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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5762_Библиотеки_им_академика_М_И_Перельмана.pdf
220
a
e
Y. Dong et al.
b
c
d
f
g
h
Fig. 9.6 A case of inammatory pseudotumor of the liver (IPT). A
hypoechoic heterogeneous focal liver lesion with a vague margin was
detected in the right lobe of liver (a). Dotted color ow signals could be
detected in the peripheral area of the lesion (b). Arterial Doppler spectrum with high resistance index (RI) as 0.77 was measured (c). The
lesion showed hyperenhancement with a vague margin in arterial phase
(d, e). Reaching peak enhancement, the area of lesion was larger than
that on B mode ultrasound (f, g, h, j). The central part of the lesion
showed early wash-out during late arterial phase (h, j). The entire lesion
showed hypoenhancement in the portal venous and late phase (k, l)
a
9 Hepatic Inammatory Pseudotumor
221
i
k
Fig. 9.6 (continued)
j
l
b
c
Fig. 9.7 A case of heterogeneous hypoechoic inammatory pseudotumor (IPT) was detected in the left lobe of liver (a). Dotted color ow
signals could be detected in the lesion (b). The lesion showed heteroge-
d
neous hyperenhancement in the arterial phase (c, d, e), followed by
wash-out in the portal venous (f) and late phase (g)
222
e
a
g
Fig. 9.7 (continued)
Y. Dong et al.
f
b
c
d
Fig. 9.8 A case of hypoechoic inammatory pseudotumor of the liver
(IPT) with a vague margin was detected in the right lobe of liver (a).
The lesion showed non-enhancement with an irregular shape during
arterial phase (b), portal venous (c) or late phases (d) of contrast
enhanced ultrasound. The peripheral area of the lesion (arrows) manifested hyperenhancement in the arterial phase, suggesting inammatory response rim (b, c, d). On MRI, the lesion showed hypointense on
T1-weighted imaging (e) and hyperintense on T2-weighted in-phase
imaging (f) and diffusion weighted imaging (g). Peripheral halo with
slightly hypointense on T1-weighted imaging and slight hyperintense
on T2-weighted imaging could be seen (arrowhead) (e, f). On dynamic
enhanced MRI, the lesion showed irregularly and progressively peripheral enhancement (h, i, j)
e
9 Hepatic Inammatory Pseudotumor
223
f
g
h
ji
Fig. 9.8 (continued)
224
a
e
Y. Dong et al.
b
c
d
f
Fig. 9.9 A case of multiple hypoechoic inammatory pseudotumor of
the liver (IPT) with vague margins were detected in the right lobe of
liver (a). The lesion showed hyperenhancement in the arterial phase
(arrow) (b), and another two similar hyperenhanced lesions could be
detected (arrowhead) (c). All lesions showed hyper/isoenhancement in
portal venous phase (arrow) (d). After second injection, more hyperenhanced lesions could be detected during arterial phase (arrow) (e, f)
9 Hepatic Inammatory Pseudotumor
225
– The IPT lesion is observed circumscribed, peripheral,
and rim-like enhancement.
– The IPT lesion has a centrifugal wash-out pattern of
enhancement.
– During short follow-up periods, spontaneous liver
tumor regression may be observed.
9.3 Dierential Diagnosis
9.3.1 Hepatocellular Carcinoma
• IPT with diffuse hyperenhancement in arterial phase is
difcult to be distinguished with HCC.
• HCC usually occurs at the cirrhosis background of HBV
infection and AFP elevating to a highly abnormal level.
• HCC lesions are round-shaped, ill-dened, and
hypoechoic on grayscale ultrasound.
• CDFI can detect arterial blood inner the HCC lesions with
a high resistance index of more than 0.60.
• The enhanced pattern of HCC is fast wash-in and fast
wash-out and the enhancement degree at the arterial phase
is higher than IPT [5].
9.3.2 Liver Metastasis Tumor
• IPT lesions with peripheral hyperenhancement in arterial
phase are often misdiagnosed as liver metastasis tumors.
• Generally, the patients with liver metastasis tumors usually have a history of other malignant primary tumor and
are found multiple lesions.
• CEA and CA19-9 could be elevated at the meantime.
• Liver metastasis tumor shows rapid wash-in and wash-out
in peripheral rim-like enhancement pattern on CEUS.
• Metastasis lesions are often well-dened and round while
IPT lesions are with ill-dened and irregular shapes.
9.3.4 Liver Abscess
• Patients with liver abscess could have different symptoms, such as fever, chill, and pain in the liver region.
• The border of abscess lesions is difcult to dene in the
early stage with diffuse fast wash-in and wash-out
enhancement patterns. At the late stage, the abscess shows
rim-like enhancement similar to IPT.
9.4 Pathology
9.4.1 General Features
• IPT lesions usually composed of granuloma tissue with
lymphocyte inltration, mainly by plasma cell and proliferating into the surrounding connective tissue.
• Some IPTs are associated with autoimmune disorders, for
example, IgG4-related disease [6].
9.4.2 Staging, Grading, andClassication
• In 2007, Zen etal. proposed a classication of hepatic
IPT into two major types based on clinical and histological features: brohistiocytic and lymphoplasmacytic [7].
– The brohistiocytic IPT type was characterized by
xanthogranulomatous inammation, multinucleated
giant cells, and neutrophilic inltration, while the lymphoplasmacytic IPT type has features of the inammatory neoplastic process with inltration of lymphocyte
cells and IgG4-positive plasma cells.
9.5 Clinical Issues
9.5.1 Presentation
9.3.3 Intrahepatic Cholangiocarcinoma
• Intrahepatic cholangiocarcinoma (ICC) lesions show heterogeneous and branched hyperenhancement. It is difcult to distinguish ICC with IPT when showing diffuse
heterogeneous hyperenhancement.
• As ICC are originated from bile duct, bile dilatation
around the tumors could be helpful for diagnosis.
• CA19-9 often elevates obviously in ICC.
• ICC is an aggressive malignant tumor and progresses rapidly. With the process of inammatory, the imaging performance varies in different IPT lesions.
• IPT patients are often lack specic clinical symptoms.
• Fever, abdominal pain, myalgia, fatigue, and weight loss
are commonly presented [8].
• Liver function tests are normal and some patients show
mild elevation of γ-glutamyltransferase and alkaline
phosphatases.
• Hematologic test are usually normal but may reveal an
inammatory syndrome in some patients with the elevation of ESR C-reaction protein.
• Tumor markers including CA19-9 and AFP are usually
normal.
226
Y. Dong et al.
9.5.2 Prognosis
• The prognosis of patients with hepatic IPT is generally
excellent. Adequate therapy for IPT is considered to be
conservative treatment with an antibiotic agent, not surgical resection [9, 10].
9.5.3 Treatment
• Surveillance, steroids, and/or antibiotics are always useful with complete regression rates of >90%, when the
diagnosis is certain.
• When malignant tumors cannot completely be ruled out,
percutaneous biopsy is necessary to make a denite diagnosis and further management [11].
• Surgery is not mandatory for hepatic IPT, if doubt exists.
Surgical removal is recommended to eliminate the possibility of malignancy [12].
References
1. Horiuchi R, Uchida T, Kojima T, Shikata T.Inammatory pseudo-
tumor of the liver. Clinicopathologic study and review of the literature. Cancer. 1990;65:1583–90.
2. Kong WT, Wang WP, Cai H, Huang BJ, Ding H, Mao F.The analy-
sis of enhancement pattern of hepatic inammatory pseudotumor on
contrast-enhanced ultrasound. Abdom Imaging. 2014;39:168–74.
3. Yang X, Zhu J, Biskup E, Cai F, Li A.Inammatory pseudotumors of the liver: experience of 114 cases. Tumour Biol.
2015;36:5143–8.
4. Iguchi H, Yamazaki H, Tsunoda H, Takahashi Y, Yokomori H. A
case of inammatory pseudotumor of the liver mimicking hepatocellular carcinoma on EOB-MRI and PET. Case Rep Med.
2013;2013:594254.
5. Chen CB, Chou CT, Hsueh C, Lee KW, Chen YL.Hepatic inammatory pseudotumor mimicking hepatocellular carcinoma. J Chin
Med Assoc. 2013;76:299–301.
6. Patel H, Nanavati S, Ha J, Shah A, Baddoura W.Spontaneous resolution of IgG4-related hepatic inammatory pseudotumor mimicking malignancy. Case Rep Gastroenterol. 2018;12:311–6.
7. Zen Y, Fujii T, Sato Y, Masuda S, Nakanuma Y.Pathological classication of hepatic inammatory pseudotumor with respect to IgG4related disease. Mod Pathol. 2007;20:884–94.
8. Patnana M, Sevrukov AB, Elsayes KM, Viswanathan C, Lubner M,
Menias CO.Inammatory pseudotumor: the great mimicker. AJR
Am J Roentgenol. 2012;198:W217–27.
9. Saito M, Seo Y, Yano Y, Miki A, Morinaga Y, Itoh T, Yoshida M,
et al. Sonazoid-enhanced ultrasonography and Ga-EOB-DTPAenhanced MRI of hepatic inammatory pseudotumor: a case report.
Intern Med. 2012;51:723–6.
10. Yamaguchi J, Sakamoto Y, Sano T, Shimada K, Kosuge
T. Spontaneous regression of inammatory pseudotumor of the
liver: report of three cases. Surg Today. 2007;37:525–9.
11. Gesualdo A, Tamburrano R, Gentile A, Giannini A, Palasciano G,
Palmieri VO. A diagnosis of inammatory pseudotumor of the
liver by contrast enhaced ultrasound and ne-needle biopsy: a case
report. Eur J Case Rep Intern Med. 2017;4:000495.
12. Calomeni GD, Ataide EB, Machado RR, Escanhoela CA, Costa
LB, Boin IF.Hepatic inammatory pseudotumor: a case series. Int
J Surg Case Rep. 2013;4:308–11.
Hepatic Artery Aneurysm
HongHan, Jia-YingCao, andWen-PingWang
10
Abbreviations
HAA Hepatic artery aneurysm
HAP Hepatic artery pseudoaneurysm
10.1 Terminology
• Hepatic artery aneurysms are rare and asymptomatic.
There is a high mortality rate associated with the rupture
of hepatic artery aneurysm. Its early diagnosis by imaging
techniques and timely treatment is of paramount
importance.
• Digital subtraction angiography (DSA) is the gold standard for the diagnosis of hepatic artery aneurysms, but it
is traumatic and should not be used as the rst choice.
• CT angiography is highly accurate in diagnosing hepatic
artery aneurysms. It can help to nd the anatomical variations of vessels and interrelation between the aneurysm
and adjacent abdominal organs or vessels.
• Color ow imaging (CFI) is convenient and fast for
detecting hepatic artery aneurysms. Critical patients can
be examined at the bedside. CDI can assess the size, location of the aneurysms, as well as the presence and extent
of thrombus in the aneurysm sac.
• Contrast-enhanced ultrasound (CEUS) is an enhanced
ultrasonic examination that can further improve the sensitivity of CFI in diagnosing hepatic artery aneurysms. In
the diagnosis and follow-up of hepatic artery aneurysm,
CEUS can partially replace CT enhancement as it is noninvasive, convenient, and requires a small dosage of contrast agent.
H. Han · J.-Y. Cao · W.-P. Wang (*)
Department of Ultrasound, Zhongshan Hospital, Fudan University,
Shanghai, China
e-mail: han.hong@zs-hospital.sh.cn; cao.jiaying@zs-hospital.sh.cn
• Evaluation of collateral vessels is as important as the
diagnosis of the hepatic artery aneurysm. Only in the
presence of collateral circulation, the aneurysm and
affected hepatic arteries can be safely ligated or embolized without causing organ ischemia following infarction.
10.2 Hepatic Artery Aneurysm
Denitions
• Hepatic artery aneurysm: An abnormal focal dilatation of
the hepatic artery.
• Hepatic artery pseudoaneurysm: A round or oval-shaped
cystic lesion located on one side of the hepatic artery,
resulting in displacement, stenosis, or occlusion of adjacent hepatic artery (Fig.10.1).
10.3 Imaging
10.3.1 General Features
• Local spindle-shaped or cystic dilatation of the hepatic
artery.
• Hepatic artery pseudoaneurysm appears as area abnormally lled with contrast agent, which is round or ovalshaped and located on one side of the hepatic artery.
10.3.2 Radiographic Findings
• Abdominal radiography documentation of calcication in
aneurysm wall is usually diagnostic.
• Barium radiography of gastrointestinal shows that the
duodenum, pylorus, and less curvature of stomach are
compressed by the aneurysm.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
W.-P. Wang et al. (eds.), Contrast-Enhanced Ultrasound Imaging of Hepatic Neoplasms,
https://doi.org/10.1007/978-981-16-1761-4_10
227
228
a
H. Han et al.
b
c
Fig. 10.1 Hepatic artery pseudoaneurysm in transplanted liver. B
mode ultrasound showed a round enlarged anechoic structure near porta
hepatis (a). Color ow image showed stirring-like blood ow in the
cavity, suspected of pseudoaneurysm (b). Arterial Doppler spectrum
10.3.3 DSA Findings
d
demonstrated an arterial waveform of the cystic lesion (c). Contrastenhanced ultrasound showed that the aneurysm sac was lled with contrast agent in arterial phase (d)
aneurysm sac in the arterial phase and no enhancement of
peripheral nodular thrombosis [1].
• DSA can not only determine the location and size of
hepatic aneurysms, their anatomical relationship with
other visceral arteries, but also be used to guide interventional procedures including embolization and stent
placement.
• Computed tomography angiography (CTA) displays
hepatic artery aneurysm from multiple angles and shows
the relationship between the lesion and the adjacent
organs or vessels, providing information needed for treatment options [1, 2].
• DSA has a high sensitivity for the diagnosis of haemobilia
caused by the hepatic artery aneurysm rupture.
10.3.5 Conventional Ultrasound Findings
10.3.4 CT Findings
• Non-enhanced CT mainly demonstrates the calcied wall
and intraluminal thrombosis of hepatic artery aneurysm.
• Contrast-enhanced CT clearly shows hepatic artery aneurysm, which appears as a marked enhancement of the
• A Hepatic artery aneurysm appears as a round or roundlike anechoic mass with a well-dened margin and uneven
thickness of the capsule wall in B mode ultrasound. CDFI
demonstrates the swirling blood ow in the aneurysm sac.
• CDFI can detect the bidirectional “to-and-fro” ow at the
rupture site of hepatic artery pseudoaneurysm.
10 Hepatic Artery Aneurysm
229
• CDFI offers a rapid visual conrmation of both arterial
ow and singular nature of the intrahepatic cystic lesion,
as well as discerns aneurysms from other vascular abnormalities, such as arteriovenous stulas and vascular malformations [3].
10.3.6 Contrast-Enhanced Ultrasound
Findings
• CEUS is an enhanced ultrasonic examination, in which
hepatic artery aneurysms appear as areas with abnormal
contrast agent lling. CEUS improves the sensitivity of
CDFI in diagnosing hepatic artery aneurysms, helping
detect those difcult to be found with general ultrasound
examinations [4].
• CEUS is useful in evaluating liver parenchyma perfusion,
which is valuable in identifying complications after
hepatic aneurysm embolization in transplanted liver, such
as infarction or abscess.
• While evaluating the efcacy of endovascular treatment
of aneurysm with CEUS, the observation time after contrast agent injection should be slightly longer because
some endoleaks with slower ow rates do not appear
immediately.
• Compared with contrast-enhanced CT, CEUS is nonradioactive and requires a small dosage of contrast agent.
CEUS can partially replace contrast-enhanced CT in the
diagnosis of hepatic aneurysm and follow-up after its
treatment. CEUS is the optimal modality for the diagnosis
of hepatic artery aneurysm in patients with renal insufciency, as the ultrasonic contrast agent does not contain
iodine and is non-nephrotoxic.
10.3.7 MRI Findings
• Ultrasound can be used as the rst choice for hepatic
artery aneurysm screening, as it has no radiation damage
and can be performed at bedside.
10.3.9 Protocol Advice
• DSA is the gold standard for the diagnosis of hepatic
artery aneurysm, but should not be used as the rst choice
for its invasiveness and complicated procedure.
• CTA is highly accurate in diagnosing hepatic artery aneurysms. It can identify collateral vessels, evaluate the interrelation between the aneurysm and adjacent abdominal
organs or feeding arteries. The disadvantage of CTA is
that it is radioactive, the contrast agent contains iodine
which is nephrotoxic.
• CDFI can be used as the rst screening method for hepatic
artery aneurysms for it has no radiation damage and is
capable of bedside operation. The disadvantage is that it is
affected by the patient’s obesity and intestinal gas; in
addition, the accuracy is highly dependent on the
operator.
• CEUS is real-time and sensitive for blood ow detection, making it a promising modality for detecting
hepatic artery aneurysm. CEUS can also be used to evaluate the efcacy of hepatic aneurysm embolization as it
is non- invasive and requires a small dosage of contrast
agent. However, limited by the relatively poor sonic
window of extrahepatic portion, the detection ability of
extrahepatic aneurysms is lower than that of intrahepatic
aneurysms.
• PET/CT can provide anatomical and functional information and is mainly used for diagnosis and staging of
tumors. Hepatic artery aneurysms are occasionally found
in the examination, and the lesions have the same FDG
uptake as the blood pool.
• Magnetic resonance imaging detection of central ow
void in the aneurysm sac and mural thrombus are usually
diagnostic.
• MR angiography can be used to assess the effect of hepatic
aneurysm embolization, and identify related complications such as aneurysm perforation and organ infarction.
10.3.8 Best Imaging Protocol Advices
• DSA is currently the gold standard for the diagnosis of
hepatic artery aneurysm (Fig.10.2).
10.4 Dierential Diagnosis
• Other vascular diseases: Arteriovenous stula, venous
aneurysm, and arteriovenous malformations.
• Focal uid collections in the porta hepatis.
• The extravasation of contrast agent from the hepatic arterial anastomosis and the Ligated stump of the hepatic
artery branch in transplanted liver would be misinterpreted as pseudoaneurysm, causing false-positive
diagnosis.