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Inflammatory myofibroblastic tumor, commonly known as inflammatory pseudotumor, is often said to be a quasineoplastic lesion. Inflammatory pseudotumor literally means an enlargement mimicking a tumor arising as a result of inflammatory accumulation of fibrous and granulation tissue as well as inflammatory cells.1,2 It is usually a benign disease that is often clinically and radiologically mistaken for a malignant condition. We present a case of inflammatory pseudotumor adherent to the cecum, which was thought to be neuroganglionoma radiologically but was found to be otherwise on histopathology.
A 17-year-old girl presented with body aches, fever, and generalized abdominal pain. She had a history of minimal weight loss and anorexia. No symptoms suggestive of infection were observed anywhere in the body. Her menstrual history was not significant, and she had no comorbidities or history of previous treatment or surgeries. Results of physical examination were normal except for pallor and lumbar kyphosis. An abdominal examination revealed a mass in the region of the right iliac fossa. The lower border of the mass was not palpable, and the mass was mildly tender and mobile. All laboratory parameters were within normal limits except for slightly reduced hemoglobin and mildly elevated alkaline phosphatase (234 U/L).
Contrast enhanced CT scan of the abdomen showed a well circumscribed, lobulated, moderate and heterogeneously enhancing mass lesion in the right hemipelvis (Figures 1 & 2). Perioperative findings revealed a hard, right iliac fossa and right hemipelvic mass with dilated veins over the surface and adhesions with the omentum. The mass was free from the iliac vessels, uterus, fallopian tube, and ovaries. It was adherent to the cecum. Histopathology revealed an inflammatory myofibroblastic tumor, commonly referred to as inflammatory pseudotumor.
The lung and orbit are the most common sites affected by inflammatory myofibroblastic tumors. We offer this report to our colleagues in gastrointestinal oncology because this relatively rare entity can easily be mistaken for a neoplasm on imaging virtually anywhere in the body, presenting as an abdominal neoplasm in this case. The incidence of inflammatory pseudotumor is higher in younger patients, with both male and females being equally affected.3 Pathology of this disease is still unclear but most believe it to be of reactive origin.4,5 Some studies suggest a relation to infection.6 Other data suggest a potential for low-grade neoplasia. 7 This notion is fueled by occasional local aggressiveness and the multifocal nature of pseudotumor.8,9
Clinical features are usually determined by site and size of the lesion. Laboratory investigations are often inconclusive. Computed tomography is one of the most commonly employed diagnostic modalities, and the impression it gives is often suggestive of a tumor. This is partly due to inconsistent radiologic appearance of these lesions, which can present with varying degrees of enhancements, peripheral enhancement, and varying patterns of calcification.3 Inflammatory pseudotumor has been mistaken for intra-abdominal gastrointestinal malignancy on numerous occasions. For example, approximately 25 cases of inflammatory pseudotumor mimicking malignancy in the pancreas have been reported. 10–13 Depending on the location of the pseudotumor within the abdominal cavity, wrong diagnoses from cholangiocarcinoma to Burkitt’s lymphoma have been made. 14,15
It is our intent to reaffirm that this entity, though rare, should always be considered as a differential diagnosis, where a well circumscribed solid lesion is seen on sectional imaging and when laboratory analyses, as well as clinical details, are inconclusive. The importance of this case lies in that is illustrative of a benign disease that is often misdiagnosed and frequently mismanaged. If inflammatory pseudotumor is diagnosed correctly, a conservative approach toward management can spare unnecessary risk to the patient and reduce treatment-associated morbidity and mortality.