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Inadvertently Discovered Round Mass in Mesentery
Clinical Challenges and Images in GI, continued
Inadvertently Discovered Round Mass in Mesentery Sanghoon Park,* Yang-Seok Chae,‡ and Hoon Jai Chun* *Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine; and ‡Department of Pathology, Korea University College of Medicine, Seoul, Korea
Question: A 77-year-old woman was referred for an incidental finding on computed tomography (CT) during treatment of ischemic colitis. She has been taking medication for hypertension and seemed to be recovered from acute illness on referral with stable vital signs and normal laboratory findings. Total colonoscopy showed findings suggestive of ischemic colitis. On physical examination, a tiny, nontender, rubbery, round nodule was palpable in the left supraclavicular region. Abdominopelvic CT revealed colonic wall thickening from ascending to sigmoid colon, conforming best to ischemic colitis. Interestingly, a round, well-enhanced mass on small bowel mesentery measuring 3.3 ⫻ 3.3 cm was discovered (Figure A). Positron emission tomography/CT fusion scan revealed an intense hypermetabolic mass on small bowel mesentery, as well as in the left supraclavicular and para-aortic region. Ultrasonography-assisted fine needle aspiration on the left supraclavicular nodule showed many lymphocytes and some histiocytes, but no malignancy was seen. To expedite diagnosis, laparoscopic excision was performed; the mass was round with a cut surface admixed of yellowish and bloody material (Figure B). What is the likely diagnosis? Look on page 1128 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.06.079
Biliary Obstruction From a Bile Duct Mass Christie Blanton, John Kalarickal, and Virendra Joshi Tulane University Medical School, New Orleans, Louisiana
Question: A 20-year-old woman with hypertension, bicuspid aortic valve, and gastroesophageal reflux disease was referred for an evaluation due to persistent jaundice, nausea, and vomiting. The patient denied abdominal pain, fevers, chills, diarrhea, constipation, or joint pain. There were no prior surgeries. Medications at the time of presentation included amlodipine, omeprazole, and oral contraceptives. The patient was afebrile on presentation with normal vital signs. The physical examination was notable for jaundice. The abdominal examination was unremarkable; no rashes or lymphadenopathy were present. Laboratory values at presentation were notable for total bilirubin 8.7 mg/dL, direct bilirubin 7.5 mg/dL, alkaline phosphatase 573 U/L, alanine aminotransferase 267 U/L, and aspartate aminotransferase 164 U/L. Total protein, albumin, prothrombin time, blood counts, and electrolytes were
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A focal ischemia of the small intestine is rare. It has been associated with a variety of condition, such as superior mesenteric artery thrombosis, embolism, trauma, strangulation, radiation, drugs, or vasculitis.1,2 Ischemic intestinal stricture often developed in the ileum and rarely in the jejunum or the colon.3 The symptoms usually occurred 2– 6 weeks after the insult to the mesenteric blood flow.1,3 An enteroclysis is useful for diagnosis in the literature. Thumbprinting or thickening of the folds occurred in the early stage. A concentric stricture joining the proximal and distal intestinal lumen in a fusiform tapering fashion occurred in the healing stage.1 The differential diagnosis included intestinal anisakiasis, carcinoma, and malignant lymphoma.2,3 To our knowledge, we report the first enteroscopic feature of ischemic jejunal stricture in the literature. A preoperative enteroscopy helps to determine the nature of the intestinal stricture and allows histologic examination. References 1. Iida M, Matsui T, Yao T, et al. Radiographic features in ischemic jejunoileitis: serial changes and comparison with pathologic findings. Gastrointest Radiol 1992;17:327–332. 2. Ghidirim G, Mishin I, Vozian M, et al. Extended poststrangulation ischemic jejunal stricture. J Gastrointest Liver Dis 2008;17:114 –115. 3. Ginai AZ, Hussain SM, Hordijk ML, et al. Case report: solitary ischaemic small bowel stenosis. Br J Radiol 1994;67:405– 407. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 812): Progressive Transformation of Germinal Center Pathologic examination revealed follicular hyperplasia with inward migration of numerous foci of perifollicular small B cells with a mantlezone phenotype into the follicle center (Figure C). Numerous small lymphocytes and occasional collections of epithelioid cells at the periphery were also seen in other microscopic fields (not shown). On immunohistochemistry, increased network of follicular dendritic cells were noted with a CD21 immunostain (Figure D); Ki-67 labeling index was relatively low, suggesting low proliferation of the mass. CD15and CD30-positive cells were not detected, indicative of low possibility of Hodgkin lymphoma. Progressive transformation of germinal center (PTGC) is a rare, reactive change of the B-cell region on lymph nodes resulting in abnormal enlargement. It is commonly asymptomatic and has a wide age and site distribution.1 Pathogenesis is generally unknown. Most of the PTGCs are localized and self-limited; the rest of ⬍5% of cases are generalized or florid. Florid PTGCs are clinically characterized as multiple lymph node enlargements, most commonly involving cervical region and less frequently the inguinal and then axillary nodes. In contrast with focal PTGCs, florid cases are commonly mistaken for malignant lymphoma, and immunohistochemical staining is essential for differentiation.2 Therapy is not recommended for PTGC unless it is clearly associated with Hodgkin lymphoma. Although PTGC is not rendered as a premalignant condition, follow-up and biopsy of enlarged lymph nodes in individuals with a prior diagnosis of PTGC is warranted.3 References 1. Licup AT, Campisi P, Ngan BY, et al. Progressive transformation of germinal centers: an uncommon cause of pediatric cervical lymphadenopathy. Arch Otolaryngol Head Neck Surg 2006;132:797– 801. 2. Good D, Gascoyne R. Atypical lymphoid hyperplasia mimicking lymphoma. Hematol Oncol Clin North Am 2009;23:729 –745.
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3. Hicks J, Flaitz C. Progressive transformation of germinal centers: review of histopathologic and clinical features. Int J Pediatr Otorhinolaryngol 2002;65:195–202. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI: Image 4 (page 812): Inflammatory Pseudotumor of the Extrahepatic Bile Duct The patient underwent laparotomy, which revealed an indurated mass surrounding the bile duct extending from common bile duct to the hilar plate. A segmental resection was performed. Histology was notable for spindle cells on a hypovascular, dense collagenous stroma (Figure D). The hepatic parenchyma and bile duct epithelium showed a mixed inflammatory cell infiltrate including plasma cells. Immunohistochemical stains for anaplastic lymphoma kinase-1, Ebstein-Barr virus, and gene rearrangements were unremarkable. Cultures for micro-organisms in bile fluids were unremarkable for acid fast bacilli. Inflammatory pseudotumor (IPT) is a rare, benign, mass-forming lesion that is most commonly found in the lung. Although the etiology is unknown, it is considered to be a reactive process to inflammatory or infectious states. About 100 cases of hepatic IPT have been reported in the literature, with 4 reported at the porta hepatis. IPTs demonstrate a wide range of patient and lesion characteristics. A recent review of the literature shows a 2:1 male predominance and a mean age of 40 (range, 10 months to 83 years). The majority of reported lesions were in the right lobe of the liver.1 Although the most common presentation of hepatic IPTs was fever and weight loss, the specific location of the mass at the porta hepatis presented with jaundice in 3 of the 4 cases.1 Laboratory findings are nonspecific and consistent with an underlying inflammatory or infectious process.2 Usual histologic features include the presence of myofibroblastic spindle cells, plasma cells, macrophages, and lymphocytes without cellular atypia.3 Because of a vague systemic presentation, lack of specific diagnostic findings, and the presence of a mass on imaging studies, it is often difficult to distinguish IPT from malignancy. The majority of cases of hepatic IPT are indeed diagnosed after lobectomy.2 Although recent studies have shown favorable outcomes with conservative management, abdominal surgery often cannot be avoided because of its concerning presentation.
Supplementary Materials Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal,org, and at doi:10.1053/j.gastro.2010.06.082. References 1. Uetuji S, Nakagawa A, Kwon A, et al. Inflammatory pseudotumor of the liver: report of a case and review of the literature. Surg Today 1996;26:517–521. 2. Ryuzo H, Toshikazu U, Takashi K, et al. Inflammatory pseudotumor of the liver: clinicopathologic study and review of the literature. Cancer 1990;65:1583–1590. 3. Milias K, Madhavan KK, Bellamy C, et al. Inflammatory pseudotumors of the liver: experience of a specialist surgical unit. J Gastroenterol Hepatol 2009;24:152–156. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Inadvertently Discovered Round Mass in Mesentery Sanghoon Park,* Yang-Seok Chae,‡ and Hoon Jai Chun* *Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine; and ‡Department of Pathology, Korea University College of Medicine, Seoul, Korea
Question: A 77-year-old woman was referred for an incidental finding on computed tomography (CT) during treatment of ischemic colitis. She has been taking medication for hypertension and seemed to be recovered from acute illness on referral with stable vital signs and normal laboratory findings. Total colonoscopy showed findings suggestive of ischemic colitis. On physical examination, a tiny, nontender, rubbery, round nodule was palpable in the left supraclavicular region. Abdominopelvic CT revealed colonic wall thickening from ascending to sigmoid colon, conforming best to ischemic colitis. Interestingly, a round, well-enhanced mass on small bowel mesentery measuring 3.3 ⫻ 3.3 cm was discovered (Figure A). Positron emission tomography/CT fusion scan revealed an intense hypermetabolic mass on small bowel mesentery, as well as in the left supraclavicular and para-aortic region. Ultrasonography-assisted fine needle aspiration on the left supraclavicular nodule showed many lymphocytes and some histiocytes, but no malignancy was seen. To expedite diagnosis, laparoscopic excision was performed; the mass was round with a cut surface admixed of yellowish and bloody material (Figure B). What is the likely diagnosis? Look on page 1128 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.06.079
Biliary Obstruction From a Bile Duct Mass Christie Blanton, John Kalarickal, and Virendra Joshi Tulane University Medical School, New Orleans, Louisiana
Question: A 20-year-old woman with hypertension, bicuspid aortic valve, and gastroesophageal reflux disease was referred for an evaluation due to persistent jaundice, nausea, and vomiting. The patient denied abdominal pain, fevers, chills, diarrhea, constipation, or joint pain. There were no prior surgeries. Medications at the time of presentation included amlodipine, omeprazole, and oral contraceptives. The patient was afebrile on presentation with normal vital signs. The physical examination was notable for jaundice. The abdominal examination was unremarkable; no rashes or lymphadenopathy were present. Laboratory values at presentation were notable for total bilirubin 8.7 mg/dL, direct bilirubin 7.5 mg/dL, alkaline phosphatase 573 U/L, alanine aminotransferase 267 U/L, and aspartate aminotransferase 164 U/L. Total protein, albumin, prothrombin time, blood counts, and electrolytes were
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A focal ischemia of the small intestine is rare. It has been associated with a variety of condition, such as superior mesenteric artery thrombosis, embolism, trauma, strangulation, radiation, drugs, or vasculitis.1,2 Ischemic intestinal stricture often developed in the ileum and rarely in the jejunum or the colon.3 The symptoms usually occurred 2– 6 weeks after the insult to the mesenteric blood flow.1,3 An enteroclysis is useful for diagnosis in the literature. Thumbprinting or thickening of the folds occurred in the early stage. A concentric stricture joining the proximal and distal intestinal lumen in a fusiform tapering fashion occurred in the healing stage.1 The differential diagnosis included intestinal anisakiasis, carcinoma, and malignant lymphoma.2,3 To our knowledge, we report the first enteroscopic feature of ischemic jejunal stricture in the literature. A preoperative enteroscopy helps to determine the nature of the intestinal stricture and allows histologic examination. References 1. Iida M, Matsui T, Yao T, et al. Radiographic features in ischemic jejunoileitis: serial changes and comparison with pathologic findings. Gastrointest Radiol 1992;17:327–332. 2. Ghidirim G, Mishin I, Vozian M, et al. Extended poststrangulation ischemic jejunal stricture. J Gastrointest Liver Dis 2008;17:114 –115. 3. Ginai AZ, Hussain SM, Hordijk ML, et al. Case report: solitary ischaemic small bowel stenosis. Br J Radiol 1994;67:405– 407. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 812): Progressive Transformation of Germinal Center Pathologic examination revealed follicular hyperplasia with inward migration of numerous foci of perifollicular small B cells with a mantlezone phenotype into the follicle center (Figure C). Numerous small lymphocytes and occasional collections of epithelioid cells at the periphery were also seen in other microscopic fields (not shown). On immunohistochemistry, increased network of follicular dendritic cells were noted with a CD21 immunostain (Figure D); Ki-67 labeling index was relatively low, suggesting low proliferation of the mass. CD15and CD30-positive cells were not detected, indicative of low possibility of Hodgkin lymphoma. Progressive transformation of germinal center (PTGC) is a rare, reactive change of the B-cell region on lymph nodes resulting in abnormal enlargement. It is commonly asymptomatic and has a wide age and site distribution.1 Pathogenesis is generally unknown. Most of the PTGCs are localized and self-limited; the rest of ⬍5% of cases are generalized or florid. Florid PTGCs are clinically characterized as multiple lymph node enlargements, most commonly involving cervical region and less frequently the inguinal and then axillary nodes. In contrast with focal PTGCs, florid cases are commonly mistaken for malignant lymphoma, and immunohistochemical staining is essential for differentiation.2 Therapy is not recommended for PTGC unless it is clearly associated with Hodgkin lymphoma. Although PTGC is not rendered as a premalignant condition, follow-up and biopsy of enlarged lymph nodes in individuals with a prior diagnosis of PTGC is warranted.3 References 1. Licup AT, Campisi P, Ngan BY, et al. Progressive transformation of germinal centers: an uncommon cause of pediatric cervical lymphadenopathy. Arch Otolaryngol Head Neck Surg 2006;132:797– 801. 2. Good D, Gascoyne R. Atypical lymphoid hyperplasia mimicking lymphoma. Hematol Oncol Clin North Am 2009;23:729 –745.
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3. Hicks J, Flaitz C. Progressive transformation of germinal centers: review of histopathologic and clinical features. Int J Pediatr Otorhinolaryngol 2002;65:195–202. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI: Image 4 (page 812): Inflammatory Pseudotumor of the Extrahepatic Bile Duct The patient underwent laparotomy, which revealed an indurated mass surrounding the bile duct extending from common bile duct to the hilar plate. A segmental resection was performed. Histology was notable for spindle cells on a hypovascular, dense collagenous stroma (Figure D). The hepatic parenchyma and bile duct epithelium showed a mixed inflammatory cell infiltrate including plasma cells. Immunohistochemical stains for anaplastic lymphoma kinase-1, Ebstein-Barr virus, and gene rearrangements were unremarkable. Cultures for micro-organisms in bile fluids were unremarkable for acid fast bacilli. Inflammatory pseudotumor (IPT) is a rare, benign, mass-forming lesion that is most commonly found in the lung. Although the etiology is unknown, it is considered to be a reactive process to inflammatory or infectious states. About 100 cases of hepatic IPT have been reported in the literature, with 4 reported at the porta hepatis. IPTs demonstrate a wide range of patient and lesion characteristics. A recent review of the literature shows a 2:1 male predominance and a mean age of 40 (range, 10 months to 83 years). The majority of reported lesions were in the right lobe of the liver.1 Although the most common presentation of hepatic IPTs was fever and weight loss, the specific location of the mass at the porta hepatis presented with jaundice in 3 of the 4 cases.1 Laboratory findings are nonspecific and consistent with an underlying inflammatory or infectious process.2 Usual histologic features include the presence of myofibroblastic spindle cells, plasma cells, macrophages, and lymphocytes without cellular atypia.3 Because of a vague systemic presentation, lack of specific diagnostic findings, and the presence of a mass on imaging studies, it is often difficult to distinguish IPT from malignancy. The majority of cases of hepatic IPT are indeed diagnosed after lobectomy.2 Although recent studies have shown favorable outcomes with conservative management, abdominal surgery often cannot be avoided because of its concerning presentation.
Supplementary Materials Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal,org, and at doi:10.1053/j.gastro.2010.06.082. References 1. Uetuji S, Nakagawa A, Kwon A, et al. Inflammatory pseudotumor of the liver: report of a case and review of the literature. Surg Today 1996;26:517–521. 2. Ryuzo H, Toshikazu U, Takashi K, et al. Inflammatory pseudotumor of the liver: clinicopathologic study and review of the literature. Cancer 1990;65:1583–1590. 3. Milias K, Madhavan KK, Bellamy C, et al. Inflammatory pseudotumors of the liver: experience of a specialist surgical unit. J Gastroenterol Hepatol 2009;24:152–156. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).