Hepatic peliosis - a rare benign tumor-like lesion

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