Ultrasound Diagnosis of Hepatic Kaposi Sarcoma Mark J. Towers, MB, FRCR,* Cynthia E. Withers, MD, FRCP(C),• Anita R. Rachlis, MD, FRCP(C)t S. Chris Pappas, MD, FRCP(C),t Amost Kolin, MD, FRCP(C):j:

Hepatic and biliary abnormalities are common in the acquired immunodeficiency syndrome (AIDS). Most are secondary to opportunistic infections or drugs. Kaposi sarcoma (KS) is the most frequent hepatic neoplasm in AIDS, 1.2 but it is not often diagnosed in life. Two previous reports of the sonographic appearances of hepatic KS have been published.3• 4 Both describe echogenic periportal tumor. We report the case of a 28 year old homosexual man with AIDS who developed cholestasis owing to periportal tumor infiltration. This was hypoechoic on sonography, and biopsy confirmed KS infiltrating along the portal tracts. Demonstration of periportal hypoechoic lesions in AIDS should raise the possibility of Kaposi sarcoma. Non-Hodgkin lym• phoma and periportal edema secondary to cholangitis also are possible, and liver biopsy is recommended for confirmation.

CASE REPORT A 28 year old homosexual man was admitted for the inves· ligation of jaundice and a left upper lobe infiltrate of recent onset. He had been well until a year previously, when AIDS was diagnosed owing to an episode of Pncumocystis carinii pneumonia. Since then he had been treated for urinary

Received April 16, 1991, from the Departments of "Radiological Sciences, tMedicine, and irathology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario. Revised manuscript accepted for publication June 13, 1991. Address correspondence and reprint requests to Dr. Withers; Department of Radiological Sciences, Sunnybrook Health Science Centre, University of Toronto, 2075 Bayview Avenue, Toronto, On· tario M4N 3MS, Canada.

cytomegalovirus. (CMV) infection and oral candidiasis. Clin· ical examination revealed deep jaundice and hepatomegaly. Abdominal sonography showed a markedly inhomogenous liver with hypoechoic tissue extending along the portal tracts (Fig. IA and lB) . Multiple small nodes less than 1.5 cm in diameter were identified in the upper abdomen. The spleen was not enlarged. Because of the sonographic findings, a percutaneous bi· opsy of the right lobe of the liver was performed. Discrete groups of spindle cells were identified lining the portal tracts, confirming the diagnosis of Kaposi sarcoma (Fig. 1C). Transw bronchial biopsy of the nodular infiltration in the left upper lobe showed poorly defined groups of similar spindle cells in the bronchial walls. There was no evidence of lymphoma, CMV, Cryptosporidillm, P11c11111ocystis cari11ii, or Mycobacterium avi11m i11traccll11/arc. lmmunoperoxidase staining for factor Vlll was positive in the cytoplasm of many of these cells, consistent with the diagnosis of KS. Owing to the patient's clinical condition, treatment was not considered feasible. Liver function deteriorated rapidly, and widespread lung consolidation and atelectasis progressed. The patient died from respiratory failure 2 weeks after admission. An autopsy was not performed.

DISCUSSION Kaposi sarcoma is the most common hepatic tumor in AIDS patients at autopsy, 1• 2 but it is rarely diagnosed by percutaneous liver biopsy.5 Most likely this is due to the subcapsular and periportal distribution of the tumor, as these areas usually are not sampled by routine blind biopsy. Hepatic involvement is associated with KS of the skin, bowel, or lung; rarely is KS confined to the liver. 5 • 6 Imaging studies also rarely reveal hepatic involvement in life.'

© 1991 by the American Institute of Ultrasound in Medicine• J Ultrasound Med 10:701-703, 1991 • 0278-4297/ 91/ $3.50

HEPATIC KAPOSI SARCOMA

702

J Ultrasound Med 10:701- 703, 1991

A

c Figure 1 A, Sagittal sonogram of the right lobe of the liver shows hypoechoic tumor (arrows) surrounding the portal tracts. 8, Oblique sonogram of the right lobe of the liver confinns the periportal distribution (arrows) of the hypoech&

oic tumor. C, Photomicrograph of liver biopsy specimen shows spindle cells of Kaposi sarcoma occupying a portal tract (curved arrows). Normal hepatocytes appear on lower right. (Hematoxylin and eosin stain, x 320.)

J Ultrasound Med 10:701 - 703, 1991

Two reports of the sonographic appearances of hepatic KS have described echogenic periportal infiltration associated with an inhomogenous parenchyma containing focal nodules. 3 • 4 Autopsy in both cases showed dense collagenous sheaths around hepatic arteries and portal veins, as well as the spindle cells of KS. Histologic examination of tissues from our patient showed periportal spindle cells but no significant fibrous reaction, which most likely accounts for the hypoechoic appearance. Subcapsular and focal intrahepatic nodules were not identified, perhaps reflecting an earlier stage of the disease. The differential diagnosis of hypoechoic hepatic lesions in AIDS patients includes non-Hodgkin lymphoma, abscesses, and biliary tract edema secondary to CMV or cryptosporidial cholangitis. 8 No evidence of these was found on special stains of the biopsy material. Hepatic KS on CT appears as low-density nodules on contrast-enhanced scans, with marked enhancement on delayed scans. 4 Again, most cases of hepatic KS are not resolved by CT, probably because the extension of tumor along the portal tracts is microscopic. A CT scan was not performed in our patient. Because high resolution sonography is being performed with increasing frequency in AIDS patients, it is likely that the varied sonagraphic appearances will become more readily identified. To our knowledge hypoechoic periportal distribution of Kaposi sarcoma has not yet been described. KS should be included in the differential diagnosis of hypoechoic periportal le-

TOWERS ET AL

703

sions along with non-Hodgkin lymphoma and opportunistic cholangitis. As appropriate medical therapy depends on accurate diagnosis, sonographically guided percutaneous biopsy is recommended.

REFERENCES 1. Reichert CM, O'Leary TJ, Levens DL, et al: Autopsy pathology in the acquired immune deficiency syndrome. Am J Pathol 112:357, 1983

2. Niedt GW, Schinella R: Acquired immunodeficiency syndrome: Clinicopathological study of 56 autopsies. Arch Pathol Lab Med 109:727, 1985 3. Defalque D, Menu Y, Matheron S, et al: Sarcome de Kaposi hepatique et SIDA. J Radio] 69:617, 1988 4. Luburich P, Bru C, Ayuso MC, et al: Hepatic Kaposi sarcoma in AIDS: US and CT findings, Radiology 175:172, 1990 5. Schneidermann DJ, Arenson DM, Cello JP, et al: Hepatic disease in patients with the acquired immune deficiency syndrome. Hepatology 7:925, 1987 6. Glasgow BJ, Anders K, Layfield LJ, et al: Clinical and pathologic findings of the liver in the acquired immune deficiency syndrome. Am J Clin Pathol 83:582, 1985 7. Nyberg DA. Federle MP: AIDS-related Kaposi sarcoma and lymphomas: Semin Roentgenol 22:54, 1987 8. Dolmatch BL, Laing FC, Federle MP, et al: AIDSarelated cholangitis: Radiographic findings in nine patients. Ra· diology 163:313, 1987

Ultrasound diagnosis of hepatic Kaposi sarcoma.

Ultrasound Diagnosis of Hepatic Kaposi Sarcoma Mark J. Towers, MB, FRCR,* Cynthia E. Withers, MD, FRCP(C),• Anita R. Rachlis, MD, FRCP(C)t S. Chris Pa...
7MB Sizes 0 Downloads 0 Views