Published online Aug 28, 2015. doi: 10.3748/wjg.v21.i32.9675
Peer-review started: February 23, 2015
First decision: March 26, 2015
Revised: April 13, 2015
Accepted: June 9, 2015
Article in press: June 10, 2015
Published online: August 28, 2015
Processing time: 188 Days and 21.3 Hours
A 77-year-old Japanese woman was transported to a nearby hospital due to sudden abdominal pain and transient loss of consciousness. Abdominal computed tomography (CT) suggested hemoperitoneum and hepatic nodule. She was conservatively treated. Contrast-enhanced CT two months later revealed an increased mass size, and the enhancement pattern suggested the possibility of hepatocellular carcinoma (HCC). Under a clinical diagnosis of HCC, transcatheter arterial chemoembolization (TACE) was performed. A subsequent imaging study revealed that most of the lipiodol used for the embolization was washed out. Therefore, surgical resection was performed. Histologically, the nodule contained numerous inflammatory cells including small lymphocytes, plasma cells and macrophages. Notably, epithelioid granulomatous features with multinucleated giant cells were observed in both the nodule and background liver. Some of the multinucleated giant cells contained oil lipid. Among the infiltrating inflammatory cells, spindle-shaped, histiocytoid or myoid tumor cells with eosinophilic cytoplasm were found. The tumor cells were positive for Melan A and HMB45. The nodule contained many IgG4-positive plasma cells; these were counted and found to number 72.6 cells/HPF (range: 61-80). The calculated IgG4:IgG ratio was 33.2%. The nodule was finally diagnosed as previously ruptured inflammatory angiomyolipoma modified by granulomatous reaction after TACE.
Core tip: Hepatic angiomyolipoma (AML) is a rare benign neoplasm. Particularly, the inflammatory variant of hepatic AML is extremely rare. Spontaneous rupture of hepatic AML is also extremely rare phenomenon. The authors herein present a case of spontaneously ruptured hepatic inflammatory AML associated with extensive granulomatous reaction induced by chemoembolization. This case is not only rare, but also suggests that chemoembolization rarely causes granulomatous reaction in hepatic tissue.