Abstract
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.
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Find the latest articles, discoveries, and news in related topics.Introduction
Hepatic lymphoma is more commonly secondary in nature due to systemic lymphoproliferative involvement. The Primary hepatic lymphoma is a rare disease that should be considered in the differential diagnosis of other primary hepatic malignancies, particularly cholangiocarcinoma, on cross-sectional imaging (Memeo et al. 1999). With this case, we share the imaging findings of this rare primary liver malignancy and highlight the pivotal role of F-18 FDG (2-fluoro 2-deoxy D glucose) PET/CT (positron emission tomography/ computed tomography) in its diagnosis.
Case report
A 37-year-old male presented with dragging sensation and mild pain in the right hypochondrium associated with weight loss for 1 month. Contrast-enhanced CT axial and sagittal images (Fig. 1; a-b) showed three hypo-enhancing hypodense lesions in the segments IV, V- VI and VII of the liver and absence of perilesional edema and regional lymph nodes with normal liver background. MRI of the liver (Fig. 2; a-g) showed T2 hyperintense lesions with marked restriction on the diffusion-weighted image and the corresponding apparent diffusion coefficient map suggesting high cellularity. Maximum Intensity Projection, fused axial and coronal images of F-18 FDG PET/CT (Fig.3; a-c) showed intense metabolic activity (SUV max- 20) in these liver lesions. There was no metabolically active disease elsewhere in the body. Serum Alpha-fetal protein, Cancer Antigen 19.9 (CA 19.9) and bilirubin were normal. Hepatitis (B and C) viral cytology was negative. Hepatic enzymes were raised with serum aspartate aminotransferase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP) being 86 U/l, 110 U/l and 152 U/l respectively. Serum lactate dehydrogenase was also elevated (410 U/l). Based on the CT, MRI, PET/CT findings a diagnosis of primary hepatic lymphoma was considered more likely than the intrahepatic cholangiocracinoma. Ultrasound guided biopsy of the liver lesion was performed. The histopathological examination and subsequent immunohistochemistry of the liver lesion (Fig. 4; a-h) confirmed the diagnosis of Germinal centre B-cell like Diffuse Large B- cell Lymphoma.
Multiphasic contrast enhanced MRI of liver. (a) Axial T2W image shows a hyperintense lesion (arrow) which depicts marked diffusion restriction on diffusion weighted image (b) and corresponding apparent diffusion coefficient (ADC) map (c) suggesting high cellularity of the lesion. Post-contrast T1W images in (d) early arterial, (e) late arterial, (f) portal venous, (g) hepatic venous phases show hypoenhancing lesion with mild progressive enhancement of the lesion
Discussion
Primary Non-Hodgkin’s lymphoma of liver is a rare disease (Memeo et al. 1999) with poor prognosis (Freeman et al. 1972). The absence of lymphadenopathy and extra-hepatic lesions differentiate it from the secondary hepatic involvement in lymphoproliferative disorders (Patel et al. 2015).Its risk factors include viral infections like HIV, HBV, HCV and EBV (Santos et al. 2003), immunosuppressive therapy (Rostaing et al. 1995) and cirrhosis (Goldin et al. 1993). Its primary treatment remains chemotherapy (Murthy et al. 2000), however surgery, radiotherapy and combined modalities have been documented (Daniel et al. 1985; Pescovitz et al. 1990; Page et al. 2001). On CT, the differential diagnoses include other primary hepatic tumors (hepatocellular carcinoma, cholangiocarcinoma, focal nodular hyperplasia), hepatic metastases and systemic lymphoma. Though literature is limited, a T2 hyperintense lesion with an intense diffusion restriction on MRI and focal or diffuse FDG uptake on PET/CT with absence of other systemic (extra-hepatic) and nodal involvement is documented in few reports (Basheer et al. 2022; Mahajan et al. 2016; Seshadri et al. 2010; Bohlok et al. 2018).The space-occupying lesions in the liver that show high metabolic activity on F-18 FDG PET/CT include metastases, lymphoma (systemic), cholangiocarcinoma and poorly differentiated hepatocellular carcinoma or neuroendocrine carcinoma (Rachh and Basu 2014). Differential diagnosis in our case was intrahepatic cholangiocarcinoma due to its multi-focal, hypovascular nature in a non-cirrhotic liver (Seo et al. 2017). However, the absence of biliary dilatation, vascular invasion, capsular retraction with presence of marked diffusion restriction , intense metabolic activity in the liver lesions and normal serum CA19.9 were against this diagnosis. In this case, we highlight the imaging of primary hepatic lymphoma in the differential diagnoses of space-occupying lesions of the liver with normal tumor markers and elevated serum lactate dehydrogenase. (see Figs. 3, 4).
Germinal centre B-cell like Diffuse Large B- cell Lymphoma. a) Hematoxylin and Eosin staining (H&E), 400x image shows diffuse infiltration of atypical lymphoid cells exhibiting nuclear pleomorphism. Immunohistochemistry revealed membranous expression of Bcl6 (b), CD 20 (c) and CD 10 (d) with high Ki 67 index (> 90%, e). It was immunonegative for Bcl2 (f) and Pancytokeratin (g) with few interspersed T cells on CD3 (h)
Conclusion
The hybrid F-18 FDG PET/CT is of significant importance in differentiating primary hepatic lymphoma from other primary malignancies of the liver due to its intense metabolic activity.
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References
Basheer S, Kumar Gauthaman D, Subramanyam P, Palaniswamy SS (2022) 18 F-FDG whole-body PET-MR in primary hepatic lymphoma mimicking focal nodular Hyperplasia. World J Nucl Med 21:338–341
Bohlok A, De Grez T, Bouazza F, De Wind R, El-Khoury M, Repullo D et al (2018) Primary Hepatic Lymphoma Mimicking a Hepatocellular Carcinoma in a Cirrhotic Patient: Case Report and Systematic Review of the Literature. Case Rep Surg. ; 2018:9183717
Daniel SJ, Attiyeh FF, Dire JJ, Pyun HJ, Carroll DS, Attia A (1985) Primary lymphoma of the liver treated with extended left hepatic lobectomy. Cancer 55:206–209
Freeman C, Berg JW, Cutler SJ (1972) Occurrence and prognosis of extranodal lymphomas. Cancer 29:252–260
Goldin R, Sayer J, Wilkins M, Price P, Thomas H (1993) Primary liver lymphoma associated with primary biliary cirrhosis. Histopathology 22:184–185
Mahajan S, Kalra S, Chawla M, Dougall P (2016) Detection of diffuse infiltrative primary hepatic lymphoma on FDG PET-CT: Hallmarks of hepatic superscan. World J Nucl Med 15:142–144
Memeo L, Pecorello I, Ciardi A, Aiello E, De Quarto A, Di Tondo U (1999) Primary non-hodgkin’s lymphoma of the liver. Acta Oncol 38:655–658
Murthy SA, Singh B, Bhalla S, Arora A, Vohra R, Aggarwal S (2000) Cure in a case of primary hepatic lymphoma. Indian J Cancer 37:165–172
Page RD, Romaguera JE, Osborne B, Medeiros LJ, Rodriguez J, North L et al (2001) Primary hepatic lymphoma: favorable outcome after combination chemotherapy. Cancer 92:2023–2029
Patel TS, Malvania R, Shah MC, Shah MJ, Gami AG (2015) Primary hepatic lymphoma: a case report. J Cytol 32:36–38
Pescovitz MD, Snover DC, Orchard P, Neglia JP, Najarian JS, Payne WD (1990) Primary hepatic lymphoma in an adolescent treated with hepatic lobectomy and chemotherapy. Cancer 65:2222–2226
Rachh S, Basu S (2014) PET/CT in patients with liver lesions of different nature. Clin Translational Imaging 2:139–155
Rostaing L, Suc B, Fourtanier G, Baron E, L loveras JJ, Durand D (1995) Liver B cell lymphoma after liver transplantation. Transplant Proc. ; 27:1781-2
Santos ES, Raez LE, Salvatierra J, Morgensztern D, Shanmugan N, Neff GW (2003) Primary hepatic non-hodgkin’s lymphomas: case report and review of the literature. Am J Gastroenterol 98:2789–2793
Seo N, Kim DY, Choi JY (2017) Cross-sectional imaging of Intrahepatic Cholangiocarcinoma: Development, Growth, Spread, and prognosis. AJR Am J Roentgenol 209:W64–W75
Seshadri N, Ananthasivan R, Kavindran R, Srikanth G, Chandra S (2010) Primary hepatic (extranodal) lymphoma: utility of [(18)F] fluorodeoxyglucose-PET/CT. Cancer Imaging 10:194–197
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TY - Concept of article, acquisition, interpretation of CT, MRI data, acquisition of histopathological data, manuscript editing, DD - Concept of article, acquisition, interpretation of PET/CT data, manuscript draft and editing, PE-acquisition, interpretation of histopathological data, manuscript editing. VV -Clinical management, manuscript editing, RK - acquisition, interpretation of PET/CT data, manuscript editing. All authors approved the final version to be published and agree to be accountable for accuracy and integrity of the whole work.
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Yadav, T., Datta, D., Elhence, P. et al. Primary hepatic diffuse large B- cell lymphoma mimicking cholangiocarcinoma. EJNMMI Rep. 8, 23 (2024). https://doi.org/10.1186/s41824-024-00215-7
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DOI: https://doi.org/10.1186/s41824-024-00215-7