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Journal of Digestive Diseases 2014; 15; 281–282
doi: 10.1111/1751-2980.12137
Letter to the editor
Peliosis hepatis: One pathology, a thousand faces, and a clinical and radiological diagnostic challenge Bilal BATTAL, Veysel AKGUN & Sebahattin SARI Department of Radiology, Gulhane Military Medical Academy, Ankara, Turkey
Sirs, We read with great interest the recent article entitled ‘Peliosis hepatis mimicking hepatic malignancy: A case report’ by Huang and Wang,1 published in Journal of Digestive Diseases. The authors presented clinical, radiological and histopathological features of a misdiagnosed case of peliosis hepatis with interesting images and interpretations. Since we have a special interest in the radiological diagnosis of focal liver lesions and we have also reported magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) findings of a very atypical peliosis hepatis case, previously,2–4 we would like to clarify a few topics and to contribute to the clinical and radiological evaluation of this challenging pathology. First, as stated by the authors, the diagnosis of peliosis hepatis may only be possible with a high level of suspicion because the radiological imaging findings are usually variable and nonspecific.1 The authors reported that the peliotic lesion was isointense on T1-weighted (T1W), T2-weighted (T2W) and diffusion-weighted MRI sequences. But pre-contrast T1W, T2W, DWI and apparent diffusion coefficient (ADC) mapped images were not presented in the article. An isointense appearance of focal hepatic lesion on each of these three MRI sequence is very rare. The signal intensity of the focal peliotic lesions on MRI largely depends on the stage and the status of the blood component. Although T1W Correspondence to: Bilal BATTAL, Department of Radiology, Gulhane Military Medical Academy, 06018, Etlik, Ankara, Turkey. Email: [email protected] Conflict of interest: None. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
imaging can demonstrate hypointense, isointense or hyperintense signals, the lesions usually appear as hyperintense on T2W images.2 Second, DWI is a powerful tool in the determination and differentiation of benign and malignant focal liver lesions.3,4 However, the signal intensity features on DWI and the ADC values on the ADC maps of focal peliosis hepatis are also variable and nonspecific, probably due to its content, including the different stage of the thrombus and hemorrhage. Although peliosis hepatis is a benign condition, it could be misdiagnosed as a malignant lesion because its ADC values may be lower than that in normal-appearing liver.2,3 We think that DW images may be superior in the determination of focal peliotic lesions due to the use of both T2W contrast and diffusion information in this sequence. Third, Battal et al.2 reported a very atypical case of multifocal peliosis hepatis which developed due to prolonged androgen therapy in a boy with Fanconi anemia. In this case report some lesions showed a fluid–fluid level on T2W images due to old and new blood products in the lesions. In addition, one of the lesions atypically extended outside the liver contours and was not completely surrounded by hepatic parenchyma, although peliotic lesions are typically surrounded by hepatic parenchyma.2 Finally, the authors concluded that if radiological findings are not suggestive of cancer, percutaneous liver biopsy can be used to confirm the diagnosis of peliosis hepatis.1 However, Tsirigotis et al.5 claimed that if clinical and radiological findings were suggestive of peliosis, a percutaneous liver biopsy should be avoided because of a significant risk of severe bleeding. Hung et al.6 suggest that liver biopsy could be made by laparoscopy in most asymptomatic patients or by laparotomy in patients in an acute clinical setting.
281
282
B Battal
REFERENCES 1 Huang CY, Wang ZW. Peliosis hepatis mimicking hepatic malignancy: A case report. J Dig Dis 2013; 14: 272–5. 2 Battal B, Kocaoglu M, Atay AA, Bulakbasi N. Multifocal peliosis hepatis: MR and diffusion-weighted MR-imaging findings of an atypical case. Ups J Med Sci 2010; 115: 153–6. 3 Battal B, Kocaoglu M, Akgun V et al. Diffusion-weighted imaging in the characterization of focal liver lesions: efficacy of visual assessment. J Comput Assist Tomogr 2011; 35: 326–31.
Journal of Digestive Diseases 2014; 15; 281–282 4 Battal B, Akgün V, Kocaog˘lu M. Diffusion-weighted MRI beyond the central nervous system in children. Diagn Interv Radiol 2012; 18: 288–97. 5 Tsirigotis P, Sella T, Shapira MY et al. Peliosis hepatis following treatment with androgen-steroids in patients with bone marrow failure syndromes. Haematologica 2007; 92: e106–10. 6 Hung NR, Chantrain L, Dechambre S. Peliosis hepatis revealed by biliary colic in a patient with oral contraceptive use. Acta Chir Belg 2004; 104: 727–9.
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2014; 15; 281–282
doi: 10.1111/1751-2980.12137
Letter to the editor
Peliosis hepatis: One pathology, a thousand faces, and a clinical and radiological diagnostic challenge Bilal BATTAL, Veysel AKGUN & Sebahattin SARI Department of Radiology, Gulhane Military Medical Academy, Ankara, Turkey
Sirs, We read with great interest the recent article entitled ‘Peliosis hepatis mimicking hepatic malignancy: A case report’ by Huang and Wang,1 published in Journal of Digestive Diseases. The authors presented clinical, radiological and histopathological features of a misdiagnosed case of peliosis hepatis with interesting images and interpretations. Since we have a special interest in the radiological diagnosis of focal liver lesions and we have also reported magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) findings of a very atypical peliosis hepatis case, previously,2–4 we would like to clarify a few topics and to contribute to the clinical and radiological evaluation of this challenging pathology. First, as stated by the authors, the diagnosis of peliosis hepatis may only be possible with a high level of suspicion because the radiological imaging findings are usually variable and nonspecific.1 The authors reported that the peliotic lesion was isointense on T1-weighted (T1W), T2-weighted (T2W) and diffusion-weighted MRI sequences. But pre-contrast T1W, T2W, DWI and apparent diffusion coefficient (ADC) mapped images were not presented in the article. An isointense appearance of focal hepatic lesion on each of these three MRI sequence is very rare. The signal intensity of the focal peliotic lesions on MRI largely depends on the stage and the status of the blood component. Although T1W Correspondence to: Bilal BATTAL, Department of Radiology, Gulhane Military Medical Academy, 06018, Etlik, Ankara, Turkey. Email: [email protected] Conflict of interest: None. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
imaging can demonstrate hypointense, isointense or hyperintense signals, the lesions usually appear as hyperintense on T2W images.2 Second, DWI is a powerful tool in the determination and differentiation of benign and malignant focal liver lesions.3,4 However, the signal intensity features on DWI and the ADC values on the ADC maps of focal peliosis hepatis are also variable and nonspecific, probably due to its content, including the different stage of the thrombus and hemorrhage. Although peliosis hepatis is a benign condition, it could be misdiagnosed as a malignant lesion because its ADC values may be lower than that in normal-appearing liver.2,3 We think that DW images may be superior in the determination of focal peliotic lesions due to the use of both T2W contrast and diffusion information in this sequence. Third, Battal et al.2 reported a very atypical case of multifocal peliosis hepatis which developed due to prolonged androgen therapy in a boy with Fanconi anemia. In this case report some lesions showed a fluid–fluid level on T2W images due to old and new blood products in the lesions. In addition, one of the lesions atypically extended outside the liver contours and was not completely surrounded by hepatic parenchyma, although peliotic lesions are typically surrounded by hepatic parenchyma.2 Finally, the authors concluded that if radiological findings are not suggestive of cancer, percutaneous liver biopsy can be used to confirm the diagnosis of peliosis hepatis.1 However, Tsirigotis et al.5 claimed that if clinical and radiological findings were suggestive of peliosis, a percutaneous liver biopsy should be avoided because of a significant risk of severe bleeding. Hung et al.6 suggest that liver biopsy could be made by laparoscopy in most asymptomatic patients or by laparotomy in patients in an acute clinical setting.
281
282
B Battal
REFERENCES 1 Huang CY, Wang ZW. Peliosis hepatis mimicking hepatic malignancy: A case report. J Dig Dis 2013; 14: 272–5. 2 Battal B, Kocaoglu M, Atay AA, Bulakbasi N. Multifocal peliosis hepatis: MR and diffusion-weighted MR-imaging findings of an atypical case. Ups J Med Sci 2010; 115: 153–6. 3 Battal B, Kocaoglu M, Akgun V et al. Diffusion-weighted imaging in the characterization of focal liver lesions: efficacy of visual assessment. J Comput Assist Tomogr 2011; 35: 326–31.
Journal of Digestive Diseases 2014; 15; 281–282 4 Battal B, Akgün V, Kocaog˘lu M. Diffusion-weighted MRI beyond the central nervous system in children. Diagn Interv Radiol 2012; 18: 288–97. 5 Tsirigotis P, Sella T, Shapira MY et al. Peliosis hepatis following treatment with androgen-steroids in patients with bone marrow failure syndromes. Haematologica 2007; 92: e106–10. 6 Hung NR, Chantrain L, Dechambre S. Peliosis hepatis revealed by biliary colic in a patient with oral contraceptive use. Acta Chir Belg 2004; 104: 727–9.
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
