Primary hepatic lymphoma: A case report

Nodular Lymphocyte-Predominant Hodgkin Lymphoma: A Rare Lymphoma with Isolated Hepatic Presentation

Primary hepatic lymphoma (PHL) is extremely rare, accounting for less than 1% of all lymphomas, and is limited to the liver without extrahepatic involvement. A 30-year-old male was admitted in the Emergency Department complaining of weakness, fever, night sweats, significant weight loss, discrete ring alopecia, hepatomegaly, right axillary adenopathy and oedema of both legs. Laboratory evaluation showed normocytic normochromic anaemia, thrombocytosis, hyperbilirubinemia, cholestasis and increased international normalised ratio (INR). A computed tomography (CT) scan found an enlarged liver with a heterogeneous structure and moderate ascites. After admission in our ward further investigation revealed increased sedimentation velocity, ferritin and serum lactate dehydrogenase. A hepatic biopsy was performed which confirmed the diagnosis as a nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL). The patient was transferred to a haematological ward and underwent chemotherapy with six cycles of R-CHOP. He is in complete remission after a year and half since the beginning of treatment. NLPHL, a very rare lymphoma, is more common in men between the third and fifth decades of life. Usually, the symptoms are very unspecific; a few patients have B symptoms at admission. This kind of presentation is also common in infectious, metabolic and autoimmune diseases, which were excluded in this case. Due to technical issues the final diagnosis was only possible due to the liver biopsy. Treatment with standard Hodgkin lymphoma protocols leads to complete remission in more that 95% of patients with NLPHL.

LEARNING POINTS

Differential diagnosis of fever, especially in young patients, is very complex and complete investigation takes time, which can delay the diagnosis of malignancies such as primary hepatic lymphoma (PHL).PHL is very rare, and overlapping symptoms with other liver diseases can make the diagnosis very challenging.When the suspicion of PHL is very high, only the hepatic biopsy can lead to the correct diagnosis because the disease has no extrahepatic involvement.

Primary hepatopancreatobiliary lymphoma: Pathogenesis, diagnosis, and management

Primary hepatopancreatobiliary lymphoma (PHPBL) is extremely rare, which is defined as a lympho-proliferative disease confined to the hepatobiliary system and pancreas without any involvement of lymph nodes, bone marrow, or other organs. The clinical and imaging manifestations of PHPBL are variable and non-special, which are akin to those of tumors of the hepatobiliary and pancreatic systems. The overall prognosis and management of PHPBL differ from those of other tumors in the hepatobiliary system and pancreas. Proper diagnosis and prompt treatment are essential for improving clinical outcomes. Due to its rarity, the optimal treatment has not been issued. However, combination chemotherapy is considered as a standard treatment for them. This review provides an overview of the pathogenesis, diagnosis, pathology, and management of PHPBL and offers clinicians the diagnosis and management schedule for PHPBL.

Primary hepatic lymphoma diagnosed using endoscopic ultrasound-guided liver biopsy: a case report

Background

Because of the rarity of primary hepatic lymphomas, diagnosis of this disease entity may often be difficult, and performing a liver biopsy is the only way to establish a definitive diagnosis. Recently, endoscopic ultrasound-guided liver biopsy has emerged as a safe technique for obtaining liver tissue. However, there is no report on the use of endoscopic ultrasound-guided liver biopsy for diagnosing primary hepatic lymphomas.

Case presentation

An 85-year-old Asian man was admitted to our hospital because of multiple liver lesions without any identifiable primary tumor or extrahepatic lymphadenopathy. Serum tumor markers, including alpha-fetoprotein, were in the normal range. We provisionally diagnosed the patient with a cancer of unknown primary origin with liver metastases. An endoscopic ultrasound-guided fine needle liver biopsy of the tumor in the left lobe of the liver was performed using a transgastric approach, and histology revealed a primary hepatic lymphoma of a diffuse large B-cell lymphoma type.

Conclusions

Primary hepatic lymphomas are quite rare, and diagnosis is often difficult without performing a biopsy. Endoscopic ultrasound-guided liver biopsy is a useful diagnostic modality even in such cases.

MRI features of primary hepatic lymphoma

PURPOSE

Our retrospective study sought to describe the spectrum of magnetic resonance imaging (MRI) features of primary hepatic lymphoma (PHL) by analyzing its morphological aspects, signal intensity before and after contrast agent (CA) administration, and diffusion-weighted imaging (DwI) with the apparent diffusion coefficient (ADC) values.

METHODS

A retrospective analysis was conducted on 25 patients with pathologically proven PHL who underwent MRI between January 2011 and December 2016. For the evaluation of the ADC, we used a control group of 87 patients (22 with hepatocellular carcinoma, 15 with cholangiocellular carcinoma, 23 with liver metastasis, 22 with focal nodular hyperplasia, and 5 with adenoma). Two radiologists evaluated the morphological features, the signal intensity before and after CA administration, and the DwI. The sensitivity and specificity of the ADC values in distinguishing the PHL lesions from other hepatic lesions were calculated by analyzing the receiver operating characteristic (ROC) curves.

RESULTS

Twenty-one patients had non-Hodgkin's lymphoma (18 had diffuse large B-cell lymphoma and three had mucosa-associated lymphoid tissue) and four had Hodgkin's lymphoma (nodular sclerosis). The PHL had a variable morphologic distribution (17 focal mass and eight multiple nodules) and mainly an insinuative growth (24/25). Usually, PHL was usually hypointense on the T1-weighted images (23/25) and hyperintense on the T2-weighted images (21/25); non-specific dynamic enhancement was found after CA administration, but in the hepatobiliary phase, PHL is mainly hypointense (92%). All PHLs showed a signal restriction in the DwI. The sensitivity and specificity in the differential diagnosis between PHL and the other malignant lesions were respectively 81.7% and 100%, with applying an ADC cut-off value of 0.918 × 10^-3 mm²/s.

CONCLUSION

Although PHL is a rare disease and biopsy is still required, an MRI could be indicative. In our series, PHL showed an insinuative growth, hypointense signal in the hepatobiliary phase, signal restriction in the DwI, and an ADC value lower than that of the other hepatic lesions analyzed.

Primary Hepatic Lymphoma Mimicking Cholangiocarcinoma

Primary hepatic lymphoma (PHL) presenting with obstructive jaundice is rare and can mimic a preoperative diagnosis of cholangiocarcinoma. We should consider PHL in patients with radiological hepatic disease with normal serum alpha-fetoprotein and carcinoembryonic antigen levels, and elevated lactate dehydrogenase. We present the case of a 67-year-old male with no significant medical history presented with abdominal pain, jaundice, fever, and abnormal liver function tests. Abdominal sonography and computed tomography scan suggested a diagnosis of obstructive jaundice and cholangitis due to cholangiocarcinoma (Klatskin tumor). A subsequent liver biopsy diagnosed PHL, and the patient was treated with combination chemotherapy, including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). PHL should be considered in patients presenting with biliary obstruction.

An unusual case of primary hepatic lymphoma with dramatic but unsustained response to bendamustine plus rituximab and literature review

Objectives:

Primary hepatic lymphoma is an uncommon cause of hepatic space-occupying lesions.

Methods:

We describe the case of a 73-year-old man with primary hepatic lymphoma, who presented with a low-grade fever and lower limb weakness which had progressed in the past 2 months.

Results:

Abdominal ultrasound and computed tomography showed multiple small hepatic tumors. Echo-guided biopsy of the hepatic tumor demonstrated primary hepatic diffuse large B cell lymphoma. Moreover, bone marrow was uninvolved, but the bone marrow smear disclosed hemophagocytosis, which is uncommon in diffuse large B cell lymphoma. Chemotherapy with bendamustine and rituximab treatment was initiated with a dramatic response: hepatic tumors markedly shrank in size shown by follow-up computed tomography and the patient returned to his normal life. Nevertheless, the response was sustained for only 8 months. Finally, the disease resisted further chemotherapy and this patient died of a severe Klebsiella pneumoniae infection.

Conclusion:

Chemotherapy with bendamustine and rituximab has shown a dramatic, but not durable, response in the present case with old age and multiple comorbidities.

Complete response to comprehensive treatment of a primary hepatic diffuse large B cell lymphoma: A case report

Primary hepatic lymphoma (PHL) is an uncommon lymphoid tumor with varied clinical features and treatment outcome. In the present study, the case of a 56-year-old patient with PHL and no clinical presentation was reported. During a routine physical examination, multiple hypodense nodules were incidentally detected in right lobes of the liver and hepatic portal in an abdominal computed tomography scan. A liver biopsy revealed the presence of a non-Hodgkin's lymphoma diffuse large B cell type that was CD20-positive, followed by the diagnosis of a PHL. The patient was treated with R-CHOP, radiotherapy and R-Hyper-CVAD/R-HD MTX-ara-C, and complete remission was achieved.