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Introduction: Hepatic inflammatory pseudotumor (HIP), albeit rare, is an important pathology to be included in differentials for hepatic masses. The benign nature and treatment of this disease process should be considered especially in comparison to malignant hepatic processes. Case Description/Methods: A 66-year-old male with pre-existing history of compensated Hepatitis C cirrhosis status post direct-acting antivirals with sustained virologic response presented in shock after a syncopal episode. Initial work up revealed leukocytosis, thrombocytopenia, acute renal injury, elevated liver enzymes, and COVID-19 positive test. Patient underwent initial liver ultrasound revealing intrahepatic and extrahepatic biliary ductal dilation. Subsequent MRCP demonstrated diffuse thickening of intra and extra hepatic bile ducts suggestive of cholangitis and several hepatic masses concerning for abscesses versus possible metastatic cholangiocarcinoma. Patient improved symptomatically with antibiotics and supportive care. A liver biopsy was performed with pathology showing lymphoplasmacytic inflammation and fibroblastic infiltration suggestive of hepatic inflammatory pseudotumor. A repeat MRCP one week later showed interval decrease in size of liver lesions and repeat liver function tests also showed improvement. Patient was discharged on a course of ciprofloxacin and metronidazole. Patient had repeat MRCP 3 months after discharge, with further significant improvement in size of liver lesions. After multi-disciplinary discussion the plan was for further surveillance with imaging and labs in 2 months. Discussion(s): Inflammatory pseudotumors are benign and non-neoplastic lesions that can occur in any organ. They can appear as a malignant lesion when they arise in the liver and an accurate identification can allow for conservative management and prevent unnecessary invasive procedures. Hepatic inflammatory pseudotumors are often seen with concomitant infection or inflammatory processes. Liver biopsies distinguish these tumors from other malignant processes as they demonstrate a characteristic dense inflammatory infiltrate interspersed in stroma of interlacing bundles of myofibroblasts. This case highlights the importance of maintaining HIP on the differential diagnosis. (Figure Presented).
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The proceedings contain 6 papers. The topics discussed include: endoscopic balloon dilatation for pediatric subglottic stenosis: systematic review and meta-analysis;a review of literature on anatomical variation of the extra-hepatic biliary tree;impact of the COVID-19 pandemic on patients with pediatric cancer in low-income, middle-income, and high-income countries: a multicenter, international, observational cohort study;preoperative mediastinal staging in resectable non-small cell lung cancer in a single surgical center;thoracotomy vs video-assisted thoracoscopic surgery in the treatment of vascular rings;and application of photogrammetry in medical education.
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Purpose: The COVID pandemic presents a unique set of challenges during pregnancy including thromboembolic complications, direct placental infection, transplacental transmission, and systemic hyperinflammatory state. The liver is the second most commonly affected organ in COVID infection after the lungs. Mechanisms of liver injury in COVID-19 patients include: direct viral cytopathic effect, drug-induced hepatotoxicity, worsening of underlying liver disease, cytokine storm, hypoxic ischemic injury, and cholangiopathy. Post-COVID cholangiopathy leads to marked cholestasis with ongoing jaundice that persists long after other organs have recovered from infection. Method(s): We describe three infants at Texas Children's Hospital with intrauterine or perinatal COVID exposure with persistent cholestasis and extrahepatic biliary obstruction (mimicking biliary atresia), suggesting cholangiopathy. Result(s): All three patients described in this case series developed liver failure in the setting of low GGT cholestasis with histologic evidence of extrahepatic biliary obstruction, and all three required liver transplantation within the first year of life. Conclusion(s): Though post-COVID cholangiopathy is described in adults in the literature, our series is unique in that it is the first to describe this phenomenon in infancy. Additionally none of our infants had moderate or severe COVID infection but still progressed to advanced liver disease. Though further studies are needed to determine if additional factors are at play, our case series certainly raises the question of if the timing of exposure/infection might play a role in overall prognosis.
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INTRODUCTION: Time from diagnosis to treatment initiation for many cancers is lengthening. During the COVID pandemic, many institutions were forced to postpone cancer treatment to reallocate resources, despite the unclear impact of treatment delays. This study sought to investigate the association between time to treatment initiation (TTI) and overall survival in patients with hepatopancreatobiliary (HPB) cancers. METHODS: The National Cancer Database (NCDB) was queried for patients diagnosed with de novo cancers of the pancreas, liver, and intrahepatic and extrahepatic bile ducts between 2004 and 2017. Kaplan-Meier survival analysis and Cox regression were used to investigate the association between TTI and overall survival for each cancer type, stratified by stage. Multivariable linear regression identified factors associated with longer TTI. RESULTS: Of 318,931 patients with HPB cancer, median TTI across all cancers was 31 days, ranging from 26 days for pancreas cancer to 48 days for liver cancer. Longer TTI was associated with increased mortality in patients with stages I, II, and III extrahepatic bile duct (EHBD) cancer (Figure 1), and stage I pancreatic adenocarcinoma. Compared to TTI of 3 to 30 days, the risk-adjusted hazard ratios for stage I EHBD cancer for TTI 31 to 60, 61 to 90, and ≥90 days were 1.17 [95% CI 1.07-1.29], 1.39 [1.21-1.59], and 1.63 [1.40-1.90], respectively. For the same time frames, hazard ratios in stage I pancreatic cancer were 1.08 [1.03-1.13], 1.19 [1.11-1.28], and 0.99 [0.90-1.09], respectively. Factors most strongly associated with increased TTI for all cancers included treatment with radiation only (β = +14.1 days, p< 0.001), early stage disease (+13.8 days for stage I vs. stage IV, p< 0.001), Black race (+4.4 days, p< 0.001), Hispanic ethnicity (+4.2 days, p< 0.001), and treatment in the West (+3.9 days vs. Northeast, p< 0.001). CONCLUSIONS: Delayed initiation of definitive therapy leads to increased mortality in stage I-III EHBD and stage I pancreatic cancer. Some patients, including Blacks and Hispanics, are more likely to experience delayed care. Treatment initiation for these cancers should be expedited, and pandemic-related postponements should be avoided if possible.