İnflamatuvar psödotümör

Özet

Karaciğer inflamatuvar psödotümörü, inflamatuvar hücreler ve fibrotik stroma içeren, görüntülemede malign kitleyi taklit edebilen tümör benzeri bir lezyondur. BT görünümü hastalığın inflamatuvar ve fibrotik bileşimine göre değişir; hipodens, sınırları belirsiz bir kitle ve bazı olgularda gecikmiş fazda periferik ya da septal kontrastlanma görülebilir. Safra yolu enfeksiyonu, inflamasyon veya önceki biliyer girişim öyküsü doğru bağlamı sağlar; yalnız görüntüyle kesin tanı her zaman mümkün değildir. Malignite sanılması gereksiz ileri işlem riskine, apse veya eşlik eden biliyer hastalığın atlanması ise gecikmiş değerlendirmeye neden olabilir.

Faz ve pencere

Kontrastsız

Lezyon çoğunlukla karaciğere göre hipodens ve sınırları belirsiz ya da kısmen belirgin bir kitle olarak görülür; santral düşük atenüasyon fibrozis, nekroz veya inflamatuvar içerikle ilişkili olabilir. Kontrast verilmeden lezyonun vasküler bileşeni karakterize edilemez.

Arteriyel tanısal

Değişken periferik, yamalı veya septal kontrastlanma görülebilir; bazı olgularda belirgin arteriyel kontrastlanma olmaz. İnflamasyon ve fibrozis oranı lezyonun erken faz davranışını değiştirir.

Portal tanısal

Lezyon çevre parankime göre hipodens kalabilir veya heterojen kontrastlanabilir; santral düşük atenüasyonlu alanlar devam edebilir. Portal ven dalları ve komşu safra yollarında eşlik eden değişiklikler araştırılır.

Gecikmiş tanısal

Fibrotik perifer ve iç septalarda kontrast birikimi belirginleşebilir; geç fazda lezyon kenarı veya septalar erken faza göre daha yoğun görünürken santral bölüm düşük atenüanslı kalabilir.

Önerilen pencereler: Karaciğer (G 150 / M 30), Batın (G 400 / M 50).

BT bulguları

• Belirsiz sınırlı hipodens kitle — çevre parankime geçişi net olmayan fokal lezyon.
• Periferik kontrastlanma — arteriyel veya gecikmiş fazda değişken kalınlıkta kenar kontrastlanması.
• Gecikmiş fibrotik kontrastlanma — kitle çevresinde ya da iç septalarda geç fazda artan kontrast tutulumu.
• Santral düşük atenüasyon — merkezde kontrastlanmayan alan bulunabilir; fibrotik perifer ve iç septalar gecikmiş fazda kontrastlanabilir.
• Heterojen iç yapı — inflamasyon, fibrozis ve nekroz bileşenleri aynı odakta farklı yoğunluklar oluşturabilir.
• Komşu safra yolu değişikliği — biliyer inflamasyon veya tıkanmaya eşlik eden segmental kanal genişlemesi görülebilir.
• Çevresel inflamatuvar değişiklik — komşu parankimde ödem veya inflamasyonla uyumlu görünüm eşlik edebilir.

Normalde

Kontrastlı BT'de inflamatuvar psödotümörün görünümü değişken olabilir; lezyon karaciğerden düşük dansiteli olup halka, periferik veya septal kontrastlanma gösterebilir ve intrahepatik kolanjiyokarsinom, metastaz ya da apseyi taklit edebilir. Lezyonun periferik kontrastlanmasını aynı düzeydeki sağlam parankimle ve arteriyel-portal-gecikmiş fazlar arasında kıyaslayın; santral düşük atenüasyonun sabit kalıp kalmadığını izleyin.

Ayırıcı tanı

İntrahepatik kolanjiyokarsinom

periferik kitle, gecikmiş fibrotik kontrastlanma ve kapsül çekintisi yapabilir; safra yolu genişlemesi ve vasküler/segmental yayılım eşlik edebilir.

Karaciğer apsesi

inflamatuvar psödotümörü taklit edebilen ayırıcı tanılardandır; apsede nekrotik merkez kontrastlanmayabilir ve “üzüm salkımı” görünümü tarif edilmiştir.

Hepatoselüler karsinom

riskli karaciğerde arteriyel hiperkontrastlanma ve portal/geç faz washout yapabilir; fibrotik geç kontrastlanma tipik değildir.

Karaciğer metastazı

bilinen primer malignite ve çoklu odaklar aranır; bazı metastazlar periferik halka ve santral nekroz gösterebilir.

Hepatik lenfoma

primer hepatik lenfoma, karaciğer ve perihepatik lenf nodlarıyla sınırlı tutulum olarak tanımlanır ve kitle oluşturan intrahepatik kolanjiyokarsinomu taklit edebilir.

Tuzaklar

• Gecikmiş periferik kontrastlanmayı tek başına kolanjiyokarsinom kabul etmeyin; inflamatuvar psödotümörde fibrotik stroma benzer geç kontrastlanma oluşturabilir.
• Santral düşük atenüans her zaman apse değildir; gaz, belirgin çevresel inflamasyon ve klinik enfeksiyon bulgularını aynı incelemede arayın.
• Tek bir faza bakarak benignlik veya malignlik kararı vermeyin; psödotümörün kontrastlanması inflamasyon ve fibrozis oranına göre değişebilir.
• Kitle görünümü altında safra yolu tıkanıklığı ya da komşu enfeksiyon odağı bulunabileceğinden segmental kanalları lezyon kenarından hilusa kadar izleyin.

Kendini dene

1. Belirsiz sınırlı hipodens karaciğer kitlesinde periferik bant ve iç septalar gecikmiş fazda belirginleşiyor. Hangi tümör benzeri lezyon olasılığı artar?

   • İnflamatuvar psödotümör
   • Kavernöz hemanjiyom
   • Basit kist
   • Fokal nodüler hiperplazi
   Cevabı göster

   İnflamatuvar psödotümör. Fibrotik inflamatuvar psödotümör geç fazda periferik veya septal kontrastlanabilir. Karaciğer inflamatuvar psödotümöründe fibrozis derecesine bağlı farklı kontrastlanma paternleri görülebilir; verilen kaynaklar diğer seçeneklerin kontrastlanma özelliklerini doğrulamıyor.

2. Santral düşük atenüasyonlu kitleye halka kontrastlanması eşlik ediyor. Apseyi destekleyen ek BT bulgusu hangisidir?

   • Lezyon içinde gaz
   • Portal ven dalı sonlanması
   • Makroskopik yağ
   • Santral yıldızsal skar
   Cevabı göster

   Lezyon içinde gaz. Santral gaz ve çevresel inflamasyon enfeksiyöz apseyi destekleyebilir. Makroskopik yağ anjiyomiyolipomda görülebilir; kaynaklarda gaz içeren karaciğer apsesi tanımlanmıştır, ancak damar sonlanması ve santral yıldızsal skarın karşılıkları belirtilmemiştir.

Kaynaklar

Bu sayfadaki 42 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 5 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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