Segmentectomy for reactive lymphoid hyperplasia of the liver: Report of a case

Clinical features, natural history and outcomes of pseudolymphoma of liver: A case-series and systematic review

BACKGROUND

Pseudolymphoma is a rare, benign, nonspecific condition that forms a mass-like lesion characterized by the proliferation of non-neoplastic lymphocytes. Lacking of specific clinical symptoms, serological markers, and imaging features, the diagnosis is difficult. We reporte five cases of hepatic pseudolymphoma and provide a systematic review of existing literatures to improve our understanding of this rare liver disease.

METHODS

We followed-up five cases of hepatic pseudolymphoma in West China Hospital from January 2002 to January 2022. We also summarized the cases of hepatic pseudolymphoma from January 1981 to December 2021 through the PubMed database and comprehensively analyzed the characteristics of the cases.

RESULTS

The pathologic features of the five cases were characterized by benign lymphoid tissue hyperplasia, lymphoid follicle formation, and a polarized germinal center. Immunohistochemistry, in situ hybridization, and gene rearrangement revealed non-malignant lymphoma. Besides, a total of 116 cases have been reported in the PubMed database from 1981 to 2021. The incidence of hepatic pseudolymphoma is higher in middle-aged and elderly women and has been reported more frequently in Asia. All cases were pathologically diagnosed, among which 85.95% of the patients were treated by surgery.

CONCLUSIONS

Hepatic pseudolymphoma is an extremely rare benign disease, mainly in middle-aged and elderly women. Without distinctive clinical and imaging characteristics, pathological diagnosis is the highly reliable method at present. Thus, in the absence of risk factors for a primary liver tumor or metastatic tumor in middle-aged and elderly women, the possibility of pseudolymphoma should be considered to avoid extensive treatments.

Diffusion-weighted imaging might be useful for reactive lymphoid hyperplasia diagnosis of the liver: A case report

BACKGROUND

Reactive lymphoid hyperplasia (RLH) of the liver is a rare liver lesion. It is considered difficult to differentiate radiologically from hepatocellular carcinoma, metastatic liver tumor and other pathologies.

CASE SUMMARY

A 54-year-old woman presented to our hospital with RLH of the liver. The patient had a diagnosis of metastatic carcinoma of the liver from an unknown origin and subsequently underwent partial hepatectomy. However, histopathological analysis revealed RLH. The lesion showed perinodular enhancement in the arterial phase on contrast-enhanced computed tomography and magnetic resonance imaging. On diffusion-weighted imaging (DWI), we encountered linear hyperintensity along the portal tract consecutive to the liver lesion, which is a new characteristic radiologic finding. This finding corresponded to the lymphoid cell infiltration of the portal tract. Furthermore, there was strongly restricted diffusion on the apparent diffusion coefficient map. We used these characteristic radiologic findings to diagnose the lesion as a lymphoproliferative disease.

CONCLUSION

The linear hyperintensity consecutive to the liver lesion on DWI provided additional valuable diagnostic information.

A case of reactive lymphoid hyperplasia of the liver in a patient with autoimmune hepatitis

Background

Reactive lymphoid hyperplasia (RLH) of the liver is a benign disorder. It is usually observed in the skin, orbit, thyroid, lung, breast, or gastrointestinal tract, but rarely in the liver. Since the first report of RLH of the liver in 1981, only 75 cases have been described in the past literature. Herein, we report a case of RLH of the liver in a patient with autoimmune hepatitis (AIH), which was misdiagnosed as hepatocellular carcinoma (HCC) preoperatively and resected laparoscopically.

Case presentation

A 43-year-old Japanese woman with autoimmune hepatitis was followed up for 5 years. During her medical checkup, a hypoechoic nodule in segment 6 of the liver was detected. The nodule had been gradually increasing in size for 4 years. Abdominal ultrasound (US) revealed a round, hypoechoic nodule, 12 mm in diameter. Contrast-enhanced computed tomography (CT) demonstrated that the nodule was slightly enhanced in the arterial dominant phase, followed by perinodular enhancement in the portal and late phases. A magnetic resonance imaging (MRI) scan showed low signal intensity on the T1-weighted image (T1WI) and slightly high signal intensity on the T2-weighted image (T2WI). The findings of the Gd-EOB-DTPA-enhanced MRI were similar to those of contrast-enhanced CT. Tumor markers were all within the normal range. The preoperative diagnosis was HCC and a laparoscopic right posterior sectionectomy was performed. Pathological examination revealed that the nodular lesion was infiltrated by small lymphocytes and plasma cells, and germinal centers were present. Immunohistochemistry was positive for B cell and T cell markers, indicating polyclonality. The final diagnosis was RLH of the liver.

Conclusions

The pathogenesis of RLH of the liver remains unknown, and a definitive diagnosis based on imaging findings is extremely difficult. If a small, solitary nodule is found in female patients with AIH, the possibility of RLH of the liver should be considered.

Hepatic pseudolymphoma: imaging features on dynamic contrast-enhanced MRI and diffusion-weighted imaging

PURPOSE

To investigate dynamic contrast-enhanced (DCE) MR findings and diffusion-weighted imaging (DWI) characteristics of hepatic pseudolymphoma.

MATERIALS AND METHODS

The MR data of 20 lesions in 14 patients with histopathologically proven hepatic pseudolymphoma were retrospectively analyzed. All patients underwent dynamic gadopentetate dimeglumine-enhanced MR imaging and DWI. Morphologic characteristics and signal features on T1- and T2-weighted images (T1WI, T2WI), and DCE pattern were qualitatively evaluated. The quantitative analysis was performed for the size, the degree of enhancement on arterial phase, signal intensity (SI) of DWI, and apparent diffusion coefficient (ADC) values. The Wilcoxon signed ranks test was used for statistical analysis.

RESULTS

The contour of all lesions was round. The lesion size was 0.7-2.8 cm (mean 1.3 ± 0.5 cm). All lesions manifested as homogeneous hypointensity on T1WI and hyperintensity on T2WI. All lesions were shown as hypervascular with various enhancement patterns on DCE MR imaging. The presence of peripheral enhancement and pseudocapsule was observed in 7 and 4 lesions, respectively. SI of the hepatic pseudolymphoma was significantly lower than that of portal vein on arterial phase (P < 0.001) and the ADC was significantly lower than that of spleen (P = 0.012).

CONCLUSION

A homogeneous nodule with small size (<2 cm), manifestation of hypervascular with lower SI than that of portal vein on arterial phase and lower ADC values than that of spleen are the common MR features of hepatic pseudolymphoma.

Reactive lymphoid hyperplasia of the liver requires differential diagnosis of hepatocellular carcinoma

Reactive lymphoid hyperplasia (RLH) of the liver is a rare and benign nodular lesion. It remains difficult to distinguish RLH from hepatocellular carcinoma (HCC) despite recent advances in imaging modalities. We report five cases of RLH that required differential diagnosis of HCC preoperatively. These cases all occurred in middle-aged women and were associated with autoimmune disease in 40% (2/5). The diameter of the nodule was less than 2 cm in all five of our cases. Four cases had a preoperative diagnosis of HCC. When a liver nodule is found in middle-aged women with an autoimmune disease, the possibility of RLH should be considered.

Hepatic pseudolymphoma: imaging-pathologic correlation with special reference to hemodynamic analysis

OBJECTIVES

To clarify radiological findings and hemodynamic characteristics of hepatic pseudolymphoma, as compared with the histopathological findings.

METHODS

Radiological findings of ten histopathologically confirmed hepatic pseudolymphomas in seven patients were examined using US, CT, and MRI. Six patients also underwent angiography-assisted CT, including CT during arterial portography (CTAP) and CT during hepatic arteriography (CTHA) to analyze hemodynamics.

RESULTS

The nodules were depicted as hypoechoic on US, hypodense on precontrast CT, hypointense on T1-weighted images, and hyperintense on T2-weighted images. On contrast-enhanced CT/MRI, they showed various degrees of enhancement, and sometimes, perinodular enhancement was observed at the arterial dominant and/or equilibrium phase. On CTAP, the nodules showed portal perfusion defects, including some in the perinodular liver parenchyma. On CTHA, irregular bordered enhancement was observed in perinodular liver parenchyma on early phase, and continued until delayed phase. Some nodules had preserved intra-tumoral portal tracts. Histopathologically, the nodules consisted of marked lymphoid cells. In perinodular liver parenchyma, stenosis or disappearance of portal venules, caused by lymphoid cell infiltration in the portal tracts, was observed.

CONCLUSIONS

Hepatic pseudolymphoma showed some characteristic radiological findings including hemodynamics on CT, MRI, and angiography-assisted CT. These findings are useful in the differentiation from hepatocellular carcinoma and other tumors.

Pseudolymphoma of the liver: Report of a case and review of the literature

We report a case of pseudolymphoma of the liver in a 49-year-old woman without an underlying disease except for liver hemangioma. A 20-mm nodule was incidentally found in segment 2 of the liver by abdominal ultrasonography during a regular follow-up of the hepatic hemangioma. After a series of radiological examinations, a left lateral sectionectomy was performed because malignant hepatic tumor could not be excluded. The patient was discharged uneventfully 7 days after the operation. The pathology examination revealed a pseudolymphoma. No recurrence of the tumor was found 5½ years after the operation. To the best of our knowledge, only 46 cases of pseudolymphoma of the liver have been reported to date. A review of the literature showed that pseudolymphomas occur predominantly in females (89.4%), usually occur as a single tumor (80.4%), are no more than 20 mm in size (90.6%), and are frequently associated with either autoimmune disease or chronic liver disease. Because an accurate diagnosis is difficult to establish, vigilant follow-up is indicated, and surgical intervention is the choice of treatment once the suspiciousness of malignancy has been raised.

Reactive lymphoid hyperplasia of the liver and pancreas. A report of two cases and a comprehensive review of the literature

BACKGROUND

Reactive lymphoid hyperplasia (RLH) is a rare non-neoplastic extranodal pathology with exceedingly rare occurrence in the liver and pancreas. We present two cases of hepatic RLH, one which had coinciding pancreatic involvement. To the best of our knowledge, concomitant hepatic and pancreatic RLH has not been previously reported. We also present a comprehensive review of the literature on hepatic and pancreatic RLH.

METHODS

An extensive literature search for all published reports on hepatic or pancreatic RLH was conducted. Data on clinical, radiographic and histopathological features were extracted in addition to therapeutic options and outcomes.

RESULTS

Forty-two hepatic and three pancreatic cases of RLH were described in the literature. The mean age of hepatic cases was 58 years, with a male-to-female ratio of above 1:7. Almost 25% of cases were associated with internal malignancy. Four hepatic cases were managed through active observation. The remainder (84%) underwent surgical resection. Due to their small number, no meaningful analysis could be made on the pancreatic cases. No recurrences were identified in any of the reported cases.

CONCLUSION

RLH should be considered in the diagnosis of hepatic nodules where biopsies fail to demonstrate malignant cells. Confirmed RLH lesions should be managed by active observation. Investigation and treatment of any potential source of lymphoid reactivity should be undertaken. More reports on pancreatic RLH need to be studied prior to drawing any useful recommendations on its management.

Reactive lymphoid hyperplasia of the liver: a clinicopathological study of 7 cases

Background. Reactive lymphoid hyperplasia (RLH) of the liver is a benign focal liver mass that may mimic a malignant liver tumor. Although rarely encountered in clinical practice, it often poses diagnostic and management dilemmas. Methods. Cases diagnosed as hepatic RLH between January 1996 and June 2011 were investigated in a retrospective study. Clinicopathological features as well as follow-up information of the cases were studied. Results. A total of seven cases of hepatic RLH were investigated, with a median age of 46 years (range: 33–76 years). Hepatic RLH was accompanied by concomitant diseases in some patients. The average size of hepatic lesions of our cases was 45 mm (range: 15–105 mm). All of the cases were not accurately diagnosed until confirmed by pathological findings, and surgical resections were performed for all. Postoperative course was uneventful for all of the patients during followup. Conclusions. RLH of the liver is a rare benign disease with a female predilection of unknown etiology. It is very difficult to correctly diagnose this disease without pathological results. Subtle differences on radiological findings of it may be helpful for differential diagnosis from other diseases. Curative resection of the lesion is suggested for the treatment of this disease.

MR imaging of reactive lymphoid hyperplasia of the liver

INTRODUCTION

Reactive lymphoid hyperplasia, also known as pseudolymphoma or nodular lymphoid lesion of the liver, is a rare benign lesion. It is mainly detected in the lung, stomach, small intestine, orbit, pancreas, skin, and breast. It remains difficult to distinguish reactive lymphoid hyperplasia from malignant disease clinically when it develops in the liver.

CASE REPORT

We have recently encountered a patient with liver reactive lymphoid hyperplasia who had undergone colon cancer surgery.

CONCLUSION

Preoperative MR imaging showed some useful findings indicating reactive lymphoid hyperplasia.

An operative case of hepatic pseudolymphoma difficult to differentiate from primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue

Hepatic pseudolymphoma (HPL) and primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases and the differential diagnosis between these two entities is sometimes difficult. We herein report a 56-year-old Japanese woman who was pointed out to have a space occupying lesion in the left lateral segment of the liver. Hepatitis viral-associated antigen/antibody was negative and liver function tests including lactic dehydrogenase, peripheral blood count, tumor markers and soluble interleukin-2 receptor were all within normal limit. Imaging study using computed tomography and magnetic resonance imaging were not typical for hepatocellular carcinoma, cholangiocarcinoma, or other metastatic cancer. Fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning showed high standardized uptake value in the solitary lesion in the liver. Under a diagnosis of primary liver neoplasm, laparoscopic-assisted lateral segmentectomy was performed. Liver tumor of maximal 1.0 cm in diameter was consisted of aggregation of lymphocytes of predominantly B-cell, containing multiple lymphocyte follicles positive for CD10 and bcl-2, consistent with a diagnosis of HPL rather than MALT lymphoma, although a definitive differentiation was pending. The background liver showed non-alcoholic fatty liver disease/early non-alcoholic steatohepatitis. The patient is currently doing well with no sign of relapse 13 months after the surgery. Since the accurate diagnosis is difficult, laparoscopic approach would provide a reasonable procedure of diagnostic and therapeutic advantage with minimal invasiveness for patients. Considering that the real nature of this entity remains unclear, vigilant follow-up of patient is essential.

Reactive nodular hyperplasia mimicking malignant lymphoma in donor liver allograft

The transmission of malignancy from donor to recipient can have devastating outcomes. Therefore, careful examination of the thoracic cavity, abdominal organs, and lymphoid tissue is important. In this report, we have described a case of a healthy 37-year-old donor with no significant past medical history who was found to have a nodule in the liver allograft during the examination at the back table. The frozen section revealed atypical lymphoid hyperplasia. Further workup revealed a rare benign lesion in the liver known as reactive lymphoid hyperplasia. Unfortunately, the liver allograft had to be discarded since low-grade lymphoma could not be excluded at the time of transplantation.

Hepatic reactive lymphoid hyperplasia in a patient with primary biliary cirrhosis

Reactive lymphoid hyperplasia (RLH) of the liver is an extremely rare lesion characterized by the proliferation of non-neoplastic lymphocytes forming follicles. Hepatic RLH is known to be associated with gastrointestinal carcinoma and autoimmune diseases including primary biliary cirrhosis (PBC). We report a case of hepatic RLH in a patient with PBC and gastric cancer. A 68 year old Japanese woman with a 10 year history of liver enzyme abnormality was admitted. Laboratory testing revealed that her anti-mitochondrial antibody was markedly elevated. Five mo after the diagnosis of PBC, she was found to have gastric cancer. Abdominal computed tomography disclosed a liver nodule in S8, suggesting metastatic gastric carcinoma. Histopathologically, the resected liver lesion comprised of a nodular proliferation of small lymphocytes with lymphoid follicles. This is the first reported case of hepatic RLH in a patient with both PBC and gastric cancer. Pre-operative diagnosis of hepatic RLH by clinical imaging is extremely difficult. Therefore, a needle biopsy could be useful to make a diagnosis of hepatic RLH, especially to differentiate from metastatic gastrointestinal carcinoma.

Hepatic pseudolymphoma: a clinicopathological study of five cases and review of the literature

Hepatic pseudolymphoma is a rare and controversial condition, the clinicopathological characteristics of which have not been well documented. In this study, we retrospectively examined clinical and pathological features of five patients (two males and three females, 40-81 years old) with hepatic pseudolymphoma. Two patients had multiple lesions (two lesions each). Three patients had histories of chronic liver disorders, including primary biliary cirrhosis, nonalcoholic steatohepatitis, and chronic viral hepatitis B. Tumor sizes ranged from 0.5 to 5.5 cm in diameter (average, 2.1 cm). Histologically, hepatic pseudolymphoma consisted of tumorous infiltrates of mature lymphocytes with multiple lymph follicles or clusters of epithelioid histiocytes. Lymphocytes characteristically extended into nearby portal tracts. Ductal structures positive for cytokeratin 7 were entrapped in the peripheral parts of nodules. In situ hybridization of immunoglobulin light chains revealed B lymphocytes and plasma cells to be polyclonal. In addition, clonal rearrangements of immunoglobulin heavy chains could not be shown in any cases using PCR. Two patients were diagnosed by needle biopsy. Interestingly, their nodules spontaneously diminished in size without any treatment. Malignant transformation was not observed in any cases during the follow-up periods. In conclusion, this study revealed that hepatic pseudolymphoma had benign behavior. The diagnosis of hepatic pseudolymphoma can be challenging especially with biopsied specimens, but could be aided by a characteristic growth pattern, in situ hybridization, analyses of gene rearrangements, or a follow-up based on images.

Pseudolymphoma of the liver associated with primary biliary cirrhosis: a case report and review of literature

We report a case of two pseudolymphomas of the liver in a 63-year-old Japanese woman with primary biliary cirrhosis. One of the lesions was found incidentally during a medical examination, presenting as a 10 mm hypodense nodule that revealed hyperdensity in the early phase and hypodensity in the late phase in computed tomography (CT) after injection of contrast medium. Retrospectively, the 10 mm nodule had first been discovered as a 4 mm nodule during CT 4 years previously. Superparamagnetic iron oxide-enhanced MRI revealed another 4 mm hyperintense nodule in segment 6 in addition to the 10 mm hyperintense nodule in segment 7. CT during arterial portography revealed two hypointense nodules. Findings with other imaging modalities such as ultrasonography, magnetic resonance imaging, and hepatic angiography were consistent with hepatocellular carcinoma. A right posterior segmentectomy was performed, and the lesions were microscopically diagnosed as pseudolymphoma. To the best of our knowledge, only 31 other cases of this disease have ever been reported, with a highly asymmetrical male:female ratio of 1:9.7. Although we could find only one case of transformation of hepatic pseudolymphoma into lymphoma in the liver, the exact nature of development from benign pseudolymphoma to malignant lymphoma is still not fully understood and cases of hepatic lymphoma need to be followed carefully.

Histiocyte-rich reactive lymphoid hyperplasia of the liver: unusual morphologic features

Reactive lymphoid hyperplasia (RLH) of the liver is a rare entity and has also been termed nodular lymphoid lesion or pseudolymphoma of the liver. We report a case of hepatic RLH exhibiting unusual histiocyte-rich histologic features in a 47-yr-old woman in conjunction with a renal cell carcinoma. A follow-up computed tomography scan was done 14 months after a right radical nephrectomy for renal cell carcinoma revealed a nodular lesion in segment 5 of the liver. The lesion was interpreted as metastatic renal cell carcinoma or hepatocellular carcinoma based on the history of the patient and radiologic findings. Wedge resection of segment 5 was done with sufficient distance from the mass. Microscopically, the lesion was composed predominantly of peculiar histiocytic proliferation and was characterized by lymphoid aggregates forming a lymphoid follicle with germinal centers. The present case and prior cases reported in the literature suggest that RLH of the liver appear to be a heterogenous group of reactive inflammatory lesions that are often associated with autoimmune disease or malignant tumors.