P1863 - A Case of Indolent Peripheral T Cell Lymphoma Mimicking Inflammatory Pseudotumor of the Liver

Maen Kamal, MD¹, Haya Omeish, MD², Michael Volk, MD^3
1Loma Linda University, Loma Linda, CA; ²Royal Jordanian Medical Centre, Amman, 'Amman, Jordan; ³Transplant Institute, Loma Linda University Medical Center, Redlands, CA

Introduction: Inflammatory Pseudotumor (IPT) is a rare disease of unknown etiology that is often indistinguishable from malignancy. First described in 1939, and while it most commonly occurs in the lung, it can involve many other organs. We report a challenging case of Peripheral T Cell Lymphoma mimicking IPT of the Liver.

Case Description/Methods: 28M presented with 10 days of RUQ pain, fevers, night sweats and a 15 lb weight loss. He was febrile to 103F. Physical exam revealed tenderness in the RUQ. Labs showed a WBC 3.1 Bil/L, ALT 146 U/L, AST 76 U/L and ALP 396 U/L and a normal Bilirubin. Abdominal US showed an ill-defined 3.4x1.9 cm lesion in the right hepatic lobe. CT scan demonstrated an enhancing 3.3 cm lesion in the right liver suspicious for a hepatic mass. Tumor markers were not elevated. MRI showed a 4.0x3.3 cm mass within hepatic segment V. A needle core biopsy demonstrated a portal predominant dense mixed cellular infiltrate with areas of spindle cell proliferation compatible with a hepatic IPT. He was treated with steroids without symptom resolution. Subsequently he underwent resection of segment V with pathology consistent with IPT. He presented a year later with fevers, neutropenia and elevated liver chemistry tests. CT scan showed hepatosplenomegaly, inguinal, retroperitoneal and mesenteric lymphadenopathy. MRI showed multiple ill-defined lesions scattered throughout the liver. PET scan showed multifocal lesions involving the liver, kidneys, inguinal lymph nodes, Left scapula, and pelvis. Bone marrow biopsies were normal. Excisional LN biopsy as well as a repeat percutaneous Liver biopsy, both exhibited atypical CD8 positive T-cell infiltrate. A diagnosis of indolent peripheral T cell Lymphoma was made.

Discussion: IPT of the liver is very rare. It is more common in men, with a male to female ratio of 8:1 with an average age at presentation of 35 years. There are several mechanisms for IPT formation, which include inflammatory reaction, infectious agents, trauma, and autoimmune disorders. The clinical presentation includes abdominal pain, weight loss and a liver mass on imaging. IPT often mimics a malignancy on imaging, and biopsy is required for diagnosis. IPT demonstrates dominant spindle cell proliferation with a variable inflammatory component. Treatment options for IPT of the liver include steroids, NSAIDs, antibiotics, radiotherapy and chemotherapy, or surgical resection. This case highlights the need for close follow-up and high index of suspicion for missed underlying causes.


Figure: Figure 1- Hyperdense enhancing 3.3 cm lesion in the right liver suspicious for a hepatic mass.
Figure 2- Abdominal MRI, a 4.0 x 3.3 cm mass within hepatic segment V with heterogeneous arterial enhancement.
Figure 3- A, Gross resection of IPT of liver. B, Hepatic parenchyma with a spindle and inflammatory process consistent with an inflammatory pseudotumor.


Disclosures:
Maen Kamal indicated no relevant financial relationships.
Haya Omeish indicated no relevant financial relationships.
Michael Volk indicated no relevant financial relationships.


Maen Kamal, MD¹, Haya Omeish, MD², Michael Volk, MD³. P1863 - A Case of Indolent Peripheral T Cell Lymphoma Mimicking Inflammatory Pseudotumor of the Liver, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.