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Hepatic peliosis
- 1. Dr. Manmohan Bir Shrestha MAC FOR RADIOLOGY
- 2. Peliosis Rare benign condition Peliosis – “Greek word” – means “dusky” or “purple”, referring to the liver parenchyma with peliosis In WHO histological classification of liver tumor, hepatic peliosis is defined as tumor-like lesion It is characterized by multiple cyst-like blood filled spaces within the liver parenchyma. Appears hypodense in CT, and may mimic metastases, hepatocellular carcinoma and hemangioma.
- 3. History Before 1970, peliosis was mainly diagnosed by autopsy Later, it was seen in patients with tuberculosis, disseminated malignancies, hematological disorders and some drug intake.
- 4. Sites Liver Spleen Lymph nodes Bone marrow Lungs Pleura Kidneys Adrenal glands Stomach Ileum
- 5. Clinical presentation Usually asymptomatic Abdominal discomfort with hepatomegaly Portal hypertension Liver failure Spontaneous rupture and may present with intrahepatic/intrasplenic/intraperitoneal hemorrhage
- 6. Etiology Idiopathic = 20-50% Drugs Anabolic steroids, corticosteroids, oral contraceptives, methotrexate, 6- mercaptopurine, tamoxifen Toxins Arsenic, polyvinyl chloride Chronic illness Tuberculosis, malignancies (particularly hepatocellular carcinoma), leprosy, Hodgkin’s disease, multiple myeloma Infection in AIDS Bacillary peliosis caused by Bartonella henselae, Bartonella quintata and Rochalimaea henselae Post renal or cardiac transplantation
- 7. Diagnosis Histopathology – Gold standard Imaging – Ultrasound Triphasic CT Scan MRI
- 8. Pathology Grossly, the peliotic lesions appears as multiple, irregularly shaped blood-filled hepatic cavities At microscopy, these are dilated sinusoids filled with RBCs and bound by cords of liver cells Lesions can involve focal part of liver or can be disseminated Pathogenesis remains uncertain With possible etiologies including Breakdown of the sinusoidal borders Hepatic outflow obstruction Dilatation of the central vein of the hepatic lobule
- 9. Ultrasound Can be hypoechoic/hyperechoic lesions Can be mixed echogenic when complicated by hemorrhage Size varies from few mm to few cm
- 10. Triphasic CT Scan Unenhanced CT Usually hypodense Can be hyperdense in the presence of hemorrhage Arterial phase Typically shows early globular enhancement & multiple accumulations of contrast in the center of the lesions Portal venous phase Centrifugal progression of enhancement is usually observed A centripetal progression can also be seen Venous phase late diffuse homogeneous hyperattenuation can also be seen in some cases of hepatic peliosis (because of the lack of hemorrhagic parenchymal necrosis)
- 11. MRI Signal depends on the age and status of blood component T1WI – typically hypointense (unless hemorrhage) T2WI – usually hyperintense to liver parenchyma Post-contrast – enhancement is usually centrifugal ( from centre to outward), but can be centripetal
- 12. 40 year old woman who is pancytopaenic on azathioprine for severe crohn disease T1
- 13. T2
- 14. Post contrast Biopsy confirmed peliosis
- 15. Case of 77-year-old man with prostate carcinoma Fig. 1 Abdominal ultrasonography shows two hepatic tumors in March 2012. a A high echoic tumor (50×36mm) with an unclear margin was observed in segment 7 ( white arrows ). b A low echoic tumor (30×18mm) with a clear margin was observed in segment 6 ( white arrowheads
- 16. In triphasic CT scan Fig. 2 Abdominal computed tomography imaging ( a – d : segment 7, e – h : segment 6). a (white arrows), e white arrowheads) Plain phases.( b, f Arterial phases. c, g Portal phases. d, h Delayed phases. a, e Both tumors are isodense before contrast injections, ( b, f ) and show hypoenhancement in the arterial phase. c, g In the portal venous phase, the tumor in segment 7 shows heterogeneous enhancement, and the tumor in segment 6 shows central enhancement. d, h In the delayed phase, the tumor in segment 7 shows more heterogeneous enhancement, and the tumor in segment 6 shows more central enhancement
- 17. Biopsy report Histological results showed marked sinusoidal dilatation throughout the lobule with cystic cavity formation. The endothelial cells lining these spaces were flat, and no cellular atypia was identified. Liver cell plates were rather atrophic. There was no evidence of malignancy. Hence, confirmed as hepatic peliosis
- 18. Differentials for hepatic peliosis Hypervascular metastases Usually hypodense Enhance less than surrounding normal parenchyma Enhancement is typically peripheral, and although there may be central filling in, on portal venous phase, the delayed phase will show washout Hepatocellular carcinoma Usually bright arterial enhancement with early washout Hemangioma Globular discontinuous peripheral enhancement tends to be centripetal (periphery first) rather than centrifugal(centre first)
- 19. Case of 26-year-old man 3 years back Surgical removal of large left retroperitoneal mass, histology = paraganglioma Splenectomy For 3 echogenic lesions in USG, which were heterogeneously enhancing in CECT Histology = benign vascular lesions with atypia with endothelial lined blood vessels
- 20. Now Patient presented with abdominal fullness & discomfort of last 1 month. Remained asymptomatic for last 3 years after operation
- 21. USG Figure 1 – Sonographic study shows multiple hypoechoic lesions of variable sizes disseminated throughout hepatic parenchyma.
- 22. NECT Figure 2 – Axial unenhanced CT images of upper abdomen. Numerous hypodense lesions of variable sizes noted in the liver parenchyma. Enlargement of left lobe of liver is noted, occupying splenic region.
- 23. Arterial phase Figure 3 – Axial and coronal CT images in arterial phase of contrast enhancement. Some lesions showing strong rim enhancement and some small-sized lesions showing strong homogeneous enhancement patterns.
- 24. Portal venous phase Figure 4 - Axial and coronal CT images in portal venous phase of contrast enhancement. Lesions showed incomplete washout of contrast.
- 25. Venous phase Figure 5 – Axial CT image in venous phase of contrast enhancement. Most of the lesions showed complete washout of contrast and some lesions showed incomplete washout of contrast.
- 26. Hematological & biochemical parameters Parameters Values Hemoglobin 11.50 g/dl White blood cell count 8200/ml Platelets 209000/ml ESR 15 mm in 1st hour Serum bilirubin (total) 0.8 mg/dl SGPT/ALT (Alanine transaminase) 31 U/L SGOT/AST (Aspartate aminotransferase) 28 U/L Alkaline phosphatase 120 U/L Alpha fetoprotein 4.2 ng/ml FNAC from hepatic lesion revealed - cords and trabecula of regular hepatocytes and blood. No malignant cell was seen in the smears examined.
- 27. REFERENCES: P. Engel, E. Tjalve & T. Horn (1993) Peliosis of the Spleen Associated with a Paraganglioma, Acta Radiologica, 34:2, 148-149 DIEBOLD J. & AUDOUIN J.: Peliosis of the spleen. Am. J. Surg. Pathol. 7 (1983), 197 Hepatic peliosis/Radiology Reference Article/Radiopaedia.org Iannaccone R, Federle MP, Brancatelli G, Matsui O, Fishman EK, Narra VR, et al. Peliosis hepatis: spectrum of imaging findings. AJR Am J Roentgenol. 2006;187:W43–52. Hidaka H, Ohbu M, Nakazawa T, et al. Peliosis hepatis disseminated rapidly throughout the liver in a patient with prostate cancer: a case report. J Med Case Rep 2015;9:194. Yi-Ning Dai, MD,a Ze-Ze Ren, MD,b Wen-Yuan Song, MD,a Hai-Jun Huang, MD PhD,a , et al. Peliosis hepatis: 2 case reports of a rare liver disorder and its differential diagnosis.
- 28. THANK YOU