The many faces of primary and secondary hepatic lymphoma: imaging manifestations and diagnostic approach

Rare Malignant Liver Tumors: Current Insights and Imaging Challenges

Rare malignant liver tumors (RMLTs) comprise a diverse group of neoplasms with distinct imaging features and significant diagnostic challenges due to their low prevalence and overlap with more common hepatic lesions. This review highlights the main radiologic characteristics of selected RMLTs-including fibrolamellar hepatocellular carcinoma, hepatic lymphoma, hepatocellular carcinoma in non-cirrhotic liver, mucinous cystic neoplasm, intraductal papillary neoplasm of the bile duct, epithelioid hemangioendothelioma, angiosarcoma, malignant hepatic adenoma, neuroendocrine tumor, hepatocholangiocarcinoma, hepatoblastoma, undifferentiated embryonal sarcoma, and infantile hepatic hemangioendothelioma-focusing on their presentation in CT and MRI. Recognizing specific imaging findings, such as arterial hyperenhancement, biliary communication, target and lollipop signs, and tumor morphology, can help narrow differential diagnoses and guide appropriate clinical management. Despite advancements in imaging, histopathologic confirmation is often required due to nonspecific features. Improved radiologic awareness of these rare entities is essential to facilitate early diagnosis and individualized treatment planning.

Malignancy can Present as Acute Liver Failure - A Case Report of B-Cell Lymphoma with Acute Liver Failure as its First Presentation

Malignant infiltration of the liver is a rare cause of acute liver failure and is associated with an exceedingly high mortality rate. We describe the case of an elderly woman presenting with fulminant hepatitis and simultaneous type B lactic acidosis, with near-normal imaging findings, who was later demonstrated to have non-Hodgkin lymphoma. The presence of acute liver failure, hepatomegaly, markedly elevated lactate dehydrogenase and/or lactic acidosis should raise suspicion for lymphoma infiltration of the liver and prompt liver biopsy early in the course of disease. We hope to raise awareness for this uncommon and elusive presentation of lymphoma, in the hope that it will help achieve earlier diagnoses and improvements in patient survival.

LEARNING POINTS

Lymphoma presenting as fulminant hepatitis is rare and frequently fatal.Malignant infiltration of the liver should be suspected in cases of acute liver failure, particularly when no clear aetiology is present, and liver biopsy should be performed promptly.The internist should be aware of lymphoma as a potential cause of type B, non-hypoxemic lactic acidosis.

Left ovarian mass revealing multivisceral lymphoma

Lymphoma encompasses a range of cancers originating in the lymphatic system, categorized into Hodgkin lymphoma and non-Hodgkin lymphoma. Hodgkin lymphoma classically present as nodal disease, whereas non-Hodgkin lymphoma tends to involve extranodal regions. While it can be part of a systemic lymphoma, isolated nodal involvement is not uncommon. Extranodal lymphoma can affect virtually any organ or tissue, with the spleen, liver, gastrointestinal tract, pancreas, abdominal wall, genitourinary tract, adrenal glands, peritoneal cavity, and biliary tract being among the most commonly involved sites, in decreasing order of frequency. We present a case involving a 54-year-old woman presented with left iliac fossa pain. A sonography was performed, which showed left pelvic mass, magnetic resonance imaging showed left ovarian mass with enlargement of the cervix. Computed tomography revealed enlargement of the pancreas and adrenal glands, along with masses in the kidneys associated with extensive pathological lymph node enlargement in the para-aortic and pelvic regions. The patient underwent biopsy of a para-aortic lymph node, which revealed a diffuse large B cell lymphoma.

State-of-the-art imaging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third most fatal and fifth most common cancer worldwide, with rising incidence due to obesity and nonalcoholic fatty liver disease. Imaging modalities, including ultrasound (US), multidetector computed tomography (MDCT), and magnetic resonance imaging (MRI) play a vital role in detecting HCC characteristics, aiding in early detection, detailed visualization, and accurate differentiation of liver lesions. Liver-specific contrast agents, the Liver Imaging Reporting and Data System, and advanced techniques, including diffusion-weighted imaging and artificial intelligence, further enhance diagnostic accuracy. This review emphasizes the significant role of imaging in managing HCC, from diagnosis to treatment assessment, without the need for invasive biopsies.

Ferritin and Iron Levels Inversely Associated With Lymphoma Risk: A Mendelian Randomization Study

Background

Current knowledge on iron's role in lymphoma development is very limited, with studies yielding inconsistent findings. To address this gap, we conducted a rigorous two-sample mendelian randomization study, aiming to elucidate the potential associations between iron storage and the risk of developing lymphoma.

Methods

This study leveraged extensive genetic data derived from a comprehensive genome-wide association study (GWAS) comprising 257,953 individuals. The primary objective was to pinpoint single-nucleotide polymorphisms (SNPs) that are significantly associated with iron storage. Subsequently, this genetic information was analyzed in conjunction with summary-level data pertaining to lymphoma cases and controls, sourced from the IEU open GWAS project, which included a sample size of 3,546 lymphoma cases and 487,257 controls. To evaluate the relationship between iron storage and lymphoma risk, an inverse variance-weighted method with random effects was employed, complemented by rigorous sensitivity analyses.

Results

Genetic predisposition to high ferritin and serum iron status was causally associated with lower odds of lymphoma. Ferritin exhibited an odds ratio (OR) of 0.777 (95% confidence interval (CI): 0.628 - 0.961, P = 0.020), indicating 22.3% reduced odds of lymphoma associated with a one standard deviation increase in ferritin levels. Similarly, serum iron demonstrated an OR of 0.776 (95% CI: 0.609 - 0.989, P = 0.040), corresponding to 22.4% decreased odds of lymphoma for a one standard deviation increase in serum iron.

Conclusions

This study suggests that individuals with genes linked to higher iron storage levels have a lower risk of developing lymphoma, but further research is necessary before making any clinical recommendations.

Peripheral T-cell lymphoma invasion of the liver: The underappreciated hypoechoic periportal cuffing on ultrasound-A case report and literature review

Liver involvement in lymphoma often manifests as nonoccupying diffuse infiltration, posing challenges in distinguishing it from primary liver disorder. Herein, we present the case of a 21-year-old female who underwent two separate diagnoses within a nine-month interval before being ultimately diagnosed with peripheral T-cell lymphoma, not otherwise specified. Our review of this case identified an ultrasound imaging feature, the hypoechoic periportal cuffing. When combined with associated increased lymphocyte count and liver enlargement, it can serve as a noninvasive suggestion for malignant disorders, in particular hemic and lymphatic diseases.

An unusual cause of liver lesions

We present the case of a 68-year-old female with no relevant medical history,   who is evaluated for weight loss. An initial blood test showed mild hypertransaminasemia with negative serologies, autoimmunity and tumoral markers. Abdominopelvic CT revealed multiple liver lesions with ring enhancement, compatible with metastasis, as well as suspicious subcarinal adenopathy. The study was completed with gastroscopy and colonoscopy, mammography and fibrobroncoscopy with punction of the adenopathy, without finding out any lesion. Abdominal ultrasound was performed, presenting multiple isoecogenic liver lesions along both lobes, with a maximum diameter of 35 mm, surrounded by a hypoechoic halo, and no Doppler Signal. In contrast-enhanced ultrasound (CEUS), these lesions had centripetal enhancement in the arterial phase and progressive washout, compatible with metastasis as well. A percutaneous biopsy of one of the lesions was taken, showing infiltration of diffuse large B-cell lymphoma. At this moment, the patient is in remission after taking chemotherapy treatment.

Typical and Atypical Imaging Features of Malignant Lymphoma in the Abdomen and Mimicking Diseases

Malignant lymphoma typically presents with homogeneous enhancement of enlarged lymph nodes without internal necrotic or cystic changes on multiphasic CT, which can be suspected without invasive diagnostic methods. However, some subtypes of malignant lymphoma show atypical imaging features, which makes diagnosis challenging for radiologists. Moreover, there are several lymphoma-mimicking diseases in current clinical practice, including leukemia, viral infections in immunocompromised patients, and primary or metastatic cancer. The ability of diagnostic processes to distinguish malignant lymphoma from mimicking diseases is necessary to establish effective management strategies for initial radiological examinations. Therefore, this study aimed to discuss the typical and atypical imaging features of malignant lymphoma as well as mimicking diseases and discuss important diagnostic clues that can help narrow down the differential diagnosis.

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.

CLINICAL AND PATHOLOGICAL CHARACTERIZATION OF HEPATIC LYMPHOMAS: A RETROSPECTIVE SINGLE-CENTER STUDY

BACKGROUND

The incidence of hepatic lymphoma has been increasing recently and diagnosis can be challenging as clinical presentation and radiological findings are usually variable and non-specific.

OBJECTIVE

The aims of this study were to describe their main clinical, pathological and imaging characteristics and identify poor prognostic factors.

METHODS

A retrospective study that included all patients with histological diagnosis of liver lymphoma over a 10-year period at our center was performed.

RESULTS

A total of 36 patients were identified, with mean age of 56.6 years and male predominance (58%). There were three patients with primary liver lymphoma (8.3%) and 33 with secondary liver lymphoma (91.7%). The most common histological type was diffuse large B-cell lymphoma (33.3%). The most common clinical manifestations included fever, lymphadenopathy, weight loss, night sweats and abdominal discomfort; three patients (11.1%) were asymptomatic. Computed tomography scan revealed heterogenous radiological patterns including a single nodule (26.5%), multiple nodules (41.2%) or diffuse infiltration (32.4%). The mortality rate during follow-up was 55.6%. Higher levels of C-reactive protein (P=0.031) and absence of treatment response (P<0.001) were significantly associated with higher mortality.

CONCLUSION

Hepatic lymphoma is a rare disease that may involve liver as part of a systemic disease or, less commonly, be confined to this organ. Clinical presentation and radiological findings are often variable and non-specific. It is associated with high mortality and poor prognostic factors include higher levels of C-reactive protein and absence of response to treatment.

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.

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.

Non-Hodgkin Lymphoma Imaging Spectrum in Children, Adolescents, and Young Adults

In children, adolescents, and young adults (CAYA), non-Hodgkin lymphoma (NHL) is characterized by various age-related dissimilarities in tumor aggressiveness, prevailing pathologic subtypes, and imaging features, as well as potentially different treatment outcomes. Understanding the imaging spectrum of NHL in CAYA with particular attention to children and adolescents is critical for radiologists to support the clinical decision making by the treating physicians and other health care practitioners. The authors discuss the currently performed imaging modalities including radiography, US, CT, MRI, and PET in the diagnosis, staging, and assessment of the treatment response. Familiarity with diagnostic imaging challenges during image acquisition, processing, and interpretation is required when managing patients with NHL. The authors describe potentially problematic and life-threatening scenarios that require prompt management. Moreover, the authors address the unprecedented urge to understand the imaging patterns of possible treatment-related complications of the therapeutic agents used in NHL clinical trials and in practice. Online supplemental material is available for this article. ^©RSNA, 2022.

Hepatic granuloma mimicking recurrent lymphoma on 18F-FDG PET/CT in a patient with primary mediastinal diffuse large B-cell lymphoma

¹⁸F-Flurodeoxyglucose (FDG) PET/CT has been considered the modality of choice in detecting, staging, restaging and following-up with lymphoma patients. However, it has an uncertain role in differentiating hepatic lymphomatous relapse from other granulomatous diseases such as in candidiasis or sarcoidosis. Therefore, it is important to correlate the imaging findings with other modalities such as ultrasound, CT scan, MRI, and histology to direct the diagnosis and treatment. We present a case of a 33-year-old woman with large B-cell lymphoma in complete remission following treatment presenting with neutropenic fever following her final cycle of chemotherapy. Ultrasound of the abdomen and enhanced CT scan of the abdomen and pelvis were negative. The FDG PET/CT scan showed multiple FDG-avid hypodense hepatic lesions that were suggestive either of lymphoproliferative involvement or nonmalignant process. However, MRI of the abdomen performed four days later was suggestive of an infectious process, rather than a lymphoproliferative disorder. A subsequent CT-guided biopsy of a hepatic lesion showed granulomatous inflammation, with no evidence of malignancy or Tuberculosis. The patient was started on Caspofungin followed by Fluconazole. After 5 weeks, the clinical condition resolved, and the subsequent FDG PET/CT showed complete resolution of the FDG-avid multiple hepatic lesions.

Clinical management and susceptibility of primary hepatic lymphoma: A cases-based retrospective study

BACKGROUND

The liver as a primary site of lymphoma is rarely seen, they are usually misdiagnosed as hepatocellular carcinoma, etc. In 2017, a review of primary hepatic lymphoma (PHL) was done in immunocompetent diffuse large B-cell lymphoma (DLBCL) patients. Yet questions that include treatment choosing or susceptibility of immunoincompetent patients remain disputable.

AIM

To investigate the clinical characteristics of patients with PHL.

METHODS

We collected PHL cases on PubMed, and extracted demographic and clinicopathological data to perform a systematic analysis. Survival analysis regarding age, lactate dehydrogenase (LDH), liver function abnormality (LFA), and treatment modalities were conducted. The Kaplan-Meier method and Cox regression were used to identify risk factors.

RESULTS

Of 116 PHL patients with DLBCL (62.1%) as the most common subtype. Biopsy methods before surgery produced a 97% positive rate. Progression-free survival (PFS) was significantly shortened in patients with elevated LDH [Hazard ratio (HR): 3.076, 95% confidence interval (CI): 1.207-7.840, P = 0.018] or LFA (HR: 2.909, 95%CI: 1.135-7.452, P = 0.026). Univariate Cox regression analysis suggesting that LDH, liver function, B symptom, hepatosplenomegaly, and lesion were significantly associated with PHL patients survival (P < 0.05). Heavy disease burden was observed in deceased patients. A few PHL patients (3.4%) have slightly higher tumor markers.

CONCLUSION

PHL patients with elevated LDH and LFA tend to have shorter PFS. Biopsy before treatment in undecided patients with no tumor markers exceeds upper limits has the most essential clinical significance, especially in immunoincompetent patients.

Follicular lymphoma with hepatic accumulation on FDG-PET/CT masquerading IgG4-related disease

Follicular lymphoma is clinically classified as a common type of indolent non-Hodgkin's lymphoma, and its clinical diagnosis is difficult because B symptoms and elevated soluble interleukin-2 receptor (sIL-2R) levels are less frequent in follicular lymphoma than in other lymphomas. We report a case of follicular lymphoma masquerading immunoglobulin G4-related disease (IgG4-RD) with elevated IgG4 levels. A 67-year-old man presented to our hospital with a 1-year history of deep right supraclavicular and para-aortic lymph node lymphadenopathy on plain computed tomography (CT) findings along with elevated IgG4 levels, and the ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan showed heterogeneous diffuse FDG uptake in the liver, and FDG uptake was noted at multiple sites in the enlarged right supraclavicular and para-aortic lymph nodes. Excisional biopsy of the right supraclavicular lymph node, performed under general anesthesia, showed a tumor-like structure mimicking a normal germinal center in the lymphoid follicle; immunostaining was positive for B-cell lymphoma 2 and CD10 proteins with some plasma cells stained with IgG, only 30% of them were positive for IgG4, and no marked fibrosis characteristic of IgG4-RD was observed; therefore, follicular lymphoma was diagnosed, and all symptoms, including FDG uptake, improved with rituximab monotherapy. Differential diagnoses of slowly progressive generalized lymphadenopathy over the years with elevated serum IgG4 levels include IgG4-RD, Castleman's disease, and indolent lymphoma. Multiple accumulation in the liver on FDG-PET/CT, if found, may suggest indolent lymphoma among them.

Primary hepatic lymphoma in liver cirrhosis: A rare case report

Primary hepatic lymphoma is rare. Clinical and radiological presentations are not specific. The diagnosis is often late. Chronic hepatitis or cirrhosis, especially post-viral C usually precedes primary liver lymphoma. The differential diagnosis arises mainly with other hepatic tumors, such as atypical hypovascular cellular hepatocellular carcinoma when there is liver cirrhosis and with hypovascular hepatic metastases, especially colorectal, stomach and lung metastases. Other differential diagnosis are tuberculosis or sarcoidosis, particularly when there is multiple lesions.

We report the case of a 52-year woman, with a history of hepatitis C infection, presenting liver cirrhosis with multiple hepatic lesions. Radiological aspect was not specific which makes it difficult to distinguish from other hepatic tumors, especially hypovascular liver metastases.

Rare primary hepatic malignancies: A case-based review

The two most common primary liver malignancies that radiologists encounter in clinical practice are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). However, there are other less common primary hepatic malignancies that radiologists should be aware of. The correct radiographic and pathologic diagnosis of these entities have important treatment and prognostic implications. In this paper, we review a series of five cases that we have encountered in clinical practice at our institution that were initially thought to be HCC or ICC, but turned out to be a rarer primary hepatic malignancy. We will review the radiographic and pathologic characteristics of each of these rare primary hepatic malignancies as well as discuss the prognosis and treatment for each.

Use of the LI-RADS classification in patients with cirrhosis due to infection with hepatitis B, C, or D, or infected with hepatitis B and D

Objective

To evaluate liver lesions, in accordance with the LI-RADS classification, using contrast-enhanced multiphase dynamic computed tomography in patients with hepatitis B, coinfected or not with hepatitis D, or with chronic hepatitis C, as well as to determine the level of agreement between radiologists.

Materials and Methods

We evaluated 38 patients with hepatitis B, coinfected or not with hepatitis D, or with chronic hepatitis C, all of whom underwent contrast-enhanced multiphase dynamic computed tomography. For each examination, two radiologists selected up to three hepatic lesions, categorizing them in accordance with the LI-RADS classification and evaluating signs of chronic liver disease and portal hypertension. To determine the level of agreement between radiologists, we calculated the kappa statistic (κ) .

Results

Radiologist 1 and radiologist 2 selected 56 and 48 liver lesions, respectively. According to radiologist 1 and radiologist 2, respectively, 27 (71%) and 23 (61%) of the 38 patients had at least one liver lesion; 13 (34%) and 12 (32%) had a LI-RADS 5 lesion (κ = 0.821); 19 (50%) and 16 (42%) had a hypervascular lesion (κ = 0.668); and 30 (79%) and 24 (63%) had splenomegaly (κ = 0.503). Both radiologists identified chronic liver disease in 31 (82%) of the patients (κ = 1.00).

Conclusion

Lesions categorized as LI-RADS 5 were detected in approximately 32% of the patients, with almost perfect agreement between the radiologists. The level of agreement was substantial or moderate for the other LI-RADS categories.

Ultrasound evaluation of schistosomiasis-related morbidity among the Xakriabá people in the state of Minas Gerais, Brazil

Objective

To use ultrasound to investigate the morbidity related to schistosomiasis in the Xakriabá indigenous population.

Materials and Methods

This was a field-based census study conducted in the territory of the Xakriabá people. A total of 166 individuals were invited, and 148 (≤ 77 years of age) agreed to participate. Most participants underwent abdominal ultrasound, physical examination, and stool examination. Mann-Whitney U and chi-square tests were used for comparisons. We determined risk by calculating odds ratio (OR) and performed logistic regression analysis.

Results

Schistosoma mansoni eggs were found in 31 (26.7%) of the 116 stool samples examined, 22 (70.9%) of the 31 being from individuals 4-16 years of age. The median count was 144 eggs/g of feces (interquartile range, 264). Of the 105 participants examined with ultrasound, 68 (64.8%) had hepatomegaly (left lobe), 6 (5.7%) had splenomegaly, and 4 (3.8%) had portal hypertension. Egg-positive stool samples were more common in those with an enlarged left lobe (OR = 3.4; 95% confidence interval (CI): 1.1-11.2; p = 0.043). Periportal fibrosis was found in 30 participants (28.6%), of whom 9 (30%) had pattern C, 10 (33.3%) had pattern D, and 11 (36.7%) had pattern Dc. Age was the only independent risk factor for fibrosis (p = 0.007). Fibrosis was up to nine-fold more common in alcohol drinkers than in nondrinkers (OR = 9.28; 95% CI: 2.60-33.06; p < 0.001). Among the 138 participants in whom the clinical form was classified, the chronic hepatic form was identified in 54 (39.1%), of whom 32 (59.2%) were under 30 years of age and one (1.8%) was hepatosplenic.

Conclusion

Schistosomiasis in the Xakriabá population is characterized by a high frequency of egg-positive stool samples, predominantly in children/adolescents, and by chronic hepatic form in the young, especially among alcohol drinkers.