Inflammatory pseudotumor of the liver: a rare case of recurrence following surgical resection

Abstract

Inflammatory pseudotumor (IPT) of the liver is a rare, benign lesion that may be mistaken for malignancy. IPTs are difficult to diagnose due to non-specific clinical, laboratory and imaging features. We report the case of a 38-year old Asian male who presented with fatigue, weight loss and hepatomegaly. He was found to have a large hepatic IPT and underwent surgical resection; approximately two and a half years later, he developed acute cholangitis secondary to IPT recurrence. We present the imaging features of hepatic IPT using ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). We also review the literature on the diagnosis and management of this disease. The unique features of this case include the IPT's recurrence following surgical resection, large size and multiple modalities presented.

Keywords: Inflammatory pseudotumor; computed tomography; inflammatory myofibroblastic tumor; liver; magnetic resonance imaging; ultrasound.

Figure 1

38-year old male with inflammatory pseudotumor of the liver. Sagittal ultrasound image of the right hepatic lobe demonstrates a large mass (demarcated by cursors) measuring 16.7cm in maximal diameter with cystic and solid components.

Figure 2

38-year old male with inflammatory pseudotumor of the liver. IV-contrast enhanced CT scan, portal venous phase, demonstrates a large mass measuring 19.5 by 16.5cm occupying the anterior segments of the right lobe and entire left lobe of the liver (kv 120 mA 180, 150cc of Optiray 380). Most of the cystic/necrotic component is within the anterior and medial segments (long arrow) and the heterogeneous predominantly solid component occupies the lateral segment (short arrow).

Figure 3

38-year old male with inflammatory pseudotumor of the liver. a) Axial FSE T2-weighted (1.5T, TE 102, TR 8571) and b) Axial T1-weighted post-gadolinium (1.5T, TE 4.2, TR 93, 28cc omniscan) MR images demonstrate a heterogeneous, complex mass measuring 20 by 16.5cm, which occupies the anterior segments of the right lobe and entire left lobe. The cystic/necrotic component (long arrow) within the anterior and medial segments demonstrate central high signal intensity surrounded by a thick irregular low signal intensity rim on the T2-weighted images and lack of enhancement following the administration of dynamic gadolinium. The heterogeneous and predominantly solid component of this mass (short arrow) occupies and expands the lateral segments. The solid component is higher in signal intensity compared to normal liver on T2-weighted images and demonstrates enhancement with gadolinium.

Figure 4

38-year old male with inflammatory pseudotumor of the liver. Gross pathology specimen of the right a) and left b) hepatic lobes measure 17 by 14cm and 9 by 6cm, respectively, and containing large, irregular areas of necrosis and hemorrhage admixed with areas of grey-tan tissue.

Figure 5

38-year old male with inflammatory pseudotumor of the liver. High power microscopic view demonstrates a moderately cellular spindle-cell proliferation with heavy inflammatory infiltrate consisting primarily of plasma cells (long arrow) and lymphocytes (short arrow) (40× magnification, hematoxylin and eosin stain).

Figure 6

41-year old male with recurrent inflammatory pseudotumor of the liver. Axial FSE T2-weighted (1.5T, TE 114, TR 2000) (a) and coronal T2-weighted (1.5T, TE 99, TR 1745) (b) MR images in a demonstrate a well-defined hyperintense hepatic mass (long arrow) measuring 5.4 by 3.7cm arising from segment 8 with possible extension into 4A/B. Peripheral biliary ductal dilatation up to 4mm in diameter (short arrows) is also present.

Figure 7

41-year old male with recurrent inflammatory pseudotumor of the liver. ERCP images (a) demonstrate the recurrent pseudotumor to cause central biliary compression and narrowing (long arrow) with resultant biliary dilatation (short arrows), which was subsequently relieved following stent placement (b, long arrow).