[Inflammatory pseudotumour of the liver: case report and review of the literature]

Abstract

We report a case of inflammatory pseudotumour of the liver in a 53-year-old woman who over the previous month had presented malaise, fever and right-sided hypochondralgia. On physical examination the liver was tender at palpation 2 cm below the right costal margin. Laboratory data were normal. Abdominal ultrasonography revealed a focal lesion, measuring 5 cm in diameter, located between the sixth and seventh segments of the liver, just beneath the liver capsule, characterised by a uniformly low level of echogenicity, a round shape with ill-defined margins and very good sound transmission. CT scan disclosed an unexpected and somewhat ambiguous pattern, with coexistence of inflammatory and neoplastic patterns. The patient was therefore submitted to a diagnostic US-guided percutaneous liver biopsy. The microbiological examination proved sterile, while the histological features revealed chronic inflammatory tissue, with fibroblasts and a number of necrotic components. For this reason, despite a strong orientation towards an inflammatory process, we could not rule out the possibility of a necrotic tumour. After two weeks of antibiotic therapy without results, the patient underwent a hepatic bisegmentectomy and a cholecystectomy. Pathological examination of the surgical specimen confirmed the biopsy findings and was suggestive of an inflammatory pseudorumour of actinomycotic origin. The patient was discharged on postoperative day 14 in good general condition, and today, after a follow-up of 5 years, she is still well without any recurrence of disease. Inflammatory pseudotumour of the liver is an unusual lesion that can mimic hepatic malignancy in its presentation and imaging. Despite the clear inflammatory nature of the mass it is almost impossible to detect any aetiological agent. Histologically, the lesion consists in interlacing bands of fibrous connective tissue, containing microscopic suppurative foci, granulocytes, neutrophils, lymphocytes, plasma cells, foamy histiocytes and a few sulphur granules suggestive of actinomycosis. The diagnosis can be made only histologically by US/CT guided-biopsy or, in a limited number of cases, directly by intraoperative frozen sections. Treatment for hepatic inflammatory pseudotumours is controversial: some Authors report cases with spontaneous regression of the disease with or without antibiotic/steroid therapy, while others favour early resection in patients unresponsive to medical therapy. This latter surgical approach is justified not only by the difficult diagnosis but also by the need to prevent complications related to the clinical course of the disease.