(Radiology. 1999;211:373-379.)
© RSNA, 1999
Inflammatory Pseudotumor of the Liver in Patients with Recurrent Pyogenic Cholangitis: CT-Histopathologic Correlation1
Kwon-Ha Yoon, MD 2,
Hyun Kwon Ha, MD,
Jin Seong Lee, MD,
Jae Hee Suh, MD,
Myung Hwan Kim, MD,
Pyo Nyun Kim, MD,
Moon-Gyu Lee, MD,
Ki Jung Yun, MD,
Suck-Chei Choi, MD,
Yong-Ho Nah, MD,
Chang Guhn Kim, MD,
Jong Jin Won, MD and
Yong Ho Auh, MD
1 From Depts of Diagnostic Radiology (K.H.Y., H.K.H., J.S.L., P.N.K., M.G.L., Y.H.A.), Diagnostic Pathology (J.H.S.), and Internal Medicine (M.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-ku, Seoul 138-040, Korea; and Depts of Anatomic Pathology (K.J.Y.), Internal Medicine (S.C.C., Y.H.N.), and Diagnostic Radiology (C.G.K., J.J.W.), Wonkwang University Hospital, Iksan, Chonbuk, Korea. Received Mar 31, 1998; revision requested Jun 25; revision received Aug 18; accepted Nov 6. Address reprint requests to H.K.H.
 |
Abstract
|
|---|
PURPOSE: To correlate computed tomographic (CT) features of inflammatory pseudotumors of the liver with histopathologic results in patients with recurrent pyogenic cholangitis.
MATERIALS AND METHODS: CT features of 13 cases of inflammatory hepatic pseudotumor in 10 patients with recurrent pyogenic cholangitis were reviewed. Diagnosis was made by means of surgical resection in all patients. CT scans were analyzed for the appearance of masses and ancillary findings in correlation with the histopathologic findings in each resected specimen.
RESULTS: The masses were 2.0–7.0 cm (mean, 3.5 cm). At nonenhanced CT, the masses appeared as ill-defined, hypoattenuating lesions. At contrast material–enhanced CT, the masses exhibited central hypoattenuating areas with an iso- or hyperattenuating thickened periphery in four cases and a multiseptate appearance with hyperattenuating internal septa and periphery in nine cases. CT-histopathologic correlation showed that the central hypoattenuating area indicated the presence of chronic inflammatory infiltrates with foamy histiocytes, plasmacytes, and lymphocytes, while iso- or hyperattenuating areas in the periphery and internal septa of the mass represented fibroblastic proliferation. All patients had CT features of recurrent pyogenic cholangitis, such as hepatolithiasis, intrahepatic duct stricture and dilatation, common bile duct calculi, pneumobilia, or parenchymal atrophy.
CONCLUSION: Although CT features are not specific, inflammatory pseudotumor should be included in the differential diagnosis in patients with recurrent pyogenic cholangitis and a hepatic mass detected at CT.
Index terms: Cholangitis, 76.289 • Liver, CT, 761.12111, 761.12114 • Pseudotumor, hepatic inflammatory, 761.3197
|
Introduction
|
|---|
Inflammatory pseudotumor of the liver is a benign hepatic lesion characterized by a large population of polyclonal plasma cells with a variable amount of fibrosis, foamy histiocytes, and other chronic inflammatory cells (1). Its synonyms include "xanthogranuloma," "fibrous xanthoma," "plasma cell granuloma," "histiocytoma," "pseudolymphoma," and even "plasmacytoma" (1–11). Although inflammatory pseudotumor has been found in many organs (12,13), to our knowledge only 55 cases have been reported in the liver since the report by Pack and Baker in 1953 (1–11). Moreover, inflammatory pseudotumor is reportedly rare in patients with recurrent pyogenic cholangitis, which is characterized by intrahepatic pigmented stones and chronic and recurrent inflammatory changes in the bile duct walls; only four of the reported cases of which we are aware were in patients with recurrent pyogenic cholangitis (6,7,14). The cause of inflammatory hepatic pseudotumor remains unclear, but some researchers have suggested occlusive phlebitis or an undetected infectious agent as the primary cause (2,4,6).
Computed tomographic (CT) features of inflammatory pseudotumor in the liver have been reported sporadically (6,14–20). In most reported cases, the masses appear hypoattenuating with a variable degree of hepatic enhancement. Therefore, many researchers have concluded that when a hypoattenuating hepatic mass is identified at CT, inflammatory pseudotumor should be included in the differential diagnosis. However, the majority of reported cases have not had an association with recurrent pyogenic cholangitis or clonorchiasis infection. In fact, patients with recurrent pyogenic cholangitis commonly develop hepatic abscesses as a complication (21,22). Furthermore, cholangiocarcinoma is strongly associated with clonorchiasis or hepatolithiasis (23–25). Therefore, in patients with recurrent pyogenic cholangitis, radiologic differentiation between cholangiocarcinoma and benign mass-forming lesions may be very difficult.
The purpose of this study was to correlate the CT features of inflammatory pseudotumors of the liver with histopathologic results in patients with recurrent pyogenic cholangitis.
|
MATERIALS AND METHODS
|
|---|
We reviewed the medical records and CT features in 13 cases of surgically proved inflammatory hepatic pseudotumor in 10 patients (five women, five men; mean age, 52.2 years; age range, 38–65 years). All patients were chosen by means of review of pathology reports from the 147 patients from two institutions (Asan Medical Center, Seoul, and Wonkwang University Hospital, Iksan, Chonbuk, Korea) who underwent partial hepatectomy due to recurrent pyogenic cholangitis with mass or hepatolithiasis between June 1992 and December 1996. All patients were Asian and had long-standing clinical symptoms of recurrent pyogenic cholangitis lasting from 6 months to 10 years. Three patients had prior histories of biliary surgery: cholecystectomy in two patients and cholecystectomy with choledochoenterostomy in the other. The data of individual cases were collected from review of medical records by two radiologists (K.H.Y., C.G.K.) and a gastroenterologist (M.H.K).
CT was performed with commercially available equipment (Somatom Plus-S, Siemens, Erlangen, Germany; or 9800 Quick system, GE Medical Systems, Milwaukee, Wis) by using contiguous, 10-mm, axial sections at 10-mm intervals from the dome of the diaphragm to the level of the fourth vertebra. The patients routinely received contrast material both orally and intravenously. Barium sulfate (E-Z-Cat; E-Z-Em, Westbury, NY) was administered orally 1 hour (600 mL) before the examination and immediately (300 mL) before the examination. Both nonenhanced and contrast material–enhanced CT scans were obtained; iopamidol (Iopamiro 300; Bracco, Milan, Italy) was administered intravenously as a 100-mL bolus drip infusion (rate, 2.0 mL/sec) in all patients. Scanning was initiated 60-100 seconds after the beginning of the infusion. In all patients, the time between CT and surgery was between 1 day and 4 weeks.
CT scans were reviewed retrospectively by two radiologists (K.H.Y., H.K.H.). If the two radiologists' interpretations differed, a third radiologist (Y.H.A.) interpreted the scans, and the majority opinion was used as the final decision. CT features were analyzed by using the number, size, and site of hepatic masses and the morphologic appearance of the masses on nonenhanced and contrast-enhanced images. The degree of contrast enhancement was recorded as hyperattenuating, isoattenuating, or hypoattenuating relative to the hepatic parenchyma. We also evaluated ancillary findings, such as hepatolithiasis, intrahepatic duct stricture and dilatation, common bile duct calculi, pneumobilia, and parenchymal changes. CT features of inflammatory pseudotumor were correlated with the histopathologic findings in surgical specimens.
|
RESULTS
|
|---|
Clinical Findings
The principal clinical and laboratory findings are shown in Table 1. Eight of the 10 patients had symptoms and laboratory data that suggested active inflammation of the liver. Symptoms included fever or chill in eight patients, right upper quadrant or epigastric pain in seven, indigestion in three, and weight loss in one. Recent symptoms lasted from 10 days to 2 months. At the time of admission to the hospital, the temperature was higher than 38°C in five patients, and white blood cell counts were elevated (range, 10,200–16,700/mm3 [10.2–16.7 x 109/L]). Liver function test results were normal in four patients and abnormal in the remaining six. Alkaline phosphatase levels were elevated in six patients, and the total bilirubin level was elevated in one patient. Glutamic oxaloacetic transaminase and glutamic pyruvate transaminase levels were elevated in one patient. The 
-fetoprotein and carcinoembryonic antigen levels were within the normal range in all patients.
View this table:
[in this window]
[in a new window]
|
TABLE 1. Clinical Features of Inflammatory Pseudotumor of the Liver in 10 Patients with Recurrent Pyogenic Cholangitis
|
|
CT Findings
The CT features of 13 inflammatory pseudotumors in 10 patients are summarized in Table 2. Of the 10 patients, eight had solitary hepatic masses, one had two masses, and one had three masses at CT. The masses were 2.0–7.0 cm (mean, 3.5 cm). The masses were in the left lobe in nine cases, in the right lobe in three cases, and in the both lobes in one case. The masses appeared in all cases as ill-defined, hypoattenuating lesions at nonenhanced CT. At contrast-enhanced CT, the masses had a multiseptate appearance with hyperattenuating internal septa and periphery in nine cases (Figs 1, 2). The remaining four cases exhibited central hypoattenuating areas with an isoattenuating or hyperattenuating thickened periphery (Fig 3).
View this table:
[in this window]
[in a new window]
|
TABLE 2. CT-Histopathologic Features of Inflammatory Pseudotumor of the Liver in 10 Patients with Recurrent Pyogenic Cholangitis
|
|
View larger version (148K):
[in this window]
[in a new window]
|
Figure 1a. Patient 3. Images obtained in a 39-year-old woman with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who underwent cholecystectomy 5 years previously due to a gallbladder stone. (a) Contrast-enhanced CT image of the liver shows two multiseptate, hypoattenuating masses (straight arrows) with hyperattenuating internal septa in the lateral segment of the left lobe. Diffuse parenchymal enhancement is visible in the left lateral segment. Irregular biliary dilatation (curved arrow) and scattered pneumobilia (arrowheads) are also visible. (b) Photograph of the resected specimen shows multiple 4-cm, 3-cm, and 2-cm yellowish masses (large arrows) with scattered small nodules. The masses are multiseptate with fibrotic bands (arrowheads). Note the dilated and thickened intrahepatic duct with periductal fibrosis (small arrows).
|
|
View larger version (107K):
[in this window]
[in a new window]
|
Figure 1b. Patient 3. Images obtained in a 39-year-old woman with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who underwent cholecystectomy 5 years previously due to a gallbladder stone. (a) Contrast-enhanced CT image of the liver shows two multiseptate, hypoattenuating masses (straight arrows) with hyperattenuating internal septa in the lateral segment of the left lobe. Diffuse parenchymal enhancement is visible in the left lateral segment. Irregular biliary dilatation (curved arrow) and scattered pneumobilia (arrowheads) are also visible. (b) Photograph of the resected specimen shows multiple 4-cm, 3-cm, and 2-cm yellowish masses (large arrows) with scattered small nodules. The masses are multiseptate with fibrotic bands (arrowheads). Note the dilated and thickened intrahepatic duct with periductal fibrosis (small arrows).
|
|
View larger version (136K):
[in this window]
[in a new window]
|
Figure 2a. Patient 5. Images obtained in a 65-year-old woman with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who had simultaneous peripheral cholangiocarcinoma. (a) Contrast-enhanced CT image of the liver shows an ill-defined, multiseptate, hypoattenuating mass (white arrows) with internal septa in the left lateral segment. Irregularly dilated duct (black arrows) and hepatolithiasis (arrowhead) are also present. (b) Contrast-enhanced CT image obtained 2 cm above a shows a hypoattenuating mass (arrows) with irregular peripheral enhancement in the left medial segment. The lesion was proved to be cholangiocarcinoma at histopathologic analysis of the surgical specimen (not shown). (c) Photograph of the resected specimen shows a lobulated, yellowish mass with septate fibrotic bands (large arrows) and periductal, multiple abscesses (arrowheads). Black stones (small arrows) within the dilated hepatic duct and whitish, periductal fibrosis are also visible.
|
|
View larger version (131K):
[in this window]
[in a new window]
|
Figure 2b. Patient 5. Images obtained in a 65-year-old woman with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who had simultaneous peripheral cholangiocarcinoma. (a) Contrast-enhanced CT image of the liver shows an ill-defined, multiseptate, hypoattenuating mass (white arrows) with internal septa in the left lateral segment. Irregularly dilated duct (black arrows) and hepatolithiasis (arrowhead) are also present. (b) Contrast-enhanced CT image obtained 2 cm above a shows a hypoattenuating mass (arrows) with irregular peripheral enhancement in the left medial segment. The lesion was proved to be cholangiocarcinoma at histopathologic analysis of the surgical specimen (not shown). (c) Photograph of the resected specimen shows a lobulated, yellowish mass with septate fibrotic bands (large arrows) and periductal, multiple abscesses (arrowheads). Black stones (small arrows) within the dilated hepatic duct and whitish, periductal fibrosis are also visible.
|
|
View larger version (71K):
[in this window]
[in a new window]
|
Figure 2c. Patient 5. Images obtained in a 65-year-old woman with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who had simultaneous peripheral cholangiocarcinoma. (a) Contrast-enhanced CT image of the liver shows an ill-defined, multiseptate, hypoattenuating mass (white arrows) with internal septa in the left lateral segment. Irregularly dilated duct (black arrows) and hepatolithiasis (arrowhead) are also present. (b) Contrast-enhanced CT image obtained 2 cm above a shows a hypoattenuating mass (arrows) with irregular peripheral enhancement in the left medial segment. The lesion was proved to be cholangiocarcinoma at histopathologic analysis of the surgical specimen (not shown). (c) Photograph of the resected specimen shows a lobulated, yellowish mass with septate fibrotic bands (large arrows) and periductal, multiple abscesses (arrowheads). Black stones (small arrows) within the dilated hepatic duct and whitish, periductal fibrosis are also visible.
|
|
View larger version (164K):
[in this window]
[in a new window]
|
Figure 3a. Patient 4. Images obtained in a 64-year-old man with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who underwent cholecystectomy 4 years previously due to gallbladder stones. (a) Nonenhanced CT image shows an ill-defined, hypoattenuating mass in the medial segment of the left lobe (arrows). Scattered pneumobilia (arrowheads) is also present. (b) Contrast-enhanced CT image of the liver shows a lobulated mass with a central, hypoattenuating area and an iso- and hyperattenuating periphery (large arrows) and satellite, hypoattenuating nodules (small arrows). (c) Photograph of the resected specimen shows a well-circumscribed, round, and lobulated 4.0-cm mass. The lesions are diffusely tan with focally scattered necrotic and chalky yellow areas.
|
|
View larger version (155K):
[in this window]
[in a new window]
|
Figure 3b. Patient 4. Images obtained in a 64-year-old man with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who underwent cholecystectomy 4 years previously due to gallbladder stones. (a) Nonenhanced CT image shows an ill-defined, hypoattenuating mass in the medial segment of the left lobe (arrows). Scattered pneumobilia (arrowheads) is also present. (b) Contrast-enhanced CT image of the liver shows a lobulated mass with a central, hypoattenuating area and an iso- and hyperattenuating periphery (large arrows) and satellite, hypoattenuating nodules (small arrows). (c) Photograph of the resected specimen shows a well-circumscribed, round, and lobulated 4.0-cm mass. The lesions are diffusely tan with focally scattered necrotic and chalky yellow areas.
|
|
View larger version (52K):
[in this window]
[in a new window]
|
Figure 3c. Patient 4. Images obtained in a 64-year-old man with inflammatory pseudotumor of the liver and recurrent pyogenic cholangitis who underwent cholecystectomy 4 years previously due to gallbladder stones. (a) Nonenhanced CT image shows an ill-defined, hypoattenuating mass in the medial segment of the left lobe (arrows). Scattered pneumobilia (arrowheads) is also present. (b) Contrast-enhanced CT image of the liver shows a lobulated mass with a central, hypoattenuating area and an iso- and hyperattenuating periphery (large arrows) and satellite, hypoattenuating nodules (small arrows). (c) Photograph of the resected specimen shows a well-circumscribed, round, and lobulated 4.0-cm mass. The lesions are diffusely tan with focally scattered necrotic and chalky yellow areas.
|
|
In addition to hepatic masses, CT demonstrated the findings of recurrent pyogenic cholangitis: intrahepatic biliary strictures and dilatation in all patients, intrahepatic stones in seven (Fig 2), common bile duct stones in two, extrahepatic biliary dilatation in three, pneumobilia in five (Fig 3), and segmental atrophy of the liver in three (Figs 1, 2). Of the five patients with pneumobilia, one had undergone choledochoenterostomy, which accounted for this finding. In the other four patients, we presumed that the pneumobilia developed as a result of spontaneous choledochoduodenal fistula formation. In one patient, cholangiocarcinoma coexisted with inflammatory pseudotumor, as indicated by a central hypoattenuating area with a thick area of peripheral enhancement at contrast-enhanced CT (Fig 2).
CT-Histopathologic Correlation
Resected gross specimens showed single or multiple solid masses, 2.0–7.0 cm in their largest diameter. Their cut surfaces had a variegated appearance with tan areas of viable tissues, chalky yellow necrotic areas, or focally hemorrhagic areas. When we correlated CT features with histopathologic findings in the resected specimen, the central hypoattenuating area of the hepatic mass at CT corresponded to chronic inflammatory infiltrates with foamy histiocytes, plasmacytes, and lymphocytes, while the iso- or hyperattenuating areas in the periphery and internal septa of the mass represented fibroblastic proliferation (Figs 1, 3). In six patients, multiple abscesses with liquefactive necrosis of the parenchymal cells infiltrated by neutrophils and lymphocytes were found. Histopathologically, we could distinguish hepatic abscess from inflammatory pseudotumor easily because hepatic abscesses usually had purulent materials and acute inflammatory cells such as neutrophils within the lesion.
In the cases in our study, there was no evidence of occlusive pylephlebitis. In all patients, the intrahepatic ducts were irregularly dilated and diffusely thickened (Fig 3). Periductal, whitish fibrosis was also noted. The hepatic duct contained dark brown to black, muddy, fragile stones in all patients (Fig 3). There were no proved cases of microorganism involvement, except for one case with numerous eggs of Clonorchis sinensis in the intrahepatic bile duct.
|
DISCUSSION
|
|---|
Inflammatory pseudotumor can be defined as a localized mass consisting of a fibrous stroma and chronic inflammatory infiltrates with a predominance of plasma cells or histiocytes and an absence of anaplasia. Some researchers (3,6) even postulate that inflammatory pseudotumor is not a disease entity but a group of solid-appearing lesions that grossly mimic tumors. These lesions can be categorized into three histopathologic subtypes (4): those with a prominent histiocytic component, or xanthogranuloma type; those with a prominent plasma cell component, or plasma cell granuloma type; and those with markedly sclerosing features, or hyalinized sclerosing type. Various combinations of these histopathologic patterns may also be seen in a single lesion, and the differences in these histologic types reflect the variation of the disease process or period. The histologic findings of foamy histiocytes and dense fibrosis predominantly seen in most of the cases in our study suggest that the inflammatory pseudotumors included in the cases in our study belong to the xanthogranuloma type in association with recurrent pyogenic cholangitis.
Although the pathogenesis of inflammatory pseudotumor is still unclear, several hypotheses have been suggested by various researchers. First, initial acute exudative inflammatory processes with atypical biliary duct epithelium, hepatocytes that respond to infection by microorganisms, and the evolution of lesions in the chronic xanthogranulomatous pattern are the principal causes of the development of an inflammatory pseudotumor of the liver (3). Second, the disease may be secondary to portal venous infection that contains some microorganisms in the hepatic parenchyma and produces an inflammatory mass in a gradually expanding fashion together with an obliterating phlebitis; such cases may show foreign-body giant cell reaction, preferentially in the medium to large portal veins (4,6). Third, if a hepatic abscess shows granulomatous features because of the presence of histiocytes and giant cells at the boundary of the necrotic zone or hyalinized fibrosis in the process of resolution, it can closely resemble inflammatory pseudotumor, the so-called granulomatous variant of hepatic abscess (6).
Although it is controversial whether inflammatory pseudotumor is linked with recurrent pyogenic cholangitis (6,7,14), the following processes in the pathogenesis seen in clinical and histologic findings suggest a relationship between these conditions: Inflammatory pseudotumor is caused by chronic infection and calculi-associated bile stasis, while recurrent inflammation and calculi provoke degeneration and necrosis of the bile duct wall, with subsequent periductal abscess or formation of xanthogranulomas, as in cases of xanthogranulomatous cholecystitis or pyelonephritis (26–28). In this regard, inflammatory pseudotumor can develop as one of the spectra of recurrent pyogenic cholangitis.
Recurrent pyogenic cholangitis, also known as cholangiohepatitis, is characterized by intrahepatic pigmented stones and recurrent attacks of abdominal pain, fever, chills, and jaundice (21,22). The cause of recurrent pyogenic cholangitis remains unclear, but associations with clonorchiasis, ascariasis, bacterial infection, biliary stasis, and nutritional deficiency have been noted (21). Histologically, there are inflammatory and fibrotic changes in the bile duct walls, periportal spaces, and hepatic parenchyma that lead to stricture formation.
Radiologic findings of inflammatory pseudotumor have been reported to have a nonspecific morphologic appearance (14–20). Fukuya et al (15) described the delayed enhancement of inflammatory pseudotumor of the liver that is frequently observed at contrast-enhanced CT. As demonstrated in our study, inflammatory pseudotumor containing abundant fibrous tissue in the periphery and internal septa may be the cause of the enhanced CT findings.
Nam et al (17) described CT findings of inflammatory pseudotumor in two cases. In one case, enhancement was broad and ill defined at the periphery of the mass, while in the other case multiple low-attenuation or nonenhanced portions were noted within the mass. In the correlation with the histopathologic findings, higher attenuation at contrast-enhanced CT corresponded to the areas of concentrated fibrous tissue, while the hypoattenuating areas corresponded to predominantly cellular infiltration with foamy histiocytes, plasma cells, and lymphocytes. These results were very similar to those in the cases in our study. Therefore, it is likely that the morphologic appearance of the mass at CT may be associated with the duration of the disease process, the amount of fibrous tissue, and the degree of cellular infiltration. In addition, because the cystic-appearing area within the mass is solid at histopathologic examination, inflammatory pseudotumor should be included as a differential consideration when a hard consistency is detected during the performance of aspiration cytology in a hepatic mass that appeared cystic at CT in patients with recurrent pyogenic cholangitis.
The differential diagnosis in such cases includes liver abscess, metastasis, peripheral cholangiocarcinoma, and hepatocellular carcinoma. In patients with recurrent pyogenic cholangitis, pyogenic liver abscess is a common representative finding. The radiologic findings, as well as the clinical symptoms and laboratory data, are similar to those of inflammatory pseudotumor of the liver (22). However, as mentioned before, failure to aspirate purulent material is helpful in distinguishing the two conditions. Both hepatocellular carcinoma and metastasis can have a similar imaging appearance to that of inflammatory pseudotumor, but the presence of CT findings of recurrent pyogenic cholangitis may be helpful for excluding the possibility of the two conditions.
Inflammatory pseudotumor also mimics peripheral cholangiocarcinoma at CT. According to Kim et al (29), peripheral cholangiocarcinoma commonly appears as an irregular mass with a markedly hypoattenuating center and a thin incomplete, rimlike, enhancing periphery at contrast-enhanced CT. Therefore, with imaging findings alone, it may be difficult or impossible to differentiate inflammatory pseudotumor from peripheral cholangiocarcinoma.
Needle biopsy may be helpful in providing a correct answer. Histopathologic findings of foamy histiocytes or plasmacytes without atypical cells obtained from the hepatic mass at fine needle aspiration or core biopsy appear to be almost specific enough to enable the diagnosis of inflammatory pseudotumor. For these cases, antibiotic therapy rather than surgery seems to be an appropriate treatment. However, if bile duct epithelium is atypical, inflammatory pseudotumor can be mistaken for a malignant lesion. Therefore, in such cases, repeated fine needle aspirations or core biopsy should be attempted (1,3). However, because cholangiocarcinoma can coexist with inflammatory pseudotumor, as seen in one of the patients in our study, follow-up ultrasonography or CT is still required in both instances.
In summary, inflammatory pseudotumor (xanthogranuloma) can develop as a complication in patients with recurrent pyogenic cholangitis. CT features of these lesions do not demonstrate discernible differences from those of pyogenic liver abscess or peripheral cholangiocarcinoma. When a hypoattenuating hepatic mass is detected at CT in patients with recurrent pyogenic cholangitis, xanthogranuloma should be included in the differential diagnosis, and percutaneous biopsy is warranted to avoid unnecessary surgery.
|
Acknowledgments
|
|---|
We thank Bonnie Hami, Department of Radiology, University Hospitals of Cleveland, Ohio, for editorial assistance in the preparation of the manuscript.
|
Footnotes
|
|---|
2 Current address: Department of Diagnostic Radiology, Wonkwang University Hospital, Iksan, Chonbuk, Korea. 
Author contributions: Guarantor of integrity of entire study, H.K.H.; study concepts, K.H.Y., H.K.H.; study design, K.H.Y., H.K.H., C.G.K.; definition of intellectual content, Y.H.A.; literature research, K.H.Y., P.N.K., S.C.C.; clinical studies, J.H.S., M.H.K., K.J.Y., M.G.L., Y.H.N.; data acquisition, K.H.Y., J.S.L., J.J.W.; data analysis, K.H.Y., H.K.H., Y.H.A.; manuscript preparation, K.H.Y.; manuscript editing, H.K.H.; manuscript review, K.H.Y., H.K.H., Y.H.A.
|
References
|
|---|
-
Anthony PP, Tekesinghe PU. Inflammatory pseudotumor of the liver. J Clin Pathol 1986; 39:761-768.[Abstract/Free Full Text]
-
Chen KT. Inflammatory pseudotumor of the liver. Hum Pathol 1984; 15:694-696.[Medline]
-
Lupovitch A, Chen R, Mishra S. Inflammatory pseudotumor of the liver: report of the fine needle aspiration cytologic findings in a case initially misdiagnosed as malignant. Acta Cytol 1989; 33:259-262.[Medline]
-
Someren A. "Inflammatory pseudotumor" of the liver with occlusive phlebitis: report of a case in a child and review of the literature. Am J Clin Pathol 1978; 69:176-181.[Medline]
-
Pack GT, Baker HW. Total right hepatic lobectomy: report of a case. Ann Surg 1953; 138:253-258.[Medline]
-
Horiuchi R, Uchida T, Kokashi T, Shikata T. Inflammatory pseudotumor of the liver: clinicopathologic study and review of the literature. Cancer 1990; 65:1583-1590.[Medline]
-
Shek T, Ng I, Chan K. Inflammatory pseudotumor of the liver: report of four cases and review of the literature. Am J Surg Pathol 1993; 17:231-238.[Medline]
-
Standiford SB, Sobel H, Dasmahapatra KS. Inflammatory pseudotumor of the liver. J Surg Oncol 1989; 40:283-287.[Medline]
-
Pokorny CS, Painter DM, Waugh RC, McCaughan GW, Gallagher ND, Tattersall MH. Inflammatory pseudotumor of the liver causing biliary obstruction: treatment by biliary stenting with 5-year follow-up. J Clin Gastroenterol 1991; 13:338-341.[Medline]
-
Hertzer NR, Hawk WA, Hermann RE. Inflammatory pseudotumor of the liver which simulates tumor: report of two cases in children. Surgery 1971; 69:839-846.[Medline]
-
Haith EE, Kepes JJ, Holder TM. Inflammatory pseudotumor of the liver involving the common bile duct of a six-year-old boy: successful pancreatico-duodenectomy. Surgery 1964; 56:436-441.[Medline]
-
Bahadori M, Liebow AA. Plasma cell granulomas of the lung. Cancer 1973; 31:191-208.[Medline]
-
Garner A. Pathology of "pseudotumours" of the orbit: a review. J Clin Pathol 1973; 26:639-648.[Free Full Text]
-
Lim JH, Lee JH. Inflammatory pseudotumor of the liver: ultrasound and CT features. Clin Imaging 1995; 19:43-46.[Medline]
-
Fukuya T, Honda H, Matsumata T, et al. Diagnosis of inflammatory pseudotumor of the liver: value of CT. AJR 1994; 163:1087-1091.[Abstract/Free Full Text]
-
Kelekis NL, Warshauer DM, Semelka RC, Eisenberg LB, Woosley JT. Inflammatory pseudotumor of the liver: appearance on contrast enhanced helical CT and dynamic MR images. JMRI 1995; 5:551-553.
-
Nam KJ, Kang HK, Lim JH. Inflammatory pseudotumor of the liver: CT and sonographic findings. AJR 1996; 167:485-487.[Free Full Text]
-
Noi I, Loberant N, Cohen I. Inflammatory pseudotumor of the liver. Clin Imaging 1994; 18:283-285.[Medline]
-
Loke KL, Chan CS, Wijesinha SS. Case report: inflammatory pseudotumor of the liver—review of clinical and radiological features. Clin Radiol 1994; 49:575-577.[Medline]
-
Abehsera M, Vilgrain V, Belghiti J, Flejou JF, Nahum H. Inflammatory pseudotumor of the liver: radiologic-pathologic correlation. J Comput Assist Tomogr 1995; 19:80-83.[Medline]
-
Lim JH. Oriental cholangiohepatitis: pathologic, clinical, and radiologic features. AJR 1991; 157:1-8.[Abstract/Free Full Text]
-
Chan FL, Man SW, Leong L, Fan ST. Evaluation of recurrent pyogenic cholangitis with CT: analysis of 50 patients. Radiology 1989; 170:165-169.[Abstract/Free Full Text]
-
Yoe CJ, Pitt HA, Cameron JL. Cholangiocarcinoma. Surg Clin North Am 1990; 70:1429-1447.[Medline]
-
Hou PT. The relationship between primary carcinoma of the liver and infestation with Clonorchis sinensis. J Pathol Bacteriol 1956; 72:239-246.
-
Choi BI, Park JH, Kim YI, et al. Peripheral cholangiocarcinoma and clonorchiasis: CT findings. Radiology 1988; 169:149-153.[Abstract/Free Full Text]
-
Hanada K, Nakata H, Nakayama T, et al. Radiologic findings in xanthogranulomatous cholecystitis. AJR 1987; 148:727-730.[Abstract/Free Full Text]
-
Chun KA, Ha HK, Yu ES, et al. Xanthogranulomatous cholecystitis: CT features with emphasis on differentiation from gallbladder carcinoma. Radiology 1997; 203:93-97.[Abstract/Free Full Text]
-
Hayes WS, Hartman DS, Sesterbenn IA. Xanthogranulomatous pyelonephritis. RadioGraphics 1991; 11:485-498.[Abstract]
-
Kim TK, Choi BI, Han JK, Jang HJ, Cho SG, Han MC. Peripheral cholangiocarcinoma of the liver: two-phase spiral CT findings. Radiology 1997; 204:539-543.
This article has been cited by other articles:
|
|
|
|
 
E. J. Heffernan, T. Geoghegan, P. L. Munk, S. G. Ho, and A. C. Harris
Recurrent Pyogenic Cholangitis: From Imaging to Intervention
Am. J. Roentgenol.,
January 1, 2009;
192(1):
W28 - W35.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G.-J. Liu, M.-D. Lu, X.-Y. Xie, H.-X. Xu, Z.-F. Xu, Y.-L. Zheng, J.-Y. Liang, and W. Wang
Real-time Contrast-Enhanced Ultrasound Imaging of Infected Focal Liver Lesions
J. Ultrasound Med.,
April 1, 2008;
27(4):
657 - 666.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. E. Tublin, A. J. Moser, J. W. Marsh, and T. C. Gamblin
Biliary Inflammatory Pseudotumor: Imaging Features in Seven Patients
Am. J. Roentgenol.,
January 1, 2007;
188(1):
W44 - W48.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. S. Park, J. M. Lee, S. H. Kim, J. Y. Jeong, Y. J. Kim, K. H. Lee, S. H. Choi, J. K. Han, and B. I. Choi
CT Differentiation of cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis.
Am. J. Roentgenol.,
August 1, 2006;
187(2):
445 - 453.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nishimura, H. Mogami, N. Teramoto, M. Tanada, and A. Kurita
Inflammatory Pseudotumor of the Liver in a Patient with Early Gastric Cancer: CT-Histopathological Correlation
Jpn. J. Clin. Oncol.,
April 1, 2005;
35(4):
218 - 220.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Venkataraman, R. C. Semelka, L. Braga, I.-M. Danet, and J. T. Woosley
Inflammatory Myofibroblastic Tumor of the Hepatobiliary System: Report of MR Imaging Appearance in Four Patients
Radiology,
June 1, 2003;
227(3):
758 - 763.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
