Misdiagnosis of primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue type, a case report

"Speckled Enhancement" on Gd-EOB-DTPA Enhanced MR Imaging of Primary Hepatic Mucosa-associated Lymphoid Tissue Lymphoma

PURPOSE

To elucidate MRI features of primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma, particularly, the "speckled enhancement" on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI.

METHODS

The institutional review board approved this retrospective observational study and waived informed consent. Using our picture archiving and communication systems and electronic medical records, five patients histopathologically diagnosed as hepatic MALT lymphoma and clinically confirmed as primary lesions who had undergone dynamic contrast-enhanced (DCE)-CT and DCE-MRI with Gd-EOB-DTPA were identified from September 2009 to December 2020. Two radiologists assessed their CT and MRI data in consensus with a pathologist's advice.

RESULTS

Overall, five lesions in five patients were included in this study. Precontrast CT showed hypoattenuation in all lesions. In the arterial phase of DCE-CT, four lesions (80%) showed hyperattenuation, whereas all lesions showed iso- to hypoattenuation in the delayed phase. A vessel penetration sign was also observed in all lesions. On MRI, all lesions showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and restricted diffusion on diffusion-weighted images. Both DCE-CT and DCE-MRI with Gd-EOB-DTPA showed similar enhancement patterns, except for the hepatocyte phase. Notably, however, four out of five lesions showed characteristic "speckled enhancement" that refers to punctate positive enhancements within the low signal lesions on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI pathologically confirmed to be hepatocyte clusters that remained in the tumor.

CONCLUSION

Primary hepatic MALT lymphomas were characterized by arterial phase enhancement, restricted diffusion, vessel penetration sign, and more specifically "speckled enhancement" in the hepatobiliary phase of DCE-MRI with Gd-EOB-DTPA.

Primary hepatic lymphoma of MALT type mimicking hepatic adenoma treated by hepatectomy: a case report and literature review

Background

Primary hepatic lymphoma (PHL) is a rare malignant tumor. Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) is an indolent lymphoma occurring at extranodal sites. The stomach is the most common organ affected by MALT lymphoma, whereas liver-related lymphoma is rarely reported. Its atypical clinical presentation often delays the diagnosis. Owing to the rarity of PHL, identifying its optimal treatment still remains a challenge. Herein, we report a case of PHL of the MALT type mimicking hepatic adenoma that was treated by hepatectomy without chemotherapy and review the scarce literature. Our findings suggest that surgery is an alternative approach to cure patients with localized hepatic lymphoma.

Case summary

A 55-year-old woman was admitted to our hospital because of upper abdominal discomfort, and a liver lesion was detected by computed tomography. She did not have nausea, fever, fatigue, jaundice, weakness, night sweats, or weight loss before admission. And her previous medical history was unremarkable. There were no positive signs on physical examination. Based on her preoperative examination including magnetic resonance imaging, the liver lesion was suspected to be a hepatic adenoma; however, the possibility of it being a malignancy like hepatocellular carcinoma was not excluded. Therefore, a decision of resection of the lesion was made. During the operation, hepatectomy of segment 4b and cholecystectomy were performed. The patient recovered well; however, after postoperative pathological examination, the lesion was diagnosed as a hepatic lymphoma of MALT type. The patient was reluctant to undergo chemotherapy or radiotherapy. At 18-month follow-up, no significant recurrence was observed, indicating that the treatment had a curative effect.

Conclusion

Notably, primary hepatic lymphoma of MALT type is a rare, low-grade B-cell malignancy. Making an accurate preoperative diagnosis of this disease is usually difficult, and liver biopsy is an appropriate avenue to improve the diagnostic accuracy. In patients with a localized tumor lesion, hepatectomy followed by chemotherapy or radiotherapy should be considered to achieve better outcomes. Although this study describes an unusual type of hepatic lymphoma mimicking a benign tumor, it has its inherent limitations. More clinical studies are required to establish guidelines for the diagnosis and treatment of this rare disease.

Primary hepatic extranodal marginal zone B-cell mucosa-associated lymphoid tissue lymphoma treated by laparoscopic partial hepatectomy: a case report

BACKGROUND

Primary hepatic extranodal marginal zone B-cell mucosa-associated lymphoid tissue (MALT) lymphoma is very rare, so it is difficult to diagnose preoperatively. And there is no established treatment for hepatic MALT lymphoma. We report herein a case of primary hepatic MALT lymphoma treated by laparoscopic partial hepatectomy, and discuss the usefulness of laparoscopic hepatectomy for a rare liver tumor.

CASE PRESENTATION

This patient was a woman in her 60s, who was diagnosed preoperatively as having synchronous liver metastasis from sigmoid colon cancer; therefore, laparoscopic partial hepatectomy was performed. She had a good course after the operation and was discharged on postoperative day 12. However, she was diagnosed pathologically as having primary hepatic MALT lymphoma. A bone marrow biopsy was also performed, and then she was finally diagnosed as having limited-stage primary hepatic MALT lymphoma. She received no postoperative treatment and showed no recurrence for 4 years postoperatively.

CONCLUSIONS

We experienced the good result of the patient with limited-stage primary MALT lymphoma treated by laparoscopic partial hepatectomy. Liver tumors are sometimes misdiagnosed by imaging examinations alone. Laparoscopic hepatectomy has been widespread recently as a minimally invasive procedure, and it may be useful for both diagnosis and treatment.

Primary hepatic mucosa-associated lymphoid tissue lymphoma: case report and literature review

BACKGROUND

The prevalence of primary hepatic mucosa-associated lymphoid tissue (MALT) lymphomas is extremely low. Here, we describe a case of this disease misdiagnosed as hepatocellular carcinoma (HCC) and review relevant literature to prevent future misdiagnoses.

CASE PRESENTATION

a 58-year-old woman complained about abdominal pain for more than four months. About two months prior, she came to our hospital with elevated levels of HBV DNA and positive HBsAg and HBcAb. After two months of entecavir treatment, HBV DNA decreased to a normal level. She returned to the hospital with worsened abdominal pain for over a month. Magnetic resonance imaging and systemic positron emission tomography-computed tomography identified two nodes in the liver, and she was diagnosed with HCC. The patient then underwent a laparoscopic hepatectomy. Microscopic examination showed a diffuse infiltrate of small-to-medium-sized lymphocytes and lymphoepithelial lesions. Immunohistochemical staining showed that most of the lymphoid cells were strongly positive for CD20, CD79a, BCL2, IgM and weakly positive for IgD, while negative for CD3, CD10, BCL6, MUM1, CD43, CD5, cyclin D1, CD23, CD30, and PD1. The Ki-67 index of lymphoid cells was 5%. Further pathologic analysis confirmed the diagnosis of primary hepatic MALT lymphoma. The patient received antiviral treatment and recovered well with no sign of relapse for 17 months.

CONCLUSIONS

Primary hepatic MALT lymphoma is an uncommon disease that is difficult to diagnose and has no widely accepted treatment. Surgical resection is a good choice for both diagnosis and local therapy, and strict follow-up of the patient is essential.

Primary hepatic extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), is one of the specific type of low-grade B-cell lymphoma not infrequently found worldwide. It typically involves mucosal sites such as stomach and conjunctiva; however, primary hepatic MALT lymphoma has been extremely rarely reported. We describe a case of hepatic MALT lymphoma in a 70-year-old male patient who underwent left hepatectomy due to the incidentally detected liver masses at a medical checkup. The resected specimen revealed multinodular masses consisting of small-to-intermediate-sized lymphoid cells with serpentine pattern and focal lymphoepithelial lesions. The tumor cells were diffusely positive for CD20 and Bcl-2 but negative for CD3, CD10, CD5, CD23, CD43, and cyclinD1. The Ki-67 labeling index was 10% and immunoglobulin heavy chain gene rearrangement study confirmed monoclonal proliferation. In this paper, we discuss several unique clinicopathologic characteristics which will be helpful to the differential diagnosis of hepatic MALT lymphoma.

Primary hepatic mucosa-associated lymphoid tissue lymphoma: A case report and literature review

RATIONALE

Primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease, and there is no consensus yet on the treatment modalities. Here, we report a new case of MALT lymphoma and review the current literature on this disease.

PATIENT CONCERNS

A 73-year-old man was admitted to our department following the incidental finding of a solitary 1.8-cm diameter mass in the liver.

DIAGNOSIS

Microscopic findings identified the mass as a tumor with infiltration of diffuse atypical B lymphocytes. Immunohistochemical analysis showed positivity for CD20 and CD79a, and negativity for CD3 and CD5. These collective data led to the diagnosis of primary hepatic MALT lymphoma.

INTERVENTIONS

The tumor was removed by surgical resection. The patient refused additional treatment after the surgery.

OUTCOMES

At the time of writing this report, the patient has been disease free for 6 months postsurgery.

LESSONS

Review of the previously published case reports on this rare tumor type indicates that in addition to chronic liver inflammation due to infection or other reasons, genetic aberrations can also contribute to the development of hepatic MALT lymphoma. Additionally, IgH rearrangement is a good genetic hallmark of this tumor. Owing to no specific clinical or radiologic features to define the disease profile for diagnosis, surgery may be a good choice for both diagnosis and therapy if the patient's condition permits.

An unusual case of hepatic lymphoma with multiple epithelial malignancies

Primary hepatic mucosa-associated lymphoid tissue lymphoma (MALToma) is a rare entity. Its coexistence with other malignancies is even rarer. Only few case reports of its association with other malignancies mostly gastric and colon cancer have been published. We report a case of primary MALToma of liver in an unusual setting of dual solid malignancy.

Primary Hepatic Lymphoma Mimicking a Hepatocellular Carcinoma in a Cirrhotic Patient: Case Report and Systematic Review of the Literature

Introduction

Primary hepatic lymphomas (PHLs) are rare liver tumors, frequently misdiagnosed preoperatively. As these tumors could be successfully treated with chemotherapy, their early recognition is essential, potentially, to avoid useless surgery. We report on the case of a cirrhotic patient with hemochromatosis who presented a PHL, initially diagnosed as a hepatocellular carcinoma (HCC), and we analyze recent data from the literature on this subject.

Case Presentation and Review of the Literature

A 45 mm liver tumor was found is a 68-year-old man with alcohol cirrhosis and hemochromatosis. At imaging, the diagnosis of HCC was suspected according to vascular characteristics and the presence of cirrhosis. FDG PET scan showed a solitary hypermetabolic liver tumor. Tumor markers were negative. Surgery consisted in left lateral hepatectomy. At pathology, the diagnosis of the primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) type was demonstrated. Twenty-two articles reporting 33 cases of true PHL of MALT type were found. Presentation lacked specific symptoms (70% asymptomatic). Half of patients were suspected to have other etiologies of liver mass (HCC, intrahepatic cholangiocarcinoma), and thus diagnosis was established postoperatively. In the patient, diagnosis was made by preoperative biopsy, and chemotherapy was first-line treatment.

Discussion

Preoperative diagnosis of PHL, and particularly of primary hepatic MALT lymphoma, is challenging. This case illustrates that PHL remains to be considered among the differential diagnosis of isolated solid liver tumors. Further, it indicates that biopsy could be still indicated in case of suspected HCC in cirrhotic patients, particularly in the presence of unusual findings such as the combination of a FDG PET scan positive tumor in the absence of elevated alpha-fetoprotein.

Prognostic value of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in primary hepatic mucosa-associated lymphoid tissue lymphoma: A case report and review of the literature

INTRODUCTION

Primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma is extremely rare and we herein report a case of a patient suffering from primary hepatic MALT lymphoma with concomitant hepatitis B virus infection.

DIAGNOSTIC MODALITIES AND OUTCOME

Double masses were found in a 59-year-old Chinese female patient. We reported the laboratory results, computed tomography (CT) and fluorine-18-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/CT images among other findings. As far as we know, only 9 cases have been reported till now using F-FDG PET/CT imaging. Our patient's lesions were found to conform to standard uptake values of FDG.

CONCLUSION

It indicates that hepatic MALT lymphoma can be studied with F-FDG PET/CT like other F-FDG-avid lymphomas. It was also noted that delayed-time-point FDG PET imaging may further improve the detection of the MALT lymphoma in liver. Although the patient in this case refused further treatment, potential management options, including rituximab, which is also discussed in this review.

Primary hepatic mucosa-associated lymphoid tissue lymphoma in a patient with no chronic liver disease: Case report

Extramarginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is a non-Hodgkin lymphoma of low-grade malignancy. The most common localization is the stomach, and the common nongastric sites are salivary glands, the skin, orbits, the conjunctiva, the lung, breasts, upper airways, other gastrointestinal sites, and the liver. Primary hepatic MALT lymphoma is a rare disease and the diagnostic can be challenging. The clinical presentation is nonspecific and may range from no symptoms to end-stage liver disease. The radiological aspect of hepatic lymphoma may indicate this diagnosis; however, the final diagnosis is made by hepatic biopsy. We report the case of a 47-year-old woman with no chronic liver disease, incidentally found with a focal liver mass at ultrasound examination. The only clinical symptom was fatigue. The blood tests were normal and tumoral markers were negative. Computed tomography and magnetic resonance imaging were performed. However, because the hepatic lesion was first described as a benign entity and, at second opinion, the suspicion of lymphoma was raised, the patient decided to undergo surgery first, without prior biopsy. The histopathologic analysis confirmed the diagnosis: hepatic MALT lymphoma positive for CD 20 and negative for CD 5, BCL6, cyclin D1, and CD 23. No lymph node involvement was noted and follow-up imaging with positron emission tomography-computed tomography did not show any other site of disease, thus confirming the diagnosis of primary hepatic MALT lymphoma. The aim of this paper was to highlight the imagistic features of primary hepatic lymphoma to contribute to the early diagnosis of this rare disease entity.

Primary hepatic extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type: A case report and literature review

RATIONALE

Primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma is an extremely rare disease. To the best of our knowledge, only 67 cases had been reported in 39 English literatures to date. The aim of this study was to add a new case of this disease to the literature and to review the current literature.

PATIENT CONCERNS

A 50-year-old man was incidentally identified with a solitary mass of 5 cm in diameter in the left lobe of the liver.

DIAGNOSES

Based on the results of imaging studies, intrahepatic cholangiocellular carcinoma was suspected, and then surgery was performed. Microscopic findings showed that the tumor was a hepatic MALT lymphoma, and immunohistochemical analysis revealed that the lymphoma cells were CD20+, CD79a+, BCL-2+, CD3-, and CD5-.

INTERVENTIONS

The patient received rituximab after surgery.

OUTCOMES

He was free of disease for 13 months at the time of this report.

LESSONS

Since previously published case reports and our case described nonspecific clinical features of this rare disease, it was usually misdiagnosed before histological confirmation and surgery resection may be a good choice for both diagnosis and local therapy.