Liver IPT was first described in 1953 by Pack and Baker (2
). To date, the etiology and pathogenesis of IPTs remain unknown. Liver IPTs are associated with a number of diseases, including Crohn’s disease, diabetes mellitus, Sjögren’s syndrome, gout, chronic cholangitis, primary sclerosing cholangitis, Kostmann’s disease and autoimmune pancreatitis (3
). The majority of patients usually present with a fever and abdominal pain (3
), and a small number of patients suffer from jaundice caused by idiopathic inflammatory structures of the extrahepatic biliary tree. Clinical manifestations and imaging are similar to those of a tumor with the exception of the benign biological behavior and the properties of spontaneous regression following treatment with antibiotics (4
) or non-steroidal anti-inflammatory drugs (5
). CT scans and MRI are the main methods to establish the diagnosis. A CT scan usually reveals lesions with variable contrast enhancement. IPTs may present with a hypovascular character in the CT scan and manifest as a low signal intensity (hypointense) on T1-weighted images with moderate to high signal intensities (hyperintense) on T2 sequences in MRI. The imaging appearance of an IPT is diverse and depends on the proportion and distribution of inflammatory cells and fibrosis within the lesion (5
). Generally, tumor markers are not useful, as the levels of the majority of markers fall within the normal range. In specific cases, a diagnosis is extremely difficult to make.
For cases of suspected IPT, the importance of percutaneous needle biopsy has been emphasized, and due to the risk of spontaneous regression, unnecessary surgery must be avoided (6
). In the current case, a percutaneous needle biopsy was not performed. The imaging appearance of the IPT indicated a malignant character, consistent with the patient history of HBV-related cirrhosis. The lesion was located on the surface of the Couinaud segment. As we were concerned over the relatively high rate of hemorrhaging following a possible percutaneous needle biopsy, as well as the risk of needle tract seeding, a surgical resection without needle biopsy was performed. Needle tract seeding has been reported to occur in 5.1% of patients with hepatocellular carcinoma who have undergone percutaneous needle biopsy (7
). Although the case was ultimately proved to be that of an IPT by a post-operative pathological examination, in our opinion, a needle biopsy should not be utilized as a routine diagnostic tool if a lesion is strongly suspected to be of malignant character. Active surgical resection must be the first choice. While hepatectomy is dangerous in patients with poor health, a liver biopsy must be considered in these cases to avoid unnecessary surgical procedures.
In general, IPTs are considered to represent benign lesions, however, the correct treatment protocol for these pseudotumors remains controversial. Certain studies have reported that lesions are likely to be completely resolved following treatment with antibiotics. However, specific lesions have recurred following this treatment protocol. By contrast, IPTs have never been reported to recur following surgical resection. We recommend that short-term observation should be performed in patients diagnosed with IPT. In addition, for cases where the lesion is difficult to differentiate from the malignancy or is associated with high risk factors, including HBV-related cirrhosis, surgical resection must be considered.