British Journal of Radiology (2005) 78, 752-754
© 2005 British Institute of Radiology
doi: 10.1259/bjr/65834078
Foreign body granuloma mimicking liver metastasis
A Poyanli1,
O Bilge2,
Y Kapran3 and
K Güven1
Departments of 1 Radiology, 2 Surgery and 3 Pathology, Istanbul Medical Faculty, Çapa 34390, Istanbul, Turkey
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Abstract
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In this study, foreign body granuloma mimicking liver metastasis diagnosed on routine follow-up examination in a 41-year-old woman with rectal adenocarcinoma is reported. To our knowledge, this is the first study in English-language literature reporting foreign body granuloma indistinguishable from liver metastasis on radiological examination.
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Introduction
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Various foreign bodies introduced into the human organism during surgery or trauma as well as exposure to some chemical substances may cause a granulomatous reaction [1]. Although rare, foreign body granulomas may cause diagnostic controversy when they present with neoplasia-like imaging findings. A foreign body granuloma mimicking liver metastasis is reported in this study.
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Case report
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A 41-year-old female patient diagnosed with carcinoma of the rectum had resection and end-to-end anastomosis of the rectum in August 2000. Histopathological examination revealed adenocarcinoma with adventitial invasion, but surgical borders in the specimen were free of disease. The patient received six sessions of chemotherapy and 23 sessions of radiotherapy, after which routine control studies in October 2001 showed a carbohydrate antigen (CA) 19-9 level of 540 U ml–1 (normal range 0–34 U ml–1). An investigation for systemic metastases was planned. Positron emission tomography (PET) revealed two adjacent metastases in Coiunaud's segment three of the liver and this segment was surgically resected.
MRI of the abdomen, performed in June 2002, showed a well circumscribed 2 cm mass in the anterior portion of Coiunaud's segment two with hypointense signal on T1 and significant and homogeneous hyperintense signal on T2 weighted series (Figures 1 and 2
). Gd-DTPA enhanced studies revealed peripheral enhancement of the tumour (Figure 3). An ultrasound (US) guided core biopsy of the mass was planned since tumour markers and blood chemistry work up was unremarkable. No evidence of malignancy was detected in the biopsy specimen which appeared well circumscribed and homogeneously hypoechoic on US. Since a negative biopsy was not enough to exclude the malignancy, surgery was planned.
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Figure 1. Well circumscribed hypointense mass is shown in the anterior portion of Couinaud's segment two on T1 weighted MRI series.
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During surgery a 2 cm hard nodule was observed in Coiunaud's segment two close to the previous resection site, and the mass was transparenchymally resected. Histopathological investigation showed a granulomatous reaction with multinucleated giant cells and no evidence of malignancy (Figure 4). A black-coloured pigment of unknown origin was thought to cause the granulomatous reaction. No glove powder, sponge or suture material was detected on the cut surface or microscopic examination.
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Figure 4. Black-coloured foreign bodies and the granulomatous reaction with multinucleated giant cells (haematoxylin and eosin x 125).
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The post-operative clinical course was uneventful. The patient is still under periodic follow up and no recurrence has been detected up to date.
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Discussion
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The causative agent in foreign body granulomas may be suture material, sponge used during surgery or pieces of wood or glass introduced during trauma. Foreign body reactions causing functional problems in target organs such as the liver and kidneys may also be encountered in patients with occupational or environmental exposure to chemical substances and drug users [1]. In our patient, no other external cause than surgery for the reaction was present.
One of the most frequently encountered foreign bodies following abdominal surgery is a surgical sponge, and radiological findings of sponge-granulomas have been well described [2]. These granulomas present as well-defined hypoechoic masses containing highly echogenic foci on US and these unusual US findings are crucial for differential diagnosis. The lesion in our patient presented as a hypoechoic mass with no internal echogenic foci. Likewise, histopathological examination did not show a causal relationship between the foreign body granuloma and surgical sponge.
The usual CT appearance of retained surgical implements is a well circumscribed hypodense lesion with a 3–10 mm thick enhancing wall and internal air bubbles [3]. Bellin et al reported increase in the size and amount of calcifications in a perirenal foreign body granuloma which they followed over a period of 4 years [4]. CT findings of the mass in this case are not available since follow up has been done by MR.
MR findings in foreign body granulomas are usually non-specific. However, hypointense bands inside the cystic cavity on T2 weighted images created by folds of fabric have been reported as "possibly characteristic" for foreign body granuloma [5].
Foreign body granulomas mimicking malignancy on clinical and imaging studies in organs other than the liver have been reported [6–9]. Ferrozzi et al have reported a renal foreign body granuloma which contained fat and calcifications and was indistinguishable from renal cell carcinoma [6]. Kothbauer et al have detected circumscribed masses with streaky enhancement in the resection site 2–7 months after the surgery in three patients operated for primitive neuroectodermal tumour [7]. Foreign body granulomas have been diagnosed during surgery performed with presumptive diagnosis of recurrent tumours. In these cases, disease progression under agressive treatment or in the early post-operative period has been emphasised as a possible feature of foreign body granuloma. However, patients who have been operated on for benign diseases are not routinely followed up, rendering this hypothesis invaluable for differential diagnosis. Kalbermatten et al have reported a foreign body granuloma which presented with soft tissue swelling 20 years after steel plate stabilization for fracture of the femur. In this case, X-ray films and MR images have shown an expansile, osteolytic mass lesion [8].
The only other foreign body granuloma in the literature with peripheral enhancement and history of surgical intervention has been reported by Epstein et al in the brain [9]. This is the first report in English-language literature, to our knowledge, which presents a foreign body granuloma in the liver with peripheral enhancement and is indistinguishable from metastasis in US and MRI studies.
In large retrospective studies, seeding of tumour cells during biopsy, although rare, still presents a substantial risk [10]. Therefore, in our institution, biopsy is avoided in surgical candidates in whom the result does not appear to alter treatment. In our patient, previous investigation following detection of high levels of CA 19-9 in routine control studies have revealed liver metastasis. However, normal levels of tumour markers and biochemical work up have led us to biopsy instead of surgery, although the lesion detected on abdominal MRI the second time strongly suggested malignancy.
In conclusion, foreign body granuloma of the liver, although it is very rare, may cause diagnostic challenges, especially in patients with a history of malignancy because of similar imaging findings with metastasis. Surgery may still be indicated in these cases, since normal levels of tumour markers as well as absence of malignant cells in the biopsy specimen are not sufficient to exclude metastasis.
Received for publication November 5, 2004.
Revision received February 2, 2005.
Accepted for publication February 24, 2005.
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References
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Abstract
Introduction
