Primary hepatic lymphoma: Imaging findings

Contrast-enhanced ultrasound findings of primary hepatic non-Hodgkin's lymphoma: a case report

Primary hepatic lymphoma (PHL) is rare, and its early diagnosis is difficult. This article presents a primary hepatic non-Hodgkin's lymphoma (NHL) case report. A 52-year-old woman was admitted to the hospital due to a fever. After undergoing laboratory examination, contrast-enhanced computed tomography (CT), ultrasound, and contrast-enhanced ultrasound (CEUS), only CEUS suggested malignancy. Then, the patient underwent a laparoscopic liver biopsy, which diagnosed NHL. Previous studies have shown that hepatic lymphoma is a hypoglycemic tumor, and the enhanced CT and magnetic resonance imaging (MRI) scans are mostly mildly intensified. At the same time, the two-dimensional and color Doppler ultrasonography are mostly atypical. CEUS has unique advantages in displaying micro-vessels, which can be helpful in the diagnosis of primary hepatic lymphoma.

An Unusual Presentation of Primary Hepatic Lymphoma

Primary hepatic lymphoma (PHL) is a rare disease that usually manifests as a heterogenous solitary intrahepatic mass, multiple lesions or a diffuse infiltrative form. PHL presenting as a small focal area of hepatic involvement and a large predominant extrahepatic component is uncommon. We report a histopathologically proven case of primary hepatic lymphoma that caused significant diagnostic dilemma on contrast-enhanced computed tomography due to its unusual imaging appearance as a hypo-enhancing intra-abdominal solid mass with relatively small area of hepatic parenchymal involvement and a large exophytic component.

Clinicopathologic Features of Lymphoproliferative Neoplasms Involving the Liver

Background and Objectives: Primary hepatic lymphoproliferative neoplasms (PHL) are uncommon. This retrospective study is aimed to present the clinicopathological characteristics of PHL and compare to secondary hepatic lymphoproliferative neoplasms (SHL). Materials and Methods: Patients who were diagnosed with lymphoproliferative neoplasms involving the liver between January 2004 and December 2018 at a tertiary medical center in central Taiwan were included. The demographic and clinical data, radiological results and histopathological findings were reviewed and summarized. Results: We analyzed 36 patients comprising 6 PHL patients and 30 SHL patients. The median age at diagnosis tended to be younger in PHL than in SHL (59 vs. 63 years old, p = 0.349). Both entities had a small male predominance. The PHL patients tended to have higher levels of aspartate aminotransferase, alanine transaminase and serum albumin and lower levels of alkaline phosphatase, total bilirubin, γ-glutamyl transferase and lactate dehydrogenase compared with SHL, but there was no significant difference. Multiple mass lesions were the most common radiological finding in both groups. Diffuse large B-cell lymphoma was the predominant subtype in both groups (67% in PHL and 40% in SHL). The PHL patients had a longer median survival than the SHL patients (not reached vs. 3 months, p = 0.003). Conclusions: Although there was no significant difference between PHL and SHL in clinical, laboratory and radiological features, the SHL patients had very poor outcomes with a median survival time of 3 months. Effective therapies are urgently required for these patients.

FDG-PET/CT Variants and Pitfalls in Haematological Malignancies

Hematologic malignancies represent a vast group of hematopoietic and lymphoid cancers that typically involve the blood, the bone marrow, and the lymphatic organs. Due to extensive research and well defined and standardized response criteria, the role of [¹⁸F]FDG-PET/CT is well defined in these malignancies. Never the less, the reliability of visual and quantitative interpretation of PET/CT may be impaired by several factors including inconsistent scanning protocols and image reconstruction methods. Furthermore, the uptake of [¹⁸F]FDG not only reflects tissue glucose consumption by malignant lesions, but also in other situations such as in inflammatory lesions, local and systemic infections, benign tumors, reactive thymic hyperplasia, histiocytic infiltration, among others; or following granulocyte colony stimulating factors therapy, radiation therapy, chemotherapy or surgical interventions, all of which are a potential source of false-positive or negative interpretations. Therefore it is of paramount importance for the Nuclear Medicine Physician to be familiar with, not only the normal distribution of [¹⁸F]FDG in the body, but also with the most frequent findings that may hamper a correct interpretation of the scan, which could ultimately alter the patients management. In this review, we describe these myriad of situations so the interpreting physician can be familiar with them, providing tools for their correct identification and interpretation when possible.

Primary hepatic diffuse large B-cell lymphoma presenting unusual imaging features

Primary hepatic lymphomas are frequently misdiagnosed, due to their rarity and non-specific clinical manifestations. As these tumors can be successfully treated with chemotherapy and/or radiotherapy, early recognition on imaging is essential to avoid unnecessary surgery. We report a case of primary hepatic lymphoma in a 73-year-old woman presenting with a 1-week history of persistent fever and elevated hepatobiliary enzymes. Ultrasound showed a hypoechoic hepatic mass in the anterior segment. Dynamic contrast-enhanced computed tomography (CT) revealed an ill-defined solitary mass showing peripherally dominant slight-to-moderate enhancement contrasting with a hypovascular central area. On magnetic resonance imaging, the mass showed moderate hyperintensity on T2-weighted imaging, hypointensity on T1-weighted imaging, doughnut-like hyperintensity on diffusion-weighted imaging, and an obviously low apparent diffusion coefficient (ADC). The pattern of enhancement resembled that of CT. Neither calcification nor any fat component was observed. Doughnut-like accumulation was seen on ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography/CT without other FDG-avid lesions. Imaging findings suggested the possibility of cholangiocellular carcinoma, but the low ADC and extremely high FDG accumulation were suggestive of malignant lymphoma, and diffuse large B-cell lymphoma was pathologically confirmed from percutaneous biopsy. The mass disappeared after radiochemotherapy, and no recurrence has been observed for 3 years.

LI-RADS to categorize liver nodules in patients at risk of HCC: tool or a gadget in daily practice?

PURPOSE

To determine the effectiveness of liver reporting and data system (LI-RADS) to diagnose hepatocellular carcinoma (HCC) and to retrospectively evaluate its impact on the adopted therapeutic strategy.

MATERIALS AND METHODS

Preoperative imaging of 40 of 350 patients (median age 66, 31 M/9 F) submitted to liver resection for suspected HCC, between January 2008 and August 2019, has been retrospectively analyzed by two radiologists with different expertise, according to CT/MRI LI-RADS^® v2018, both blinded to clinical and pathological results and untrained to using aforementioned scoring system.

RESULTS

The perfect agreement between the readers was about 62.5% (25/40) (Cohen k: 0.41), better for LR-5 category (16/25) and higher in magnetic resonance imaging (MRI) investigations (68%; 13/19), which has been demonstrated the modality of choice for diagnosis of high probable and certain HCC, with arterial phase hyperenhancement as the most sensitive and accurate major feature. Compared to final histology, LR4 and LR5 scores assigned by senior radiologist reached sensitivity, specificity, positive and negative predictive values (PPV, PNV) and diagnostic accuracy of 90,9%, 29,0%, 93,8%, 62,5% and 87,5%, respectively, slightly higher than junior's ones. Misdiagnosis of HCC was done by both radiologists in the same two patients: 1 primary hepatic lymphoma (PHL) and 1 regenerative liver nodule (RLN). If LI-RADS would have been applied at the time of pre-surgical imaging, treatment planning would be modified in 10% of patients (4/40); the patient scheduled as LR-3 and finally resulted a focal nodular hyperplasia would have avoided liver resection.

CONCLUSIONS

Application of LI-RADS, especially on MRI, may provide a more accurate evaluation of suspected HCC. PHL and RLN are the Achille's heels according to our experience.

[Extranodal abdominal lymphomas]

BACKGROUND

Extranodal manifestations occur in up to 40% of non-Hodgkin lymphomas. The prevalence of extranodal involvement has increased.

OBJECTIVES

A comprehensive overview on lymphoma involvement in the parenchymatous abdominal organs, the gastrointestinal tract, and the peritoneal cavity under due consideration of clinical implications is given.

MATERIALS AND METHODS

A selective literature search with analysis of dedicated original research articles and reviews was carried out. Clinical guidelines are discussed.

RESULTS

Extranodal abdominal lymphoma involvement usually occurs secondarily in advanced disease. Sites involved most frequently are the liver and the gastrointestinal tract. Extranodal abdominal lymphoma involvement is more common in the immunocompromised patient.

CONCLUSION

Imaging findings of extranodal abdominal lymphoma are variable. Lymphoma is an important differential diagnosis to be considered in unclear tumor diseases.

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.

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.

Hematologic malignancies of the liver: spectrum of disease

The incidence of hematologic malignancies and their extranodal manifestations is continuously increasing. Previously unsuspected hepatic involvement in hematologic malignancies such as Hodgkin disease and non-Hodgkin lymphoma, posttransplant lymphoproliferative disorder, myeloid sarcoma (chloroma), multiple myeloma, Castleman disease, and lymphohistiocytosis may be seen by radiologists. Although the imaging features of more common hepatic diseases such as hepatocellular carcinoma, metastases, and infection may overlap with those of hepatic hematologic malignancies, combining the imaging features with clinical manifestations and laboratory findings can facilitate correct diagnosis. Clinical features that suggest a hematologic neoplasm as the cause of liver lesions include a young patient (<40 years of age), no known history of cancer, abnormal bone marrow biopsy results, fever of unknown origin, and night sweats. Imaging features that suggest hematologic malignancy include hepatosplenomegaly or splenic lesions, vascular encasement by a tumor without occlusion or thrombosis, an infiltrating mass at the hepatic hilum with no biliary obstruction, and widespread adenopathy above and below the diaphragm. Familiarity with the imaging features of hepatic hematologic malignancies permits correct provisional diagnosis and may influence therapeutic management. For example, when biopsy is performed, core biopsy may be needed in addition to fine-needle aspiration so that the tissue architecture of the neoplasm can be discerned. The predominant treatment of hematologic malignancies is chemotherapy or radiation therapy rather than surgery. Online supplemental material is available for this article.

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.

The imaging conundrum of hepatic lymphoma revisited

Abstract

The imaging manifestations of hepatic lymphoma, both in its primary and secondary form, are extremely variable and overlap with a number of other more common hepatic diseases. However, in the appropriate clinical context, combining the imaging and laboratory features can aid in making the correct diagnosis. Since the management and prognosis of lymphomas are significantly different from other malignancies, early diagnosis and prompt commencement of therapy is of paramount importance. The various morphological appearances of hepatic lymphoma on imaging have been described here along with their possible differentials.

Teaching points

• Primary hepatic lymphoma is extremely rare.

• Secondary liver involvement occurs in 50 % of patients with non-Hodgkin lymphoma.

• The imaging manifestations of hepatic lymphoma are largely non-specific.

• Some imaging features may be helpful in the appropriate clinical setting.

• Management and prognosis of lymphoma is significantly different from other malignancies.

Primary hepatic non-Hodgkin's lymphoma with rectal cancer: A case report

Primary hepatic non-Hodgkin’s lymphoma (NHL) is an extremely rare disease that is commonly neglected as a possible diagnosis. The present study reports the case of a middle-aged male with chronic hepatitis B in which primary hepatic NHL and rectal cancer occurred simultaneously. A large solitary tumor in the left lobe of the liver was incidentally detected on routine examination prior to the laparoscopic resection of the rectal cancer. Laparoscopic resection of the rectal cancer and a liver biopsy were performed simultaneously. The pathology revealed that the hepatic tumor was NHL and that the rectal cancer was adenocarcinoma. Systemic staging revealed no evidence of nodal or bone marrow involvement, therefore, primary hepatic lymphoma (PHL) was diagnosed. PHL associated with rectal adenocarcinoma is extremely rare and to the best of our knowledge, has never been reported. At present, the cause and most effective therapy for the condition remain unclear.

Primary hepatic peripheral T-cell lymphoma: A case report

Primary hepatic peripheral T-cell lymphoma (PHL) is extremely rare. A case of primary hepatic peripheral T-cell lymphoma of a 59-year-old male is presented in the current study. PHL lesions are diagnosed by the existence of a hepatic mass, in the absence of lymphadenopathy, splenomegaly or bone marrow involvement associated with normal tumor markers. Treatment options are surgical resection and subsequent chemotherapy. Histopathological examination by immunohistochemical staining of the tissue biopsies at laparotomy confirmed a diagnosis of PHL.

A novel use of early radiation therapy in the treatment of hyperbilirubinemia in a patient with primary hepatic lymphoma and chronic hepatitis C

Lymphomas arising in the liver are extremely rare. Here, we describe a case of Hepatitis C virus infection with primary hepatic lymphoma (PHL) presenting with hyperbilirubinemia. A 45-year-old African American male presented with abdominal pain, pruritus, and itching for two days. CT of abdomen and pelvis with contrast showed numerous masses in the liver. The liver biopsy was consistent with diffuse large B cell lymphoma (DLBCL). Conventional chemotherapy was avoided initially because of hyperbilirubinemia. Hence, radiation therapy was given initially to reduce his bilirubin levels and tumor size. The patient was able to complete six cycles of rituximab combined with cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) chemotherapy and achieved a complete response verified by positron emission tomography-computed tomography (PET-CT). PHL should be considered when there are numerous space occupying liver lesions seen on imaging. Hyperbilirubinemia may be a reason for delay in treatment for some of these patients. Hence, the role of radiation therapy prior to treatment with R-CHOP is an alternative to management for stage IV diffuse large B cell lymphoma.

Contrast-enhanced ultrasound in the preoperative, intraoperative and postoperative assessment of liver lesions

The use of contrast agents (CA) with liver ultrasound (US) has gained recently an established role for the diagnosis of various hepatic diseases due to their safety, high versatility and low costs (contrast-enhanced ultrasound: CEUS). The purpose of this review is to provide a state-of-the-art summary of the available evidence for their use in the characterization of focal liver lesions. A published work search was conducted for all preclinical and clinical studies involving CA on hepatic US imaging. CEUS increases the sensitivity for lesion detection and the specificity to differentiate between benign and malignant diseases due to the enhanced visualization of the tumor microcirculation. Results achieved seem at least equivalent to those of spiral computed tomography or magnetic resonance imaging. The association of CA with intraoperative ultrasound has changed the surgical approach in 25% of patients and guarantees complete ablations by a single session in most of them. CEUS provides detailed information about tumor vasculature, improves the preoperative characterization and therefore the therapeutic strategy, and can evaluate the intraoperative completeness of the ablation.

Primary hepatic lymphoma: dilemmas in diagnostic approach and therapeutic management

Primary hepatic lymphoma (PHL) is a very rare malignancy and is characterized by liver involvement at presentation with no affectation of the spleen, lymph nodes, peripheral blood, bone marrow, or other tissues until at least 6 months after diagnosis. PHL should be considered in the differential diagnosis in a patient with space-occupying liver lesions and normal levels of alpha-fetoprotein and CEA. A computed tomography (CT) scan is the commonly used modality for staging lymphomas. The widespread use of positron emission tomography/CT results in the improvement in the accuracy of detecting the extent of disease, response evaluation, and prognostication. The liver biopsy, due to its pleomorphic appearances in the needle biopsy specimen, can be very challenging. Current literature favors the combination of chemotherapy as the frontline treatment for its least invasiveness and improved survival. Favorable prognosis of PHL can be obtained by early surgery combined with chemotherapy in strictly selected patients. However, the optimal therapy is still unclear and the outcomes are uncertain.

Imaging of multifocal liver lesions in children and adolescents

Multifocal liver lesions are encountered regularly in children and adolescents. By knowing the specific ultrasonographic, computed tomographic, and magnetic resonance imaging (MRI) features of benign and malignant pediatric liver lesions as well as the particular clinical setting, radiologists can frequently narrow the differential diagnosis and sometimes offer a definitive diagnosis. The purpose of this review article is to illustrate the imaging findings of numerous benign and malignant causes of multifocal liver lesions in the pediatric population.

18F-fluorodeoxyglucose PET/CT findings of a solitary primary hepatic lymphoma: A case report

Primary hepatic lymphoma is extremely rare, and only a few cases have been described on positron emission tomography (PET) or PET/computed tomography (PET/CT) imaging in the English literature. We report a case of a 55-year-old woman who presented with low-grade fever and weight loss of three months. On CT scanning, a mass was identified which appeared to be a hypoattenuating lesion, on ultrasonographic imaging, the mass was hypoechoic, therefore, liver abscess or hepatic metastasis from a gastrointestinal primary was initially suspected. Tumor markers such as alpha-fetoprotein, carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. PET/CT demonstrated a large abnormal ring-like hypermetabolic focus in the right liver lobe. The lesion was resected and the histopathological findings were consistent with lymphoma. The patient was discharged two weeks after surgery and did not receive any further treatment. After 25 mo follow-up, she is in good health. ¹⁸F-fluorodeoxyglucose PET/CT is useful in confirming the diagnosis of primary hepatic lymphoma by demonstrating no other foci with high uptake in other parts of the body.

Progress in research of primary hepatic lymphoma

Primary hepatic lymphoma (PHL) is a rare malignancy whose pathogenesis is still unclear. Most PHL patients present with upper abdominal pain, upper abdominal distention or discomfort. Laboratory tests may reveal either a cholestatic or a cytolytic process, with elevated lactate dehydrogenase in most patients. Imaging tests often reveal an isolated lesion in the liver. The predominant histological type of PHL is B-cell lymphoma. At present, there are no standard diagnostic criteria for PHL. PHL is often misdiagnosed as many other liver diseases. Biopsy is usually performed to make a definite diagnosis. Treatment options for PHL include various modalities, and the prognosis of PHL is better than that of primary hepatic carcinoma.