DOI: 10.1148/rg.233025073
Inflammatory Pseudotumor1
Lakshmana Das Narla, MD,
Beverley Newman, MD,
Stephanie S. Spottswood, MD,
Shireesha Narla, MD and
Rajasekhar Kolli, MD
1 From the Department of Radiology, Medical College of Virginia VCU Health System, Main Hospital 3rd Fl, 1250 E Marshall St, Richmond, VA 23298 (L.D.N., S.S.S.); Department of Radiology, Children’s Hospital of Pittsburgh, Pa (B.N.); Department of Primary Care Physicians, McGuire Veterans Hospital of Richmond, Va (S.N.); and Department of Surgery, Long Island Jewish Hospital, New Hyde Park, NY (R.K.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received April 1, 2002; revision requested May 13 and received December 10; accepted December 12. Address correspondence to L.D.N. (e-mail: ldnarla@hsc.vcu.edu).
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Figure 1a. Pulmonary pseudotumor in a 9-year-old boy with a 1-year history of fever and cough. (a) Frontal chest radiograph reveals a rounded area of soft-tissue opacity in the right upper lobe. No associated pleural effusion or bony abnormalities were noted. (b) Axial unenhanced CT scan demonstrates a well-circumscribed mass with focal calcification in the right upper lobe. No mediastinal lymphadenopathy was noted. Findings from surgical excision and histologic analysis confirmed the diagnosis of inflammatory pseudotumor.
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Figure 1b. Pulmonary pseudotumor in a 9-year-old boy with a 1-year history of fever and cough. (a) Frontal chest radiograph reveals a rounded area of soft-tissue opacity in the right upper lobe. No associated pleural effusion or bony abnormalities were noted. (b) Axial unenhanced CT scan demonstrates a well-circumscribed mass with focal calcification in the right upper lobe. No mediastinal lymphadenopathy was noted. Findings from surgical excision and histologic analysis confirmed the diagnosis of inflammatory pseudotumor.
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Figure 2a. Endobronchial inflammatory pseudotumor in a 7-year-old boy with a prolonged history of cough and fever. (a) Chest radiograph shows complete opacification of the left lung with ipsilateral cardiomediastinal shift, findings suggestive of atelectasis. (b) Axial contrast material-enhanced CT scan reveals a patent right main stem bronchus, an obstructed left main stem bronchus with left mediastinal shift, and atelectasis of the left lung. The left main stem bronchus lesion was resected and pathologically diagnosed as inflammatory pseudotumor. (c) Postoperative frontal chest radiograph shows reexpansion of the left lung.
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Figure 2b. Endobronchial inflammatory pseudotumor in a 7-year-old boy with a prolonged history of cough and fever. (a) Chest radiograph shows complete opacification of the left lung with ipsilateral cardiomediastinal shift, findings suggestive of atelectasis. (b) Axial contrast material-enhanced CT scan reveals a patent right main stem bronchus, an obstructed left main stem bronchus with left mediastinal shift, and atelectasis of the left lung. The left main stem bronchus lesion was resected and pathologically diagnosed as inflammatory pseudotumor. (c) Postoperative frontal chest radiograph shows reexpansion of the left lung.
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Figure 2c. Endobronchial inflammatory pseudotumor in a 7-year-old boy with a prolonged history of cough and fever. (a) Chest radiograph shows complete opacification of the left lung with ipsilateral cardiomediastinal shift, findings suggestive of atelectasis. (b) Axial contrast material-enhanced CT scan reveals a patent right main stem bronchus, an obstructed left main stem bronchus with left mediastinal shift, and atelectasis of the left lung. The left main stem bronchus lesion was resected and pathologically diagnosed as inflammatory pseudotumor. (c) Postoperative frontal chest radiograph shows reexpansion of the left lung.
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Figure 3a. Pulmonary pseudotumor in a 10-year-old girl who developed left-sided anterior chest pain after minor trauma. (a) Initial chest radiograph shows a 3-cm rounded opaque area in the left mid lung with a small pleural effusion. The patient was treated with antibiotics. Ten months later, she developed pleuritic chest pain, night sweats, and decreased exercise tolerance. (b) Repeat chest radiograph shows marked increase in the size of the mass and volume loss of the left lung. (c) Contrast-enhanced CT scan of the chest reveals a mildly enhancing, large left-sided mass surrounding the left bronchus and extending into the left chest wall. Analysis of the specimen obtained at CT-guided fine-needle aspiration confirmed a diagnosis of inflammatory pseudotumor. (d) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) shows inflammatory cells and myofibroblasts. Because the mass was deemed unresectable, the patient was given prednisone (20 mg three times a day). The patient’s symptoms improved, and the dose of steroids was reduced to 5 mg every other night over the next 18 months and finally stopped. (e) Repeat chest CT scan, obtained with intravenous contrast material, shows resolution of the mass with some residual scarring.
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Figure 3b. Pulmonary pseudotumor in a 10-year-old girl who developed left-sided anterior chest pain after minor trauma. (a) Initial chest radiograph shows a 3-cm rounded opaque area in the left mid lung with a small pleural effusion. The patient was treated with antibiotics. Ten months later, she developed pleuritic chest pain, night sweats, and decreased exercise tolerance. (b) Repeat chest radiograph shows marked increase in the size of the mass and volume loss of the left lung. (c) Contrast-enhanced CT scan of the chest reveals a mildly enhancing, large left-sided mass surrounding the left bronchus and extending into the left chest wall. Analysis of the specimen obtained at CT-guided fine-needle aspiration confirmed a diagnosis of inflammatory pseudotumor. (d) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) shows inflammatory cells and myofibroblasts. Because the mass was deemed unresectable, the patient was given prednisone (20 mg three times a day). The patient’s symptoms improved, and the dose of steroids was reduced to 5 mg every other night over the next 18 months and finally stopped. (e) Repeat chest CT scan, obtained with intravenous contrast material, shows resolution of the mass with some residual scarring.
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Figure 3c. Pulmonary pseudotumor in a 10-year-old girl who developed left-sided anterior chest pain after minor trauma. (a) Initial chest radiograph shows a 3-cm rounded opaque area in the left mid lung with a small pleural effusion. The patient was treated with antibiotics. Ten months later, she developed pleuritic chest pain, night sweats, and decreased exercise tolerance. (b) Repeat chest radiograph shows marked increase in the size of the mass and volume loss of the left lung. (c) Contrast-enhanced CT scan of the chest reveals a mildly enhancing, large left-sided mass surrounding the left bronchus and extending into the left chest wall. Analysis of the specimen obtained at CT-guided fine-needle aspiration confirmed a diagnosis of inflammatory pseudotumor. (d) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) shows inflammatory cells and myofibroblasts. Because the mass was deemed unresectable, the patient was given prednisone (20 mg three times a day). The patient’s symptoms improved, and the dose of steroids was reduced to 5 mg every other night over the next 18 months and finally stopped. (e) Repeat chest CT scan, obtained with intravenous contrast material, shows resolution of the mass with some residual scarring.
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Figure 3d. Pulmonary pseudotumor in a 10-year-old girl who developed left-sided anterior chest pain after minor trauma. (a) Initial chest radiograph shows a 3-cm rounded opaque area in the left mid lung with a small pleural effusion. The patient was treated with antibiotics. Ten months later, she developed pleuritic chest pain, night sweats, and decreased exercise tolerance. (b) Repeat chest radiograph shows marked increase in the size of the mass and volume loss of the left lung. (c) Contrast-enhanced CT scan of the chest reveals a mildly enhancing, large left-sided mass surrounding the left bronchus and extending into the left chest wall. Analysis of the specimen obtained at CT-guided fine-needle aspiration confirmed a diagnosis of inflammatory pseudotumor. (d) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) shows inflammatory cells and myofibroblasts. Because the mass was deemed unresectable, the patient was given prednisone (20 mg three times a day). The patient’s symptoms improved, and the dose of steroids was reduced to 5 mg every other night over the next 18 months and finally stopped. (e) Repeat chest CT scan, obtained with intravenous contrast material, shows resolution of the mass with some residual scarring.
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Figure 3e. Pulmonary pseudotumor in a 10-year-old girl who developed left-sided anterior chest pain after minor trauma. (a) Initial chest radiograph shows a 3-cm rounded opaque area in the left mid lung with a small pleural effusion. The patient was treated with antibiotics. Ten months later, she developed pleuritic chest pain, night sweats, and decreased exercise tolerance. (b) Repeat chest radiograph shows marked increase in the size of the mass and volume loss of the left lung. (c) Contrast-enhanced CT scan of the chest reveals a mildly enhancing, large left-sided mass surrounding the left bronchus and extending into the left chest wall. Analysis of the specimen obtained at CT-guided fine-needle aspiration confirmed a diagnosis of inflammatory pseudotumor. (d) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) shows inflammatory cells and myofibroblasts. Because the mass was deemed unresectable, the patient was given prednisone (20 mg three times a day). The patient’s symptoms improved, and the dose of steroids was reduced to 5 mg every other night over the next 18 months and finally stopped. (e) Repeat chest CT scan, obtained with intravenous contrast material, shows resolution of the mass with some residual scarring.
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Figure 4a. Cardiac inflammatory pseudotumor in a 7-month-old girl with no significant medical history who presented with pallor, tachypnea, and decreased oral intake. Blood gas analysis on room air revealed a PO2 of 80. Initial echocardiogram indicated the presence of a right atrial mass. (a) Axial T1-weighted MR image shows a relatively homogenous mass (M) occupying most of the right atrium and contiguous with its inferolateral wall (arrows). The mass is slightly greater in signal intensity relative to that of muscle. (b) Axial T2-weighted image demonstrates increased signal intensity of the mass (M) relative to that of muscle. Coronal images (not shown) showed a clear plane of separation between the mass and the interatrial septum. (c) Axial T1-weighted image obtained after gadolinium injection shows heterogeneous enhancement of the mass (M) and the interatrial septum (arrows). When the mass was surgically resected, a 3 x 3-cm defect was created in the inferior wall of the right atrium and was repaired with a patch of bovine pericardium. Histopathologic examination of the resected mass showed cellular spindle cell proliferation with scattered foci of inflammatory cells. No cytologic atypia was found, and the diagnosis was inflammatory pseudotumor of the right atrium. The patient is currently doing well, and follow-up echocardiograms show no evidence of recurrence. (Fig 4a-4c reprinted, with permission, from reference 20.)
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Figure 4b. Cardiac inflammatory pseudotumor in a 7-month-old girl with no significant medical history who presented with pallor, tachypnea, and decreased oral intake. Blood gas analysis on room air revealed a PO2 of 80. Initial echocardiogram indicated the presence of a right atrial mass. (a) Axial T1-weighted MR image shows a relatively homogenous mass (M) occupying most of the right atrium and contiguous with its inferolateral wall (arrows). The mass is slightly greater in signal intensity relative to that of muscle. (b) Axial T2-weighted image demonstrates increased signal intensity of the mass (M) relative to that of muscle. Coronal images (not shown) showed a clear plane of separation between the mass and the interatrial septum. (c) Axial T1-weighted image obtained after gadolinium injection shows heterogeneous enhancement of the mass (M) and the interatrial septum (arrows). When the mass was surgically resected, a 3 x 3-cm defect was created in the inferior wall of the right atrium and was repaired with a patch of bovine pericardium. Histopathologic examination of the resected mass showed cellular spindle cell proliferation with scattered foci of inflammatory cells. No cytologic atypia was found, and the diagnosis was inflammatory pseudotumor of the right atrium. The patient is currently doing well, and follow-up echocardiograms show no evidence of recurrence. (Fig 4a-4c reprinted, with permission, from reference 20.)
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Figure 4c. Cardiac inflammatory pseudotumor in a 7-month-old girl with no significant medical history who presented with pallor, tachypnea, and decreased oral intake. Blood gas analysis on room air revealed a PO2 of 80. Initial echocardiogram indicated the presence of a right atrial mass. (a) Axial T1-weighted MR image shows a relatively homogenous mass (M) occupying most of the right atrium and contiguous with its inferolateral wall (arrows). The mass is slightly greater in signal intensity relative to that of muscle. (b) Axial T2-weighted image demonstrates increased signal intensity of the mass (M) relative to that of muscle. Coronal images (not shown) showed a clear plane of separation between the mass and the interatrial septum. (c) Axial T1-weighted image obtained after gadolinium injection shows heterogeneous enhancement of the mass (M) and the interatrial septum (arrows). When the mass was surgically resected, a 3 x 3-cm defect was created in the inferior wall of the right atrium and was repaired with a patch of bovine pericardium. Histopathologic examination of the resected mass showed cellular spindle cell proliferation with scattered foci of inflammatory cells. No cytologic atypia was found, and the diagnosis was inflammatory pseudotumor of the right atrium. The patient is currently doing well, and follow-up echocardiograms show no evidence of recurrence. (Fig 4a-4c reprinted, with permission, from reference 20.)
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Figure 5a. Inflammatory pseudotumor of the adrenal gland in an 8-year-old girl with a history of nonspecific fever, weight loss, and elevated platelet count. Unenhanced abdominal CT scan (not shown) revealed a right adrenal mass with no calcifications. (a) Contrast-enhanced CT scan shows an unusual pattern of early, dense, peripheral enhancement. (b) On a delayed CT image, the center of the lesion has filled in with contrast material. Findings from surgical excision and histologic analysis confirmed the diagnosis of inflammatory pseudotumor.
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Figure 5b. Inflammatory pseudotumor of the adrenal gland in an 8-year-old girl with a history of nonspecific fever, weight loss, and elevated platelet count. Unenhanced abdominal CT scan (not shown) revealed a right adrenal mass with no calcifications. (a) Contrast-enhanced CT scan shows an unusual pattern of early, dense, peripheral enhancement. (b) On a delayed CT image, the center of the lesion has filled in with contrast material. Findings from surgical excision and histologic analysis confirmed the diagnosis of inflammatory pseudotumor.
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Figure 6a. Inflammatory pseudotumor of the iliopsoas muscle mimicking rhabdomyosarcoma in a 20-month-old girl with a 4-week history of limping with her right leg. The patient was afebrile at presentation, and radiographs of her pelvis were normal. Sonograms (not shown) revealed a hypoechoic mass in the right pelvis that appeared to be arising from or was contiguous with the right iliopsoas muscle. (a) Axial contrast-enhanced CT scan shows a 2.5 x 3.5-cm mildly enhancing mass, contiguous with the right iliopsoas muscle (arrows), with no evidence of lymphadenopathy or bone destruction. Analysis of a fine-needle aspirate from the mass suggested a sarcoma. At surgery, the mass was found to be adherent to the pelvic vessels and was unresectable. Wedge biopsies were performed, and findings from histologic examination confirmed the diagnosis of inflammatory pseudotumor. The patient was managed conservatively, and her limp resolved spontaneously. (b) Axial contrast-enhanced CT scan obtained 6 weeks later shows resolution of the mass. (Fig 6a and 6b reprinted, with permission, from reference 30.)
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Figure 6b. Inflammatory pseudotumor of the iliopsoas muscle mimicking rhabdomyosarcoma in a 20-month-old girl with a 4-week history of limping with her right leg. The patient was afebrile at presentation, and radiographs of her pelvis were normal. Sonograms (not shown) revealed a hypoechoic mass in the right pelvis that appeared to be arising from or was contiguous with the right iliopsoas muscle. (a) Axial contrast-enhanced CT scan shows a 2.5 x 3.5-cm mildly enhancing mass, contiguous with the right iliopsoas muscle (arrows), with no evidence of lymphadenopathy or bone destruction. Analysis of a fine-needle aspirate from the mass suggested a sarcoma. At surgery, the mass was found to be adherent to the pelvic vessels and was unresectable. Wedge biopsies were performed, and findings from histologic examination confirmed the diagnosis of inflammatory pseudotumor. The patient was managed conservatively, and her limp resolved spontaneously. (b) Axial contrast-enhanced CT scan obtained 6 weeks later shows resolution of the mass. (Fig 6a and 6b reprinted, with permission, from reference 30.)
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Figure 7. Orbital pseudotumor in a 48-year-old woman with a painful, proptotic left eye. Axial CT scan of the orbit shows an enlarged left medial rectus muscle. The patient was treated with high doses of corticosteroids, and the symptoms resolved.
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Figure 8. Orbital pseudotumor in a 57-year-old woman with decreased vision in her left eye. Axial contrast-enhanced CT scan of the orbit demonstrates a left orbital mass involving the optic canal, cavernous sinus, and left posterior optic nerve.
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Copyright © 2003 by the Radiological Society of North America.
