Tumor-like conditions that mimic liver tumors.

Non-neoplastic tumor-like conditions of the liver can appear similar to hepatic neoplasms. In many cases, a biopsy is required to confirm the pathology. However, several tumor-like conditions can be correctly diagnosed or suggested prospectively, thus saving patients from unnecessary anxiety and expense. In this image-focused review, we present the ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography scan features of eight such entities. Clues that indicate the correct pathology are discussed, and the usual clinical setting is described. Many of these lesions are treated differently from true neoplasms, and the current treatment plan is discussed in many of the cases presented. After reviewing this article, the reader will have a better understanding of these lesions and the situations in which they should be included in the differential diagnosis.

Peliosis of the spleen as an unusual cause of splenic rupture: A case report and a review of literature.

Isolated splenic peliosis is an extremely rare condition characterized by the presence of multiple blood-filled cavities, occasionally resulting in non-traumatic splenic rupture with fatal bleeding. In our case, a 64-year-old man was brought by ambulance due to weakness and abdominal pain without nausea or febrility. On clinical examination, the patient was sensitive to palpation with significant tenderness over the abdomen but no associated features of peritonitis. He collapsed during the imaging examination and became unconscious and asystolic. Cardiopulmonary resuscitation was not successful. The patient died approximately within 2 hours of admission to the hospital. Postmortal examination showed 2800 ml of intraperitoneal blood with clots and a laceration of the lower pole of the spleen. Macroscopic examination of the spleen revealed huge nodular splenomegaly, measuring 21 cm x 19 cm x 5 cm, weighing 755 g. On the cut surfaces, multiple randomly distributed blood-filled cavities ranging from 0,5 to 2 cm in diameter were seen. At microscopic examination, the specimens showed multiple irregular haemorrhagic cyst-like lesions that were not lined by any epithelium or sinusoidal endothelium, consistent with the diagnosis of peliosis lienis. Although the condition is often clinically silent, the forensic pathological significance arises from the differential diagnosis of resultant intraperitoneal haemorrhage and sudden death, mimicking a violent death.

Splenic Peliosis as a Rare Cause of Spontaneous Splenic Rupture: A Case Report.

Atraumatic splenic rupture is a serious intraabdominal emergency that requires emergent intervention. This can be due to a number of causes. In this case report, we introduce a rare cause of atraumatic splenic rupture, which is an otherwise benign asymptomatic disease that only manifests clinically upon rupture, namely splenic peliosis. There is limited existing knowledge concerning the disease's etiology and diagnosis; however, this study presents the possible etiological explanations, associated risk factors, and possible radiologic diagnostic modalities.

Two Rare Benign Lesions on 18F-FDG PET/CT: Peliosis Hepatis and SANT.

Peliosis hepatis (PH) and sclerosing angiomatoid nodular transformation of the spleen are uncommon benign lesions. Diagnosis can be difficult in some patients. Herein, we present the case of a 28-year-old woman referred with abdominal pain who had spleen lesions. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography revealed multiple non-FDG avid lesions in the liver and hypermetabolic lesions in the spleen. In addition, abdominal magnetic resonance imaging was performed. Histopathology revealed sclerosing angiomatoid nodular transformation in the spleen and PH in the liver.

Spontaneous Hepatic Rupture in the Setting of Peliosis Hepatis and End-Stage Renal Disease.

Rare and sometimes fatal, spontaneous hepatic rupture (SHR) is frequently documented in conjunction with various benign and malignant hepatic tumors, peliosis hepatis (PH), amyloidosis, and polyarteritis nodosa. PH is a rare disease characterized by the presence of sinusoidal dilation and blood-filled cysts throughout the hepatic parenchyma. Handling and identifying this condition can be challenging, particularly in the absence of a history of liver cirrhosis or a tumor. The present case involves a 61-year-old male with a SHR and PH, accompanied by a significant history of end-stage renal disease (ESRD) over the past year. The patient presented to the emergency department with a three-week history of right flank pain. Hemoglobin levels were found to be low; the Glasgow Coma Scale (GCS) score was progressively decreasing. A computed tomography (CT) scan revealed a rupture of the right liver capsule, hemoperitoneum, PH, and an edematous gall bladder. The current case illustrates the diagnosis and management of PH and hemoperitoneum. This case emphasizes the challenging diagnosis of this potentially fatal liver complication in an outwardly healthy male, highlighting the connection between PH and ESRD.

A rare case of localized peliosis hepatis during adjuvant chemotherapy including oxaliplatin mimicking a liver metastasis of colon cancer.

BACKGROUND: Oxaliplatin-based regimens are commonly used as adjuvant chemotherapy following surgery for colorectal cancer. Adverse events associated with oxaliplatin include blue liver, which is caused by sinusoidal dilation and diffuse peliosis hepatis. We report herein a case of localized peliosis hepatis closely resembling a metastatic liver tumor. CASE PRESENTATION: The patient, a 50-year-old male, underwent a robotically assisted colectomy for rectosigmoid colon cancer, which was discovered when hematochezia occurred. The patient received a diagnosis of pStage IIIb and was treated with four courses of CAPOX as adjuvant chemotherapy starting at postoperative month 1. At postoperative month 4, contrast-enhanced computed tomography (CT) of the abdomen revealed a 20-mm, low-density area with heterogeneous internal structure in S6/7 of the liver. Abdominal ultrasound and gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) findings led to a diagnosis of metastatic liver tumor, for which a laparoscopic partial hepatectomy was performed. The resected lesion was a dark reddish-brown nodule with indistinct margins that appeared to be continuous with the surrounding area. Histopathological analysis revealed severe, localized dilatation of the sinusoids and congestion consistent with the gross nodule. Based on these findings, localized peliosis hepatis associated with oxaliplatin-induced sinusoidal damage was diagnosed. CONCLUSIONS: Localized peliosis hepatis associated with oxaliplatin use can be difficult to distinguish from a metastatic liver tumor on imaging studies.

Spontaneous splenic rupture due to Peliosis and the association with malignancy: A case series and literature review.

INTRODUCTION AND IMPORTANCE: Isolated splenic peliosis is an extremely rare condition. The associations of splenic peliosis with various infections, medications, and conditions have unclear significance. We present three patients from the past twenty years with spontaneous splenic rupture due to peliosis, two of whom had hematologic malignancy, to draw attention to a possible correlation. CASE PRESENTATION: A 31-year-old male with essential thrombocytopenia and antiphospholipid-antibody syndrome presented with worsening abdominal pain and hypotension. The patient denied any trauma. Computed-tomography demonstrated hemoperitoneum and splenic rupture with innumerable blood-filled splenic cysts. An uncomplicated emergency open splenectomy was performed with shed-blood reinfusion. The patient was discharged on postoperative day five. The patient developed acute myelogenous leukemia and died six years later. A 44-year-old otherwise healthy male presented with left upper-quadrant and shoulder pain without reported trauma. Computed-tomography (CT) imaging revealed splenomegaly, multiple splenic cystic lesions, and free intraperitoneal blood. A laparoscopic splenectomy, complicated by a pancreatic leak that was managed with a drain, was performed. The patient was discharged on postoperative day three and was well at 37 months follow-up. A 78-year-old male with splenomegaly and chronic anemia on warfarin for atrial fibrillation presented in shock with a distended abdomen after falling from a standing height. The patient was resuscitated with two units of packed red blood cells and underwent emergent abdominal exploration. The spleen was ruptured. An open splenectomy was performed and four liters of intraperitoneal blood were evacuated. Pathology confirmed splenic peliosis and historic diffuse large B-cell lymphoma. The patient had an excellent response to chemotherapy but died 12 years later. CLINICAL DISCUSSION: Splenic peliosis is a rare vascular phenomenon of unclear etiology. Several toxic and pharmaceutical agents have been associated with spontaneous splenic rupture in patients with peliosis. There are also a number of reported patients who were noted to have hematologic disorders, suggestive of a potential association to the pathophysiology of peliosis. CONCLUSION: Based on our clinical experience and focused literature review, it appears likely that there is a relationship between splenic peliosis and hematologic malignancy.

Isolated splenic peliosis: a case report.

BACKGROUND: Peliosis is a rare condition with anatomopathological characteristics that affect the liver. However, splenic peliosis is even more unique and rare. Patients with such abnormality usually exhibit no symptoms. Moreover, this is a lethal condition due to the high probability of splenic rupture accompanied by shock. CASE PRESENTATION: We present a case of a 29-year-old Arab female who was admitted to the hospital with severe upper abdominal pain that started 1 week from the date of admission, associated with nausea, anorexia, low-grade fever, and vomiting, with no past medical history or comorbidities. A computerized tomography scan with contrast showed intraperitoneal free fluid along with multiple hypodense splenic cysts. Hence, an emergent exploratory laparotomy with splenectomy was performed. Splenic peliosis was confirmed by the histopathological examination. CONCLUSION: Further investigations are warranted if peliosis is confirmed in one organ, for example, the liver, to detect its presence in any other potential organs that can be affected by peliosis. Splenic peliosis is extraordinarily rare. Furthermore, such a disease has no established management plan. Definitive treatment is surgical. Many aspects of splenic peliosis remain puzzling requiring more research in the near future.

Solitary peliosis hepatis mimics a liver metastasis on contrast-enhanced ultrasound.

Peliosis hepatis remains a rare focal liver lesion with inconclusive imaging features. The unknown pathogenesis represents a wide possible range of etiologies including the breakdown of the sinusoidal borders, a potential hepatic outflow obstruction or dilatation of the central vein of a hepatic lobule. In histopathology, a blood-filled cystlike appearance with sinusoidal dilatation was reported. On ultrasound, B-mode features are not specific demonstrating a irregular, moreover hypoechogenic focal liver lesions. Postcontrast imaging features on Contrast-Enhanced-Ultrasound may mimic a malignant lesion with irregular contrast inflow and washout during late phase. Our case demonstrates a peliosis hepatis with malignant image features on contrast-enhanced ultrasound, ruled out by PET-CT and core needle biopsy with corresponding histopathological workup.

MRI of Peliosis Hepatis: A Case Series Presentation With a 2022 Systematic Literature Update.

BACKGROUND: Peliosis hepatis (PH) is a rare benign condition, characterized by hepatic sinusoidal dilatation and blood-filled cystic cavities, often found incidentally, with still challenging diagnosis by imaging due to polymorphic appearance. PURPOSE: Based on a retrospective analysis of our series (12 patients) and systematic literature review (1990-2022), to organize data about PH and identify features to improve characterization. STUDY TYPE: Retrospective case series and systematic review. POPULATION: Twelve patients (mean age 48 years, 55% female) with pathology-proven PH and 49 patients (mean age 52 years, 67% female) identified in 33 studies from the literature (1990-2022). FIELD STRENGTH/SEQUENCE: 1,5-T; T1-weighted (T1W), T2-weighted (T2W), diffusion-weighted (DW), contrast-enhanced (CE) T1W imaging. ASSESSMENT: We compared our series and literature data in terms of demographic (gender/age/ethnicity), clinical characteristics (symptoms/physical examination/liver test), associated conditions (malignancies/infectious/hematologic/genetic or chronic disorders/drugs or toxic exposure) percentage. On magnetic resonance imaging lesion numbers/shape/mean maximum diameter/location/mass effect/signal intensity were compared. PH pathological type/proposed imaging diagnosis/patient follow-up were also considered. STATISTICAL TESTS: Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports/Series quality assessment. Intraclass correlation and Cohen's kappa coefficients for levels of inter/intrareader agreement in our experience. RESULTS: Patients were mainly asymptomatic (92% vs. 70% in our study and literature) with associated conditions (83% vs. 80%). Lesions showed homogeneous T1W-hypointensity (58% vs. 65%) and T2W-hyperintensity (58% vs. 66%). Heterogeneous nonspecific (25% vs. 51%), centrifugal (34% vs. 8%), or rim-like centripetal (25% vs. 23%) patterns of enhancement were most frequent, with hypointensity on the hepatobiliary phase (HBP), without restricted diffusivity. Good inter- and intrareader agreement was observed in our experience. Concerning JBI Checklist, 19 out of 31 case reports met at least 7 out of 8 criteria, whereas 2 case series fulfilled 5 and 6 out of 10 items respectively. DATA CONCLUSION: A homogeneous, not well-demarcated T1W-hypointense and T2W-hyperintense mass, with heterogeneous nonspecific or rim-like centripetal or centrifugal pattern of enhancement, and hypointensity on HBP, may be helpful for PH diagnosis. Among associated conditions, malignancies and drug exposures were the most frequent. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY: Stage 2.

Chemotherapy-Induced Liver Injury in Patients with Colorectal Liver Metastases: Findings from MR Imaging.

Chemotherapy-induced liver injury has been found to be quite common in cancer patients undergoing chemotherapy. Being aware of chemotherapy-induced hepatotoxicity is important for avoiding errors in detecting liver metastases and for defining the most appropriate clinical management strategy. MRI imaging has proven to be a useful troubleshooting tool that helps overcome false negatives in tumor response imaging after chemotherapy due to liver parenchyma changes. The purpose of this review is, therefore, to describe the characteristics of magnetic resonance imaging of the broad spectrum of liver damage induced by systemic chemotherapeutic agents in order to avoid misdiagnoses of liver metastases and disease progression and to define the most appropriate clinical management strategy.

Versatility of Anabolic Androgenic Steroid-Induced Hepatotoxicity.

The modified derivatives of testosterone, termed as androgenic steroids are indicated in the management of hypogonadism, visceral obesity and metabolic disorders. Anabolic androgenic steroids (AASs) however are surreptitiously used by athletes and body builders for cosmetic purpose owing to their anabolic effects on muscle mass and strength. The unsurveilled use of AASs subjects these users to various side effects involving multiple systems such as the endocrine, genitourinary, hepatobiliary, central nervous, musculoskeletal and psychosocial system. The liver is a hormone-sensitive organ owing to abundance of androgen receptors and is vulnerable to a wide array of hepatotoxicity ranging from asymptomatic liver enzyme elevation to life-threatening subacute liver failure. The type of drug-induced liver injury (DILI) due to AASs can be hepatocellular injury, cholestasis, fatty liver disease, chronic vascular injury and neoplastic disease. Herein, we report three cases of AAS-related DILI associated with AAS abuse.

An autopsy case of recurrent pneumothorax and peliosis-like intrapulmonary hematoma with X-linked myotubular myopathy.

BACKGROUND: The typical non-muscle complications of long-surviving X-linked myotubular myopathy (XLMTM) include scoliosis, head deformity, macrocephaly, gastroesophageal reflux disease and peliosis hepatis. Recently, pulmonary blebs and recurrent pneumothorax have also been reported as uncommon complications, whereas no reports on autopsy cases have focused on lung lesions. CASE PRESENTATION: An 8-year-old boy with XLMTM presented recurrent pneumothorax requiring bleb resection and pleurodesis. He subsequently developed multiple pulmonary mass lesions. He died of hemorrhagic shock due to peliosis hepatis. Autopsy showed multiple peliosis-like hematomas in the blebs of the lung. The histopathological examination of the hematomas revealed pooled blood without a pathway to bronchus. No apparent increase in desmin- or α-smooth muscle actin (α-SMA)-positive cells, namely myofibroblasts, was observed around hematomas, suggesting that the mutation in the myotubularin gene was involved in the defective repair process in the liver and lung tissues. CONCLUSION: Recurrent pneumothorax should be considered as a non-muscle complication of XLMTM. Peliosis-like intrapulmonary hematoma may also be a critical complication caused by poor proliferation of myofibroblasts in the tissue repair process.

Adult Scurvy Presenting with Painful Purpura on the Legs.

Prolonged vitamin C deficiency can result in numerous metabolic abnormalities like impaired tissue repair and defective collagen synthesis. This case report describes a middle-age Japanese man presenting painful purpura on his lower limbs, severe anemia, and altered consciousness. The patient had been eating a selective diet lacking in vegetables and fruits since childhood. A serum analysis demonstrated a low level of vitamin C. The patient was treated with vitamin supplementation and psychological intervention. Scurvy is an under-considered illness with a favorable prognosis if diagnosed early while it is still sporadically encountered in some patients with malabsorption or malnutrition even in modern times.

Splenic peliosis associated with spontaneous rupture and massive bleeding.

We report findings from an autopsy case who died from massive bleeding because of splenic peliosis. The case subject was an 80-year-old man who had diabetes mellitus and who was receiving hemodialysis and anticoagulant therapy. Postmortem computed tomography demonstrated massive intra-abdominal hemorrhage especially seen around the spleen. At autopsy, we found abundant hemorrhagic ascites, including a large number of clots, in the abdominal cavity. The spleen had several distinct dark red areas ranging in size from 1.5 to 2.5 cm and showed spontaneous rupture along with hematoma formation on the outside of the splenic capsule on the anterior side. From these findings, we concluded that the cause of death in this case was massive hemorrhage owing to spontaneous rupture of splenic peliosis. Although peliosis itself rarely causes death, but when it is destroyed, massive bleeding leads to death. Thus, it is necessary to know the histopathological characteristics of peliosis, in forensics.

Peliosis Hepatis with Chylous Ascites in a Dog.

A 6-year-old spayed female Toy Poodle dog was referred to the Hokkaido University Veterinary Teaching Hospital for abdominal distension. Abdominocentesis yielded ascitic fluid that had a mildly increased total protein concentration and a 2.7-fold higher triglyceride concentration than plasma, and was interpreted as chylous ascites. The patient had an enlarged liver, which contained multiple, small, nodular masses and cyst-like structures. Microscopically, these lesions were multifocal dilated spaces containing lymphocytes, endothelial cells, fibrin and islands of hepatocytes. Increased α-smooth muscle actin-positive cells were observed in hepatic sinusoids. Based on these findings, we diagnosed peliosis hepatis with chylous ascites, which is likely to have been due to lymphangiectasia and disrupted hepatic sinusoids. Neither Bartonella spp DNA nor mutations in ACVRL1 and MTM1 genes were detected, although there was a 47-fold increase in hepatic ACVRL1 expression compared with age-matched control liver. To the authors' knowledge, this is the first report of chylous ascites resulting from peliosis hepatis in any species.

Newly detected liver nodules with a history of colorectal cancer: are they metastatic? Review of 2,632 cases in a single center.

BACKGROUND: The diagnosis of newly detected liver nodules in patients with colorectal cancer (CRC) is crucial for determining prognosis and treatment. Accurate identification of benign nodules can help avoid unnecessary therapy. The aim of our study was to retrospectively review patients with CRC who underwent liver resection for benign liver nodules misdiagnosed as CRC metastasis (CRLM) in our institution. METHODS: We reviewed all patients with a history of CRC who underwent liver resection from January 2012 to December 2019 in our institution. We specifically focused on nodules pathologically confirmed as benign. The pathology was rechecked by an independent pathologist. The clinicopathological characteristics of these patients were collected. Preoperative imaging examinations, including ultrasound (US), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) were reviewed. RESULTS: From 2012 to 2019, a total of 2,632 patients with CRC who were preoperatively diagnosed CRLM received liver resection, among which 2,584 (98.2%) cases were proven to be malignant, and 48 (1.8%) cases were benign. Among these 48 cases, 24 were pathologically confirmed as focal nodular hyperplasia (FNH), 9 were peliosis, 10 were inflammatory lesions, and 5 were hemangioma. At least one preoperative imaging examination indicated CRLM, with a median size of 2.0 cm (range, 0.4-8.0 cm). Before liver resection, ten patients received chemotherapy after the discovery of liver nodules. CONCLUSIONS: It should be noted that newly detected liver nodules in patients with a history of CRC could be benign. Accurate diagnosis of liver nodules in CRC is necessary to avoid overtreatment and to identify cost-effective medication.

Hepatic lesions in captive owl monkeys (Aotus infulatus) with ultrasonographic "starry sky" liver.

BACKGROUND: The "starry sky" (SK) liver is ultrasonographic pattern characterized by multiple hyperechogenic foci in hepatic parenchyma. The study aimed to characterize the microscopic hepatic lesions in captive owl monkeys with SK liver. METHODS: Thirty-seven clinically healthy owl monkeys had their liver scanned and 18 of them had liver biopsy. Animals with SK and peliosis hepatis (PH) were subjected to immunohistochemical and molecular screening for Bartonella spp. RESULTS: SK liver occurred in 59.4% (22/37) of the owl monkeys. Biopsied animals showed steatosis, hydropic degeneration, hemosiderosis, PH, and multifocal granulomatous hepatitis. Two monkeys had SK, granulomatous hepatitis, and PH which were negative for Bartonella spp. CONCLUSIONS: PH and granulomatous hepatitis associated with hepatocellular degenerative lesions may present as hyperechoic nodular liver lesions consisted of SK liver; therefore, concomitant occurrence of two lesions or more contributed to the hepatic SK pattern among owl monkeys and such cases might be clinically monitored.

Ultrasound findings in peliosis hepatis.

PURPOSE: The aim of this study was to retrospectively evaluate contrast-enhanced ultrasound (CEUS) findings in patients with peliosis hepatis (PH). METHODS: A retrospective analysis was conducted of CEUS features in 24 patients with histopathologically confirmed PH (11 men and 13 women; mean age, 32.4±7.1 years; range, 28 to 41 years). All lesions were histologically proven, either by core needle biopsy (n=10) or by hepatic surgery (n=14). RESULTS: The mean size was 36.8±12.4 mm (range, 10 to 80 mm). On B-mode ultrasonography (BMUS), all PH lesions were heterogeneously hypoechoic, with well-defined margins but irregular shapes. No mass effect was observed. During the arterial phase of CEUS, all lesions displayed mild heterogeneous hyperenhancement (83.3%, 20/24) or isoenhancement (16.7%, 4/24). Furthermore, 87.5% of the PH lesions showed mild washout after 1 minute in the portal venous phase (30-120 seconds) and mild washout in the late phase (>120 seconds). CONCLUSION: The lack of a mass effect on BMUS, mild heterogeneous arterial hyperenhancement, and washout in the very late portal venous phase (after 1 minute) on CEUS are characteristic of PH. Although it is a histological diagnosis, PH should be considered in the differential diagnosis when the clinical context does not favor a malignancy or infection.