse therapy was effective, and rapid resolution of the disease was observed.

Hepatic inflammatory pseudotumor presenting in an 8-year-old boy: A case report and review of literature

Hepatic inflammatory pseudotumors are uncommon benign lesions.Accurately diagnosing hepatic inflammatory pseudotumor can be very challenging because the clinical presentation and radiological appearances are nonspecific and cannot be certainly distinguished from malignant neoplastic processes.Herein,we present a case of hepatic IPT in an 8-yearold boy who presented to clinic with a 3-mo history of a tender hepatic mass,fever of unknown origin,and9-kg weight loss.The physical examination was notable for tender hepatomegaly.Laboratory investigations were notable for a normal hepatic profile and elevated erythrocyte sedimentation rate and C-reactive protein.A T2-attenuated magnetic resonance imaging scan of the abdomen showed a 4.7 cm x 4.7 cm x 6.6cm,contrast-enhancing,hyper-intense,well-defined lesion involving the right hepatic lobe.In view of the unremitting symptoms,tender hepatomegaly,thrombosed right hepatic vein,nonspecific radiological findings,and high suspicion of a deep-seated underlying infection or malignancy,a right hepatic lobectomy was recommended.Microscopically,the hepatic lesion exhibited a mixture of inflammatory cells(histiocytes,plasma cells,mature lymphocytes,and occasional multinucleated giant cells) in a background of dense fibrous tissue.Immunohistochemically,the cells stained negative for SMA,ALK-1,CD-21 and CD-23,diffusely positive for CD-68,and focally positive for lgG4.The final histopathological diagnosis was consistent with hepatic IPT.At the postoperative 4-mo follow-up,the patient was asymptomatic without radiological evidence of recurrence.

Rare case of an abdominal mass: Reactive nodular fibrous pseudotumor of the stomach encroaching on multiple abdominal organs

Reactive nodular fibrous pseudotumor(RNFP), which presents abdominal clinical manifestations and malignant radiographic results, usually requires radical resection as the treatment. However, RNFP has been recently described as an extremely rare benign postinflammatory lesion of a reactive nature, which typically arises from the sub-serosal layer of the digestive tract or within the surrounding mesentery in association with local injury or inflammation. In addition, a postoperative diagnosis is necessary to differentiate it from the other reactive processes of the abdomen. Furthermore, RNFP shows a good prognosis without signs of recurrence or metastasis. A 16-year-old girl presented with a 3-mo history of epigastric discomfort, and auxiliary examinations suggested a malignant tumor originating from the stomach; postoperative pathology confirmed RNFP, and after a 2-year follow-up period, the patient did not display any signs of recurrence. This case highlights the importance of preoperative pathology for surgeons who may encounter similar cases.

Relationship between dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor and paranasal sinusitis

AIM：To determine the clinical features of the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor and its relationship with paranasal sinusitis.· METHODS：A retrospective analysis of 46 patients who received surgical treatment at the Department of Ophthalmology,Beijing Tongren Hospital,Capital Medical University for the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor from October 2010 to December 2012.Each patient underwent magnetic resonance imaging（MRI） of the orbits and the 4paranasal sinuses.Disease status and the level of serum immunoglobulin G4（IgG4） was measured before and6 mo after surgery.· RESULTS：The initial clinical feature of the idiopathic dacryoadenitis type of orbital inflammatory pseudotumor was redness or swelling of the eyelids.Masses were palpated in the area of the lacrimal gland in some patients.Of the 46 patients,16 also suffered from sinusitis（34.8%）,with 14 cases of ethmoid sinusitis,8cases of maxillary sinusitis,9 cases of sphenoid sinusitis,and 8 cases of frontal sinusitis.Of the 16 patients with sinusitis,4 patients had a medical history of rhinitis（range：10mo to 15 y previously）,10 patients had occasional nasal congestion,and 2 patients had no nasal congestion.Thirteen of the 46 patients had elevated serum IgG4 levels.Nine of these 13 patients had MRI signs of sinusitis.All patients（n=46） received oral glucocorticoid treatment for approximately 3mo after surgery.No sign of recurrence was found in the orbital MRI 6mo after surgery.Of the 16 patients with sinusitis,9cases of elevated serum IgG4 levels improved after treatment with decreased serum IgG4 level and 7 cases of normal serum IgG4 levels remained unchanged.· CONCLUSION：Some patients with the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor may also suffer from paranasal sinusitis.The incidence of paranasal sinusitis was much higher in patients with IgG4-elevated dacryoadenitis subtype orbital inflammatory pseudotumor than in those with normal IgG4 levels.Dacryoadenitis subtype orbital inflammatory pseudotumor and paranasal sinusitis may both the clinical manifestations of IgG4-related disease involved in different locations.

Role of MR in the differentiation of IgG4-related from non-IgG4-related hepatic inflammatory pseudotumor

BACKGROUND:Hepatic inflammatory pseudotumor(IPT)is classified into 2 types based on IgG 4 stain:IgG 4-related and non-IgG4-related; the two types differ not only in their pathological characteristics, but also in the clinical features. This study aimed to investigate the MR character of hepatic IPT,and differentiate the IgG4-related IPT from the non-IgG4-related IPT.METHODS:Twenty-five patients with 27 histologically proven hepatic IPTs were retrospectively analyzed. Ten lesions were diagnosed as IgG4-related IPT, and the other 17 as non-IgG4-related IPT. The MR signal features on T1,T2-weighted, dynamic-enhanced, and diffusion-weighted imaging were evaluated and compared. RESULTS:The dominant lesions were subcapsularly distributed(n=17, 63.0%) with clear boundary(n=20, 74.1%), and showed progressive enhancement pattern(n=21, 77.8%) with diffuse homogeneous(n=12, 44.4%) or heterogeneous(n=8,29.6%) hyperintensity, accompanied by delayed capsule-like enhancement(n=17, 63.0%) and central nonenhanced areas(n=18, 66.7%). Morphological features(P>0.05) were not sufficient to differentiate IgG4-related IPT from non-IgG4-related IPT; the wash-out pattern was only found in 2 IgG 4-related IPT, while the progressive enhancement pattern was more common in the non-IgG4-related lesions(n=16)(P=0.022).During portal and delayed phases, iso-/hypoenhanced lesions were only seen in 3 IgG4-related IPT, and circular-enhanced lesions(n=5) existed exceptionally in the non-IgG4-related group with significant differences(P=0.029 and 0.027). Most IgG4-related IPTs had lower apparent diffusion coefficient compared with the liver parenchyma(n=6), while most non-IgG4-related IPTs had higher apparent diffusion coefficient value(n=13)(P=0.046).CONCLUSIONS:Although MR images of hepatic IPT have certain characteristics, they are not enough to differentiate IgG4-related IPT from non-IgG4-related IPT. The enhancement pattern, signal features on portal and delayed phases, and the apparent diffusion coefficient value of the lesion may be helpful for the diagnosis.

Liver inflammatory pseudotumor or parasitic granuloma?

INTRODUCTION Liver pseudotumor is a very rare benign lesion.Since the first case reported by Pack and Baker in1953,only 40 cases had been reported up to 1996.The diagnostic challenge of hepatic inflammatorypseudotumor is emphasized by the fact that most ofthe reported cases were diagnosed by surgicalprocedures.Pathogenesis and etiology of

Inflammatory pseudotumor of the colon causing intussusception: A case report and literature review

Inflammatory pseudotumor(IPT) is a rare spaceoccupying lesion of unknown etiology that can mimic malignancy on clinic-radiological and pathological examination. We describe a rare case of ileocecal intussusception from clinically suspected malignancy of the right colon where the patient underwent righthemicolectomy. Histopathology of the resected specimen confirmed IPT of the colon. This patient was observed to have abnormally elevated total leukocyte count and platelets before and after surgery. In an adult with intussusception associated with an abdominal mass, the possibility of IPT of the colon should be considered. Considering the abnormally high total leukocyte and platelet counts and colonic IPT, it is necessary to prevent postoperative adverse effects due to these changes. Although IPT of the colon is usually a benign process, controversy regarding its management still exists. We consider hemicolectomy as a safe treatment approach for colonic IPT and review the existing literature.

Inflammatory pseudotumor-like follicular dendritic cell sarcoma: A brief report of two cases

BACKGROUND Follicular dendritic cell(FDC)sarcoma/tumor is a rare malignant tumor of follicular dendritic cells,which is considered a low-grade sarcoma that can involve lymph nodes or extranodal sites.Conventional FDC sarcomas are negative for Epstein-Barr virus(EBV),whereas the inflammatory pseudotumorlike variant consistently shows EBV in the neoplastic cells.CASE SUMMARY We report two cases of inflammatory pseudotumor-like FDC sarcoma in the liver that received 3D laparoscopic right hepatectomy and open right hepatectomy separately.CONCLUSION EBV probe-based in situ hybridization and detection of immunohistochemical markers of FDC play an important role in the diagnosis and differential diagnosis of inflammatory pseudotumor-like FDC sarcoma.Complete surgical excision combined with regional lymphadenectomy may be effective in reducing the postoperative recurrence and metastasis and improving long-term survival rates.

Imaging findings of inflammatory pseudotumor-like follicular dendritic cell tumors of the liver:Two case reports and literature review

BACKGROUND Inflammatory pseudotumor-like follicular dendritic cell(IPT-like FDC)tumors of the liver is an uncommon tumor with extremely low incidence.To date,the radiologic findings of this tumor in multiphase computed tomography(CT)and magnetic resonance imaging(MRI)imaging have not been described.CASE SUMMARY Patient 1 is a 31-year-old Chinese female,whose complaining incidentally coincided with the finding of multiple liver masses.In the local hospital,an abdominal enhanced CT found two hypo-dense solid lesions,with heterogeneous sustained hypoenhancement,in the upper segment of the liver’s right posterior lobe.In our hospital,enhanced magnetic resonance imaging(MRI)with hepatocyte-specific contrast agents showed a similar enhanced pattern of lesions with patchy hyperintensity in the hepatobiliary phase(HBP).The patient underwent surgery and recovered well.The final pathology confirmed an IPTlike FDC tumor.No recurrence was found on the regular re-examination.Patient 2 is a 48-year-old Chinese male admitted to our hospital for a huge unexpected hepatic lesion.A dynamic enhanced abdominal CT revealed a huge heterogeneous enhanced solid tumor in the right lobe of the liver with a size of 100 mm×80 mm,which showed a heterogeneous sustained hypoenhancement.In addition,enlarged lymph nodes were found in the hilum of the liver.This patient underwent a hepatic lobectomy and lymph node dissection.The final pathology confirmed an IPT-like FDC tumor.No recurrence was found upon regular re-examination.CONCLUSION When a hepatic tumor shows heterogeneous sustained hypoenhancement with a patchy enhancement during HBP,an IPT-like FDC tumor should be considered in the differential diagnosis.

Hilar inflammatory pseudotumor mimicking hilar cholangiocarcinoma

BACKGROUND: Inflammatory pseudotumor of the biliary tract is a benign disease, and is extremely rare. Its diagnosis often depends on pathological examination after operation. The histopathological examination shows inflammatory lesions with a polymorphous infiltration and variable amounts of fibrous tissue. This study was undertaken to elucidate that an inflammatory pseudotumor in the right hepatic duct is especially difficult to distinguish from hilar cholangiocarcinoma. METHOD: The clinical data of one patient with inflammatory pseudotumor of the right hepatic duct were analyzed. RESULTS: An occupying lesion of the right hepatic duct was revealed by abdominal ultrasound and magnetic resonance cholangiopancreatography. The right hepatic duct inflammatory pseudotumor was not identified during the operation but was confirmed by postoperative histopathological analysis. The patient recovered well without any serious complication. CONCLUSIONS: The preoperative evaluation for optimizing surgical management is important to the diagnosis of hepatobiliary occupying lesions. The evaluation involves clinical manifestations, imaging appearance and tumor markers. Malignant tumors and possible benign lesions should be considered to avoid aggressive surgical treatment. (Hepatobiliary Pancreat Dis Int 2010; 9: 219-221)

Successful emergency resection of a massive intra-abdominal hemophilic pseudotumor

An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor Ⅷ. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor Ⅷ. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73 rd hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor Ⅷ replacement therapy.

Coumadin ridge: An incidental finding of a left atrial pseudotumor on transthoracic echocardiography

Coumadin ridge is a normal anatomic variant that is occasionally found in the left atrium. It can present as a linear or nodular mass which can undulate with cardiac motion and if particularly prominent, can easily be mistaken for a tumor or thrombus. Careful evaluation and consideration of the common variants discussed in this review can help limit misdiagnosis, as well as unnecessary workup and treatment. We present a case of coumadin ridge that was found on a patient using two-dimensional transthoracic echocardiography.

Pseudotumoral acute cerebellitis associated with mumps infection in a child

Pseudotumoral cerebellitis in childhood is an uncommon presentation of cerebellitis mimicking a brain tumor. It often follows an inflammatory or infectious event, particularly due to varicella virus. Patients could have a wide clinical spectrum on presentation. Some patients may be asymptomatic or present at most with mild cerebellar signs, whereas others may suffer severe forms with brainstem involvement and severe intracranial hypertension mimicking tumor warranting surgical intervention. Imaging techniques especially multimodal magnetic resonance imaging represent an interesting tool to differentiate between posterior fossa tumors and acute cerebellitis. We describe a case of pseudotumoral cerebellitis in a 6-year-old girl consequent to mumps infection and review the literature on this rare association.

Hemophilic Pseudotumor: A Case Report and Review of Literature

A hemophilic pseudotumor is one of the rarer complications of hemophilia that results from repetitive bleeding resulting in an encapsulated mass of clotted blood and necrosed tissue. These have become rarer over the years with better treatment modalities for bleeding disorders like factor replacement. In this case report, we describe the natural history and clinical course of a patient with hemophilia who presented with a massive pseudotumor. A review of literature follows which explores all the relevant data to date on the presentation, complications, diagnostic modalities and therapies that have been implemented in the management of this rare complication of a common bleeding disorder.

Follow-up of patients with pseudotumoral chronic pancreatitis: Outcome and surveillance

AIM:To follow up patients with pseudotumoral chronic pancreatitis(PCP)to assess their outcome and identify an optimal surveillance interval.METHODS:Data obtained prospectively were analyzed in a retrospective manner.Patients with clinical evidence of chronic pancreatitis(abdominal pain in the epigastrium,steatorrhea,and diabetes mellitus),endoscopic ultrasound(EUS)criteria>4,and EUS-fine needle aspiration(FNA)were included.A pseudotumor was defined as a non-neoplastic space-occupying lesion,a cause of chronic pancreatitis that may mimic changes typical of pancreatic cancer on CT or endoscopic ultrasound but without histological evidence.A real tumor was defined as a neoplastic space-occupying lesion because of pancreatic cancer confirmed by histology.RESULTS:Thirty-five patients with chronic pancreatitis were included,26(74.2%)of whom were men.Nine(25.7%)patients were diagnosed with pseudotumoral chronic pancreatitis and two(2/35;5.7%)patients with pseudotumoral chronic pancreatitis were diagnosed with pancreatic cancer on follow-up.The time between the diagnosis of pseudotumoral chronic pancreatitis and pancreatic adenocarcinoma was 35 and 30 d in the two patients.Definitive diagnosis of pancreatic adenocarcinoma was made by surgery.In the remaining six patients with pseudotumoral chronic pancreatitis,the median of follow-up was 11 mo(range 1-22 mo)and they showed no evidence of malignancy on surveillance.In the follow-up of patients without pseudotumoral chronic pancreatitis but with chronic pancreatitis,none were diagnosed with pancreatic cancer.According to our data,older patients with chronic pancreatitis are at risk of pseudotumoral chronic pancreatitis.CONCLUSION:According to characteristics of patient,detection of PCP should lead a surveillance program for pancreatic cancer with EUS-FNA in<1 mo or directly to surgical resection.