Primary hepatic non-Hodgkin's lymphomas: case report and review of the literature

Primary hepatic diffuse large B- cell lymphoma mimicking cholangiocarcinoma

Primary lymphoma of liver is a rare malignancy with non-specific clinical features and tumor markers. The presentation and imaging features may be indistinguishable from other hepatic malignant lesions. Pathological diagnosis is the gold standard, and early detection is essential to choose the treatment modality. Here, we share an interesting case of Primary Diffuse Large B cell lymphoma of liver and its imaging findings on Computed tomography (CT), Magnetic Resonance Imaging (MRI) and F-18 FDG PET/CT.

Challenges in Diagnosis: Primary Hepatic Lymphoma Presenting as a Space-Occupying Liver Lesion

Non-Hodgkin lymphoma is a heterogeneous group of lymphoid neoplasms, the incidence of which has increased over the past 3 decades. Primary non-Hodgkin lymphoma of the liver is a very rare malignancy. We outline a case describing primary hepatic lymphoma in an 85-year-old woman with a history of breast cancer who presented with generalized weakness and nonspecific symptoms. The patient had normal liver function, serum alpha fetoprotein level, and hemoglobin. A computed tomography scan of the chest, abdomen, and pelvis showed numerous low-attenuation lesions scattered throughout the liver. This case underscores the importance of including primary hepatic lymphoma as a differential diagnosis for space-occupying liver lesions, especially in the setting of normal alpha fetoprotein level.

Prognosis of primary hepatic lymphoma: A US population-based analysis

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Primary hepatic lymphoma (PHL) is a rare form of extranodal lymphomas, mainly invading the liver and local tissues.

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The incidence, clinical characteristics and survival of patients with PHL in the United States.

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An applicable PHL model can forecast the dynamic survival rate of patients with PHL.

Objective

Primary hepatic lymphoma (PHL) is a rare malignancy with lesions confined to the liver. It is characterized by a large number of monomorphic, medium-sized lymphocytic infiltrates in the hepatic sinusoid. Due to the rarity of this malignancy, our current understanding of PHL is limited.

Methods

We collected incidence, mortality, and clinical data of PHL patients diagnosed between 1975 and 2016 using the Surveillance, Epidemiology, and End Results (SEER) database. The annual percentage changes (APCs) and prognoses were analyzed using the Joinpoint and R package.

Results

Among the 1,372 patients, white males were prevalent, and the most common histological subtype was diffuse large B-cell lymphoma (DLBCL). The incidence and mortality rate of PHL was 0.075/100,000 person-years and 0.055/100,000 person-years, respectively. The annual incidence rate of PHL increased significantly, with an APC of 2.74% (P < 0.001). The 3- and 5-year overall survival (OS) rates of patients with PHL were 43.553% and 39.242%, respectively. The 3- and 5-year relative survival (RS) rates were 46.925% and 45.300%, respectively. Multivariate Cox regression analysis revealed that older age, black, DLBCL, and advanced-stage disease were independent predictors of unfavorable OS and RS. The C-index and receiver operating characteristic (ROC) analysis confirmed the prognostic value of the nomograms established in this study.

Conclusion

The nomogram established in this study is a robust tool to predict the prognosis of PHL patients.

Primary Liver Lymphoma Presenting as Liver Nodules

The liver is usually affected in advanced stages of lympho-proliferative diseases, but primary liver lymphomas (PLLs) are rare. The diagnosis is usually late, especially in patients without identifiable risk factors, with consequent worse prognosis. We report the case of a 59-year-old female with progressive worsening pain in the right hypochondrium and weight loss. She was previously healthy and had a family history of gastrointestinal and gynecologic neoplasms. During the initial investigation, three liver nodules suggestive of liver metastases were found. Nevertheless, no primary neoplasm was identified in a subsequent evaluation with imaging and endoscopic exams. Laboratory exams excluded hepatic infections, metabolic diseases, and acquired immunosuppression. Biopsy of the lesions revealed diffuse large B-cell lymphoma. Lymph node and medullar involvement were excluded, and the diagnosis of PLL was assumed. The patient started chemotherapy with R-CHOP. With this case, we intend to alert for this differential diagnosis of liver nodules, even in the absence of predisposing conditions for lymphoma. We point out the need to define universal diagnosis criteria for this pathology.

Fever of Unknown Origin due to Primary Hepatic Diffuse Large B-cell Lymphoma: A Case Report

We present a rare case of primary hepatic lymphoma. An 82-year-old female patient presented with altered mental status, and fever. Her labs were significant for abnormal liver functions with markedly elevated lactate dehydrogenase. All infectious and auto-immune workup was negative. Imaging studies were only significant for hepatosplenomegaly, and no liver masses were detected. A liver biopsy was diagnostic of CD5+ CD20+ diffuse large b-cell lymphoma of the liver. Chemotherapy was planned with rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Unfortunately, the patient died before initiation of therapy. This case would highlight the importance of early liver biopsy in patients with abnormal liver functions and with no clear explanation, even if there were no discrete masses on computed tomography (CT) or magnetic resonance imaging (MRI). Lymphomas and other infiltrative processes should be considered in the differential diagnosis in such cases.

Primary hepatic lymphoma treated with liver resection followed by chemotherapy: a case report

Non-Hodgkin lymphoma often involves the liver. However, primary hepatic lymphoma (PHL) confined to the liver without evidence of lymphomatous involvement is rare. The optimal therapy for PHL is still unclear. Most patients present with poor prognostic features. Here, we report a case of PHL treated with liver resection followed by chemotherapy. A 65-year-old male was referred for further evaluation about a liver mass detected on ultrasound. Abdominal computed tomography (CT) scan showed well-defined single mass of 6 cm in diameter. Positron emission tomography/CT scan revealed a hot uptake lesion on the segment 8 of the liver. Colonoscopy showed no abnormal finding. It was diagnosed as intrahepatic cholangiocarcinoma. A right anterior sectionectomy was performed. Postoperative pathology revealed diffuse large B-cell lymphoma. Bone marrow biopsy showed normal findings. The final diagnosis was confirmed as PHL. The patient subsequently received six cycles of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone) regimen. The patient is doing well without relapse after 60 months of follow-up. Because of its rarity and the lack of specific laboratory, radiological, or clinical finding, liver biopsy is essential for definite diagnosis of PHL. Optimal treatment for PHL is currently uncertain. However, surgical resection followed by adjuvant chemotherapy should be considered for select individuals to achieve better outcome.

Primary malignant tumours in the non-cirrhotic liver

Intrahepatic chlangiocarcinomas (CCs), the second most common primary malignant liver tumours, usually occur in non-cirrhotic liver, and can be classified into three types based on gross morphology: mass-forming; periductal infiltrating; and intraductal growing. Among them, mass-forming intrahepatic CCs are the most common type and characterized by homogeneous mass with an irregular but well-defined margin with peripheral enhancement on late arterial phase and delayed enhancement in central portion of tumours corresponding to the fibrous stroma. Several imaging features such as enhancement pattern and degree of diffusion restriction have been suggested as prognostic markers for mass-forming CCs. Hepatocellular carcinomas (HCCs) are the most common primary malignant liver tumors, and usually arise from the cirrhotic liver. However, approximately 20% of HCCs involve the non-cirrhotic liver (hereafter, non-cirrhotic HCC), and non-cirrhotic HCCs are often detected at an advanced stage due to the lack of surveillance for patients with non-cirrhotic liver. Other primary malignant liver tumours other than CCs and HCCs including angiosarcoma, undifferentiated embryonal sarcoma are quite rare, and imaging diagnosis is often difficult. This review offers a brief overview of epidemiology, risk factors and imaging features of primary malignant tumours in non-cirrhotic liver. Understanding of radiologic appearance and predisposing clinical features as well as differentials of primary malignant tumour in non-cirrhotic liver can be helpful for radiologists to adequately assess these tumours, and subsequently to make optimal management plan.

Non-Hodgkin Lymphoma of the Liver: A US Population-based Analysis

Background and Aims: Non-Hodgkin lymphoma (NHL) of the liver is a rare lymphoid malignancy, accounting for less than 1% of extranodal lymphomas. Methods: I conducted an analysis of the U.S Surveillance, Epidemiology, and End Results (SEER) database to evaluate the histological subtypes and the survival outcomes of 785 cases with hepatic NHL between 1973 and 2012. Results: There were 785 of 312 459 cases with NHL had a first primary hepatic NHL (0.25%). Of the total 785 cases, the median age at diagnosis was 61 years (range 3-95 years) and male-female ratio of 1.7:1. The most common subtype was diffuse large B cell lymphoma (63.2%). In all patients, the median overall survival (OS) was 33 months (95%CI, 22-48 months). The 5-year OS rate for indolent B-cell NHLs was 62%, compared with 44% for an aggressive B-cell NHLs and 42% for T-cell NHLs. The median OS improved from 19 months in patients diagnosed in a period 1996-2000 to 60 months when diagnosed between 2006 and 2012 (p < .001). In a multivariable Cox regression analysis, the age ≥80 years (adjusted hazard ratio [aHR] 3.21, p < .001), male gender (aHR 1.26, p = .02), Black race (aHR, 1.70, p < .001), and T-cell NHL variants (aHR 1.73, p = .03) were unfavourable prognostic factors. Conclusion: NHL of the liver comprises about 0.3% of all NHLs and survival was improved in the recent calendar period.

Primary Diffuse Large B-Cell Lymphoma of the Liver in a Patient with Sjogren Syndrome

Sjögren's syndrome (SS) has the highest incidence of malignant lymphoproliferative disorders transformation among autoimmune diseases. We present a case of extranodal high grade lymphoma of the liver in a 52-year-old patient with long history of SS. Lymphoma manifested with sharp significant pain in the right hypochondrium, weakness, and profuse night sweats. Contrast-enhanced computed tomography scan (CT-scan) of the abdomen revealed multiple low density foci with homogeneous structure and clear contours in both lobes of the liver. Histologically, proliferation of medium sized lymphoma cells with round-oval and slightly irregular nuclei with fine chromatin was shown. Immunohistochemical and molecular features of the tumors allowed diagnosis of diffuse large B-cell lymphoma (DLBCL). To exclude secondary liver lesion by non-Hodgkin lymphoma, chest and small pelvis CT-scan, endoscopy of upper and lower gastrointestinal tract and study of bone marrow were performed. After 8 cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), the complete remission was achieved, which persists after 45 months of follow-up. Primary hepatic lymphomas are extremely rare, and previously only low-grade hepatic lymphomas have been described in SS. To our knowledge, the patient described here represents the first reported case of DLBCL with primary liver involvement in SS.

Lymphoma of the liver: Clinicopathological features of 19 patients

BACKGROUND

Liver is an organ that could either be involved by widespread lymphoma or rarely as a primary site of lymphoma. Although secondary involvement of liver by lymphoma is relatively common, primary hepatic lymphoma (PHL) represents only about 0.016% of all cases of non-Hodgkin lymphoma. Understanding the clinicopathological features of hepatic lymphoma would direct appropriate treatment and patient management.

METHODS

We did a retrospective cohort study of 19 patients with liver biopsy-proven lymphoma, either as part of a systemic lymphoma or as a primary lesion, who were evaluated and treated at Harbor-UCLA Medical Center between 2004 and 2014.

RESULTS

The 19 cases were divided into two groups. Nine of them showing systemic involvement including not only liver but also spleen and/or lymph nodes were grouped together. The other 10 cases which showed confined liver lesions without involvement of other lymphoid structures were grouped in the PHL group. Clinical features of the two groups were compared. Our study demonstrated that PHL most commonly affected middle-aged individuals (median age: 50 years), with a male-to-female ratio of about 2.3 to 1. The most frequent presenting symptom was right upper quadrant pain. In contrast, the group with systemic lymphoma involving liver most commonly affected younger patients (median age: 40 years), with a male-to-female ratio of about 8 to 1, and with abdominal pain as well as fever/chills as the most common presenting symptoms. The tumor burden at the presentation as suggested by serum lactate dehydrogenase (LDH) level was statistically significantly lower in the PHL group compared to the systemic group in this study (p<0.05). Viral infections were found in both groups, and we did not observe a clear association of any particular viral infection with PHL. Diffuse large B-cell lymphoma was identified as the major type of primary hepatic lymphoma (8 of 10 cases). Finally, the prognosis in the PHL group demonstrated by the duration of follow-up (average follow up: 50 months) was statistically significantly better than that in the systemic group (average follow up: 5.5 months), p<0.01.

CONCLUSION

Patients with PHL showed different clinicopathological features from those with widespread lymphoma involving liver. The outcome of the patients with PHL appeared much more favorable than that of the patients with liver involvement by systemic lymphoma in this study.

Primary hepatic Epstein-Barr virus-associated CD30-positive peripheral T-cell lymphoma of cytotoxic phenotype

Primary hepatic peripheral T-cell lymphoma (PTCL) is exceedingly rare. We encountered such a case in a 58-year-old Hispanic female with a history of chronic sinusitis and hypothyroidism who presented with 4weeks of fever and weight loss. Laboratory studies showed altered liver function and mild pancytopenia. Hepatitis and HIV infection were excluded by negative serological tests. A computed tomography (CT) scan showed innumerable small low-density lesions throughout the liver without splenomegaly or lymphadenopathy. CT-guided liver core biopsy showed scattered small lymphoid aggregates located mainly in the portal tracts and periportal regions. Within the lymphoid aggregates, scattered large pleomorphic lymphoma cells were seen, admixed with smaller lymphoid cells and histiocytes. By immunohistochemistry, the lymphoma cells expressed CD2, CD3, CD8, CD30, CD43, CD45, granzyme B, TIA-1, and negative for CD4, CD5, CD7, CD56, βF1, ALK-1, and B-cell markers. In situ hybridization for Epstein-Barr virus-encoded RNA (EBER) was positive in some lymphoma cells. To our knowledge, this is the first reported case of primary hepatic Epstein-Barr virus-associated PTCL with CD30 expression.

Clinical and radiographic observations from four patients with primary hepatic lymphoma

The aim of the present study was to delineate the radiographic and clinical features of primary hepatic lymphoma (PHL). Four histopathologically confirmed cases of PHL were analyzed with respect to the radiological, clinical and pathological characteristics. The main clinical manifestations included upper right quadrant pain and lymphoma-associated B symptoms, such as fever, night sweating and weight loss. All the patients had elevated serum levels of lactate dehydrogenase. Furthermore, all the patients underwent plain and enhanced computed tomography examinations, which identified low-density lesions without marked enhancement. Solitary masses were observed in two cases, while multiple focal lesions were noted in one case and diffuse multi-speckled nodules were observed in one case. Two patients underwent abdominal magnetic resonance imaging, which revealed lesions that were hyperintense on T1-weighted imaging (WI) scans and hypointense on T2WI scans, and exhibited slight to moderate enhancement with a dynamic contrast-enhanced protocol. In one case, vessels were visible within the lesion. Therefore, the present study concluded that PHL is a rare condition that exhibits non-specific clinical and radiological features. A combination of imaging results and clinical manifestations can be used to facilitate a diagnosis of PHL.

[Primary hepatic lymphoma in a female patient with Sjögren's disease: A case report and literature review]

The paper describes a case of primary hepatic diffuse large B-cell lymphoma in a 52-year-old woman with a 27-year history of Sjögren's disease. It gives the data available in the literature on the etiology, diagnosis, and morphological characteristics of primary hepatic lymphoma and touches upon the issues of differential diagnosis.

Primary hepatic lymphoma: A case report

Primary non-Hodgkin lymphoma of the liver is a very rare malignancy. In this case report, we describe a case of primary hepatic lymphoma (PHL) in a 60-year-old man who presented with lump and pain in the abdomen of 2 months’ duration. The patient had altered liver function, normal serum alfa fetoprotein level (AFP), normal hemogram and bone marrow. A computed tomography scan of the abdomen and pelvis showed an ill-defined hypodense mass with specks of calcification involving the liver, suggestive of primary malignant mass of liver. Diagnosis of PHL was established on the cytology smear and confirmed by immunohistochemistry on tissue biopsy. This case demonstrates that PHL should be considered in the differential diagnosis of space-occupying liver lesions in the presence of a normal level of AFP. Fine needle aspiration cytology is a faster and safer diagnostic modality even in such a rare case. The case has many unique features like negative serology for viruses, no type B symptom and normal lactate dehydrogenase level.

Primary Hepatic Non-Hodgkin's Lymphoma: An Enigma Beyond the Liver, a Case Report

We have discussed a unique presentation of primary diffuse large cell B-cell non-Hodgkin (DLBC NHL) hepatic lymphoma involving the porta hepatis and biliary confluence causing obstructive jaundice with contiguous soft tissue involvement of the right lobe of liver extending up to the right renal cortex. This appears to be the only case in literature where primary hepatic lymphoma has shown contiguous localized intra- and extrahepatic tumor infiltration. A 67-year-old gentleman presented with history of significant loss of appetite and weight in 2 months with associated progressive painless cholestatic jaundice. Physical evaluation revealed normal vitals with pallor, deep icterus, scratch marks over the abdomen, generalized muscle wasting, grade II clubbing and a palpable non-tender liver with a globular, firm mass beneath the liver. He had a total serum bilirubin of 15.9 mg/dL and direct bilirubin of 9.24 mg/dL. His liver enzymes were moderately elevated with raised serum creatinine and dyselectrolytemia. Serology for enterohepatic viruses was negative. Contrast-enhanced magnetic resonance imaging (CEMRI) showed poorly enhancing multiple soft tissue masses in both lobes of liver with the largest mass involving, biliary confluence and porta hepatis causing right bile duct and portal vein encasement. The mass occupied the posterior right lobe and extended to the inferior surface of liver with contiguous invasion of the right renal upper pole cortex. The mass was associated with a retracted liver capsule in the involved segments and delayed enhancement, mimicking a cholangiocarcinoma. Tissue biopsy revealed hepatic DLBC type NHL and patient was subsequently treated with a CHOP-R (cyclophosphamide-doxorubicin-vincristine-prednisolone/rituximab) regimen, on which he has shown non-progressive disease at 1-year follow-up. DLBC NHL of the liver is a very rare tumor with propensity for isolated involvement of the liver and minimal extrahepatic spread. This case shows many interesting features such as obstructive jaundice for 2 months, porta hepatis involvement and tumor infiltration up to the right renal parenchyma. We have illustrated various imaging findings which should be considered when evaluating such a lesion to help differentiate it from cholangiocarcinoma. The literature is extensively reviewed. The case demonstrates relevant diagnostic parameters for physicians, radiologists and oncologists who are likely to encounter patients with tumor-induced obstructive jaundice in their daily practice.

Diagnostic value of open biopsy for malignant T-cell lymphoma of the liver

A 62-year-old man was referred to our hospital because of pain in the right upper quadrant. Laboratory tests revealed normal levels of tumor markers. Abdominal ultrasonography showed a hypoechoic mass of approximately 9 cm in diameter in the right lobe of the liver. Computed tomography revealed a low-density mass with peripheral enhancement in the posterior segment of the right lobe. Magnetic resonance imaging showed a low-intensity mass on T(1)-weighted images and a high-intensity mass on T(2)-weighted images. Abdominal angiography showed enhanced staining only at the periphery of the tumor. An open biopsy was performed and intraoperative examination of frozen sections indicated malignant lymphoma. The histopathologic diagnosis was malignant T-cell lymphoma. After combined chemotherapy, the tumor shrank to 4 cm in diameter. To our knowledge, only 15 cases of malignant T-cell lymphoma have been reported previously. Diagnosis is particularly challenging because this type of tumor has no distinctive imaging characteristics or signs or symptoms. This case emphasizes the need to include malignant T-cell lymphoma in the differential diagnosis and demonstrates the importance of open biopsy in patients with a suspected liver tumor.

Primary lymphoma of the liver - A complex diagnosis

A 59-year-old woman presented with the clinical symptoms and radiologic investigations of a liver lesion suspect of metastasis. However, postoperative histopathology revealed a primary hepatic lymphoma (PHL). The case of a patient with a solitary PHL, which was treated by resection and subsequent chemotherapy, will be discussed with a short overview of the literature.

Hodgkin disease relapse discovered at the time of liver transplant for acute liver failure

Lymphoma is a recognized cause of liver damage and in rare instances presents as ALF. In such cases, the underlying malignancy is often difficult to detect. Historically, the prognosis has been poor. Cure has occasionally been achieved with chemotherapy alone. LT in this setting is controversial, but has contributed to successful outcomes, as in the case of the five-yr-old girl reported here.

Acute liver failure because of chronic lymphocytic leukemia: case report and review of the literature

Infiltration of the liver by hematologic malignancies is an uncommon cause of liver failure. B-Cell chronic lymphocytic leukemia (cll) is a usually indolent disease that may infiltrate the liver, but based on a review of the literature, has never been reported to induce acute liver failure. Here, we describe the case of a 78-year-old woman with acute liver failure secondary to infiltration with cll being unresponsive to chemotherapy and causing death. This case is notable because of its atypical presentation and ultimate poor prognosis.

Clinicopathological features of primary liver lymphoma and its surgical therapy

AIM: To study clinicopathological features of primary liver lymphoma (PLL) and its diagnostic as well as therapeutic methods.

METHODS: Seven cases of primary liver lymphoma, diagnosed and treated at our hospital during 1975 and 2008, were retrospectively studied. The etiology, clinical presentations, morphology (detected by light microscopy, electron microscopy, or immunohistochemistry), serological tests of alpha fetal protein (AFP), carcinoma embryonic antigen (CEA), hepatitis B surface antigen (HBsAg), and lactate dehydrogenase (LDH), as well as therapeutic results were systematically analyzed.

RESULTS: Of the 7 patients, 4 patients presented with epigastric pain and fever, and 3 patients had fever, night sweats, and loss of weight. Five patients were complicated with chronic hepatitis or cirrhosis. Histopathological findings showed that 5 patients were B cell phenotype with positive staining of CD20 and CD79α. Electron microscopy of B cell lymphoma revealed an abundance of blood capillaries among tumor cells and organelles in cytoplasm. The other 2 patients belonged to T cell phenotype with positive expression of CD3 and CD45RO. Scant cytoplasm and few of organelles were prominent ultrastructural characteristics of T cell lymphoma. Serological test showed that 5 patients were negative for AFP and CEA, and HBsAg was positive in 5 patients. LDH level was elevated (range: 675.54 U/L-1246.5 U/L). The longer survival time was achieved in the 3 patients treated by surgical resection plus biochemotherapy (average survival: 23 months), compared with the 4 patients receiving surgical resection plus chemotherapy (average survival: 9.5 months).

CONCLUSION: Hepatitis B virus (HBV) infection is prevalent in PLL patients. The major clinicopathological features of PLL include B symptoms, space-occupying lesion in the liver, and elevated LDH level. Surgical resection plus biochemotherapy is a more effective approach, which prolongs survival time of PLL patients.

Co-morbid health conditions at mid-life in the Iowa adoptees

Adverse health effects due to alcohol and illicit drug abuse and dependence have been well documented. This study examines the effect of substance misuse on five major groups of health conditions using a sample of well characterized adoptees. The sample consisted of 742 adoptees interviewed in the last wave of the Iowa Adoption Studies. Death rate analyses included an additional 34 participants who had died prior to the last follow-up. Substance use patterns and medical history were assessed using the SSAGA-II (Bucholz, K. K., Cadoret, R. J., Cloninger, C. R., Dinwiddie, S. H., Hesselbrock, V. M., Nurnberger, J. L., Jr., et al. (1994). A new, semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA. Journal of Studies on Alcohol, 55 (2), 149-158). Subjects were divided into three groups according to DSM-IV diagnostic criteria, controls, alcohol abuse or dependence only (alcohol only), and the Alcohol-Drug group (abuse or dependence diagnosis on at least one illicit substance with or without alcohol diagnosis). Incidence rates of various diseases were measured using logistic regression. Survival analyses were used to examine whether substance abusers developed cardiovascular or metabolic disease at an earlier age than control subjects. Diagnostic grouping made no difference in the incidence rates or age of onset of health conditions. The amount of alcohol consumed by males significantly predicted higher number of overall health complaints as well as higher incidence rates of cardiovascular disease. The amount of illicit drug exposure did not predict an earlier age of diagnosis for cardiovascular or metabolic disease. Individuals in the Alcohol-Drug group had an increased incidence of deaths than either the alconly or the control groups.

Primary hepatic lymphoma with spindle cell components: a case report

Diffuse large B-cell lymphoma (DLBCL) with spindle cell components is extremely rare and often misdiagnosed as carcinoma or sarcoma. Here, we present a case of primary DLBCL with spindle cell components arising in the liver, for which a preoperative diagnosis by needle biopsies was unsuccessful. The patient was a 70-year-old man with a continuous cough. Thoracic computed tomography incidentally detected a mass of 5 cm in diameter in his liver. The initial and second needle biopsies from the liver mass were pathologically diagnosed as suspicious for sarcomatoid hepatocellular carcinoma. He underwent an extended left hepatectomy. Histological examination revealed a diffuse or epithelioid arrangement of round and polygonal cells, mixed with the fascicles of spindle-shaped cells. Immunohistochemically, all the morphological types of tumor cells showed positive reactions for a lymphocytic marker (CD45RB) and B-cell markers (CD20 and CD79a). Double-immunostaining revealed that the spindle-shaped tumor cells expressed CD20, but never expressed alpha-smooth muscle actin. Malignant lymphoma with a spindle cell morphology is quite uncommon, and this variant can be a diagnostic pitfall, especially in tiny biopsy specimens. We emphasize that pathologists should be reminded of lymphoma as a differential diagnosis of spindle cell tumors.

Acute liver failure due to natural killer-like T-cell leukemia/lymphoma: A case report and review of the Literature

Acute liver failure (ALF) is a medical emergency requiring immediate evaluation for liver transplantation. We describe an unusual case of a patient who presented with ascites, jaundice, and encephalopathy and was found to have ALF due to natural killer (NK)-like T cell leukemia/lymphoma. The key immunophenotype was CD2+, CD3+, CD7+, CD56+. This diagnosis, which was based on findings in the peripheral blood and ascitic fluid, was confirmed with liver biopsy, and was a contraindication to liver transplantation. A review of the literature shows that hematologic malignancies are an uncommon cause of fulminant hepatic failure, and that NK-like T-cell leukemia/lymphoma is a relatively recently recognized entity which is characteristically CD3+ and CD56+. This case demonstrates that liver biopsy is essential in diagnosing unusual causes of acute liver failure, and that infiltration of the liver with NK-like T-cell lymphoma/leukemia can cause acute liver failure.

Primary liver lymphoma in a patient with chronic hepatitis C

Primary liver lymphoma is a very rare disease and is frequently overlooked as a possible diagnosis. We report the case of an asymptomatic middle-aged man with chronic hepatitis C who developed primary liver lymphoma (PLL). A large solitary tumor in the left lobe of the liver was incidentally detected on routine ultrasound examination. Imaging studies showed mixed iso- and hypoechogenicity with hypoechoic rim, hypodense in the pre-contrast phase and thick wall enhancement in the post-contrast phase on computed tomographic study, hypointensity on T1WI, and hyperintensity of the central portion and slightly higher intensity in the peripheral wall on T2WI. These pictures were different from focal nodular hyperplasia, hepatocellular carcinoma, cholangiocarcinoma or metastases. Atypical hepatectomy was performed and the pathology of the hepatic tumor revealed non-Hodgkin's lymphoma. Systemic staging revealed no evidence of nodal or bone marrow involvement, so PLL was diagnosed. There was no tumor recurrence more than 4 years after operation and chemotherapy. PLL should be included in the differential diagnosis of solitary hepatic tumor in patients who are hepatitis C virus-positive, and who have atypical imaging and no known malignancy or elevated tumor marker levels.

Adult T-cell leukemia presenting with acute liver failure

Malignant infiltration of the liver is a rare cause of acute liver failure accounting for less than 1% of cases. We describe a case of adult T-cell leukemia (ATL) that presented with a prodromal illness that progressed to jaundice, hepatic encephalopathy, multisystem failure and death within 8 weeks. Liver histology revealed massive infiltration with atypical lymphocytes typical of ATL and liver necrosis.

Fulminant hepatic failure from primary hepatic lymphoma: successful treatment with orthotopic liver transplantation and chemotherapy

Systemic lymphomas may involve the liver but rarely cause fulminant hepatic failure (FHF). Acute liver failure from primary hepatic lymphoma (PHL) is even less common with most patients succumbing to the sequelae of FHF before the correct diagnosis is made. We report a patient who underwent successful orthotopic liver transplant (OLT) and chemotherapy for FHF secondary to PHL. This previously-well male developed profound coagulopathy and encephalopathy 6 weeks after the onset of jaundice and fatigue. Workup failed to reveal the underlying cause of his liver failure and the patient soon required urgent OLT. Pathologic evaluation of his explanted liver revealed a malignant T-cell rich, large B-cell non-Hodgkin's lymphoma with widespread hepatocellular necrosis. The patient made an excellent clinical recovery and is undergoing CHOP-Rituxan chemotherapy. This scenario demonstrates that lymphoma should be considered in the differential diagnosis of FHF without clear etiology because of the potential for intervention with transplant and chemotherapy.

Primary non-Hodgkin's lymphoma of the liver

We review the literature on primary hepatic lymphoma (PHL). PHL is a rare malignancy, and constitutes about 0.016% of all cases of non-Hodgkin's lymphoma. It has been reported to occur with increased frequency in patients with chronic hepatitis C infection. Most patients with PHL present with abdominal pain, constitutional symptoms and have hepatomegaly on examination. Imaging studies reveal solitary, or less often, multiple masses in the liver. The predominant histology is B-cell lymphoma, most commonly diffuse large cell type. Most patients are treated with chemotherapy, with some physicians employing a multimodality approach incorporating surgery and radiotherapy with chemotherapy. The prognosis is variable, with good response to early aggressive combination chemotherapy.