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Multifocal peliosis hepatis simulating metastatic malignancy
G Model YDLD-2639; No. of Pages 2
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Correspondence Multifocal peliosis hepatis simulating metastatic malignancy Dear Editor, A 78-year-old male presented with multiple incidentally detected liver lesions, identified on computed tomography (CT) during an admission for gallstone pancreatitis. There was no history of liver disease or malignancy. Progress CT showed increase in lesion size and number over a period of 17 months (Fig. 1A). Positron emission tomography (PET) showed lesional metabolic activity was similar to background liver. Tumour markers were normal, as were liver function, plasma biochemistry and full blood count. An echocardiogram showed normal cardiac function and his spleen was not enlarged. The lesions were suspicious for metastatic malignancy and the patient underwent a liver biopsy in January 2013. This biopsy revealed largely normal liver transitioning into areas of pelioid change. Due to the clinical suspicion of metastatic disease, the possibilities of nonspecific perilesional effects or artefact could not be excluded. A repeat biopsy was thus performed in October 2013. This showed features identical to the first biopsy (Fig. 1B). Normal hepatocyte cell plates were seen on reticulin staining. A diagnosis of peliosis hepatis (PH) was made. The patient remained asymptomatic at his latest review in March 2014, and a decision was made for active monitoring. PH is defined as the presence of dilated blood-filled spaces within the liver [1], thought to be the result of abnormal blood flow. It is associated with anabolic steroid use and Bartonella henselae infection, with the latter occurring almost invariably in human immunodeficiency virus-positive individuals [2,3]. Clinically it can range from asymptomatic and detected incidentally, to presenting with fatal spontaneous haemorrhage [4]. The radiological appearance of PH is highly variable. It can appear as a solitary lesion or as a diffuse process. On CT, differences in lesion size, rate of blood flow, presence of haemorrhage, and presence of necrosis result in a range of nonspecific appearances [5]. PET findings have not been published previously. In our case, the lesions demonstrated identical metabolic activity to background liver and were difficult to discern. This may be of value in distinguishing PH from neoplastic processes, which are usually well defined and show increased uptake on PET. Histologically, PH is characterised by blood-filled spaces randomly distributed throughout the liver parenchyma. In more subtle examples, the spaces are microscopic and merge with sinusoidal dilatation. The background liver is usually normal or shows mild nonspecific changes only. The diagnosis of PH is straightforward on excision specimens; however, core biopsies present special challenges. Once a biopsy is obtained, the clinical suspicion of a neoplastic process may lead to an impression the lesion has not been sampled, with a diagnosis
Fig. 1. (A) On computed tomography, multiple hypodense lesions are seen within the liver. (B) Pelioid spaces are seen in association with sinusoidal dilatation (H&E, 100×).
of nonspecific perilesional changes only. In well-developed PH, a core biopsy may sample only the wall of a large space, resulting in fragmentation and again a nonspecific diagnosis. The more subtle examples resemble and may be indistinguishable from sinusoidal dilatation. Lastly, if diffuse nodularity is noted on imaging and the biopsy shows pelioid spaces and sinusoidal dilatation, nodular regenerative hyperplasia (NRH) must be considered. While clinical background may suggest NRH (for example the presence of autoimmune disorders or portal hypertension), the diagnosis requires the identification of hyperplastic and atrophic areas. In small or fragmented biopsies this distinction may be difficult, and a reticulin stain is useful in this situation. Nonetheless, in all of these instances a representative biopsy easily excludes a neoplastic process, which is the major clinical differential.
http://dx.doi.org/10.1016/j.dld.2014.04.015 1590-8658/Crown Copyright © 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l. All rights reserved.
Please cite this article in press as: Liu C, et al. Multifocal peliosis hepatis simulating metastatic malignancy. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.015
G Model YDLD-2639; No. of Pages 2
ARTICLE IN PRESS
2
Correspondence / Digestive and Liver Disease xxx (2014) xxx–xxx
We thus describe a case of PH presenting as multiple liver lesions, simulating metastatic malignancy. Its PET findings are emphasised, which have not been described in the literature. PH is an uncommon differential for a diffusely nodular liver; however, with an adequate biopsy, characteristic features can be identified. Conflict of interest None declared. Acknowledgements We would like to thank Dr Alvin So for his assistance in acquiring and interpreting the radiologic images.
[3] Perkocha LA, Geaghan SM, Yen TS, et al. Clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection. New England Journal of Medicine 1990;323:1581–6. [4] Buelow B, Otjen J, Sabath AP, et al. Peliosis hepatis presenting as liver rupture in a vulnerable adult: a case report. American Journal of Forensic Medicine and Pathology 2012;33:307–10. [5] Iannaccone R, Federle MP, Brancatelli G, et al. Peliosis hepatis: spectrum of imaging findings. American Journal of Roentgenology 2006;187:W43–52.
Cheng Liu ∗ Asokan Pasupathy Anatomical Pathology, Nepean Hospital, Kingswood, Australia Martin Weltman Gastroenterology, Nepean Hospital, Kingswood, Australia
References [1] Zak FG. Peliosis hepatis. American Journal of Pathology 1950;26:1–15. [2] Neri M, Bello S, Bonsignore A, et al. Anabolic androgenic steroids abuse and liver toxicity. Mini Reviews in Medicinal Chemistry 2011;11:430–7.
∗ Corresponding
author. Tel.: +61 413795875. E-mail address: [email protected] (C. Liu)
Please cite this article in press as: Liu C, et al. Multifocal peliosis hepatis simulating metastatic malignancy. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.015
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Correspondence Multifocal peliosis hepatis simulating metastatic malignancy Dear Editor, A 78-year-old male presented with multiple incidentally detected liver lesions, identified on computed tomography (CT) during an admission for gallstone pancreatitis. There was no history of liver disease or malignancy. Progress CT showed increase in lesion size and number over a period of 17 months (Fig. 1A). Positron emission tomography (PET) showed lesional metabolic activity was similar to background liver. Tumour markers were normal, as were liver function, plasma biochemistry and full blood count. An echocardiogram showed normal cardiac function and his spleen was not enlarged. The lesions were suspicious for metastatic malignancy and the patient underwent a liver biopsy in January 2013. This biopsy revealed largely normal liver transitioning into areas of pelioid change. Due to the clinical suspicion of metastatic disease, the possibilities of nonspecific perilesional effects or artefact could not be excluded. A repeat biopsy was thus performed in October 2013. This showed features identical to the first biopsy (Fig. 1B). Normal hepatocyte cell plates were seen on reticulin staining. A diagnosis of peliosis hepatis (PH) was made. The patient remained asymptomatic at his latest review in March 2014, and a decision was made for active monitoring. PH is defined as the presence of dilated blood-filled spaces within the liver [1], thought to be the result of abnormal blood flow. It is associated with anabolic steroid use and Bartonella henselae infection, with the latter occurring almost invariably in human immunodeficiency virus-positive individuals [2,3]. Clinically it can range from asymptomatic and detected incidentally, to presenting with fatal spontaneous haemorrhage [4]. The radiological appearance of PH is highly variable. It can appear as a solitary lesion or as a diffuse process. On CT, differences in lesion size, rate of blood flow, presence of haemorrhage, and presence of necrosis result in a range of nonspecific appearances [5]. PET findings have not been published previously. In our case, the lesions demonstrated identical metabolic activity to background liver and were difficult to discern. This may be of value in distinguishing PH from neoplastic processes, which are usually well defined and show increased uptake on PET. Histologically, PH is characterised by blood-filled spaces randomly distributed throughout the liver parenchyma. In more subtle examples, the spaces are microscopic and merge with sinusoidal dilatation. The background liver is usually normal or shows mild nonspecific changes only. The diagnosis of PH is straightforward on excision specimens; however, core biopsies present special challenges. Once a biopsy is obtained, the clinical suspicion of a neoplastic process may lead to an impression the lesion has not been sampled, with a diagnosis
Fig. 1. (A) On computed tomography, multiple hypodense lesions are seen within the liver. (B) Pelioid spaces are seen in association with sinusoidal dilatation (H&E, 100×).
of nonspecific perilesional changes only. In well-developed PH, a core biopsy may sample only the wall of a large space, resulting in fragmentation and again a nonspecific diagnosis. The more subtle examples resemble and may be indistinguishable from sinusoidal dilatation. Lastly, if diffuse nodularity is noted on imaging and the biopsy shows pelioid spaces and sinusoidal dilatation, nodular regenerative hyperplasia (NRH) must be considered. While clinical background may suggest NRH (for example the presence of autoimmune disorders or portal hypertension), the diagnosis requires the identification of hyperplastic and atrophic areas. In small or fragmented biopsies this distinction may be difficult, and a reticulin stain is useful in this situation. Nonetheless, in all of these instances a representative biopsy easily excludes a neoplastic process, which is the major clinical differential.
http://dx.doi.org/10.1016/j.dld.2014.04.015 1590-8658/Crown Copyright © 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l. All rights reserved.
Please cite this article in press as: Liu C, et al. Multifocal peliosis hepatis simulating metastatic malignancy. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.015
G Model YDLD-2639; No. of Pages 2
ARTICLE IN PRESS
2
Correspondence / Digestive and Liver Disease xxx (2014) xxx–xxx
We thus describe a case of PH presenting as multiple liver lesions, simulating metastatic malignancy. Its PET findings are emphasised, which have not been described in the literature. PH is an uncommon differential for a diffusely nodular liver; however, with an adequate biopsy, characteristic features can be identified. Conflict of interest None declared. Acknowledgements We would like to thank Dr Alvin So for his assistance in acquiring and interpreting the radiologic images.
[3] Perkocha LA, Geaghan SM, Yen TS, et al. Clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection. New England Journal of Medicine 1990;323:1581–6. [4] Buelow B, Otjen J, Sabath AP, et al. Peliosis hepatis presenting as liver rupture in a vulnerable adult: a case report. American Journal of Forensic Medicine and Pathology 2012;33:307–10. [5] Iannaccone R, Federle MP, Brancatelli G, et al. Peliosis hepatis: spectrum of imaging findings. American Journal of Roentgenology 2006;187:W43–52.
Cheng Liu ∗ Asokan Pasupathy Anatomical Pathology, Nepean Hospital, Kingswood, Australia Martin Weltman Gastroenterology, Nepean Hospital, Kingswood, Australia
References [1] Zak FG. Peliosis hepatis. American Journal of Pathology 1950;26:1–15. [2] Neri M, Bello S, Bonsignore A, et al. Anabolic androgenic steroids abuse and liver toxicity. Mini Reviews in Medicinal Chemistry 2011;11:430–7.
∗ Corresponding
author. Tel.: +61 413795875. E-mail address: [email protected] (C. Liu)
Please cite this article in press as: Liu C, et al. Multifocal peliosis hepatis simulating metastatic malignancy. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.015