Primary hepatic lymphoma mimicking acute hepatitis

Management approaches for primary hepatic lymphoma: 10 year institutional experience with comprehensive literature review

Purpose/objective

Primary hepatic lymphomas (PHL) are an extremely rare form of non-Hodgkin Lymphoma (NHL) for which there are no established treatment guidelines, with available literature largely comprised of small case reports. Therefore, we evaluate our institutional experience treating PHL within the context of existing literature to better understand treatment modalities, role of radiotherapy (RT), and outcomes.

Materials/methods

We conducted a single institutional retrospective study of all patients with PHL diagnosed from 2000-2021, defined as a biopsy-proven liver lesion in the absence of other lymphomatous solid organ involvement, except for concurrently diagnosed hepatosplenic lymphomas. Subgroup analysis was performed for diffuse large B-cell lymphoma (DLBCL) and indolent lymphomas, which included marginal zone lymphoma (MZL), Grade 1-2 follicular lymphoma (FL), and low-grade B-cell lymphoma (BCL), NOS. Univariable (UVA) and multivariable analysis (MVA) for overall survival (OS) were performed using the Cox proportional hazards model. A literature review was conducted using key words "liver", "lymphoma", and "treatment" to identify relevant literature.

Results

We identified 30 patients with PHL within the institutional cohort and 192 patients from comprehensive literature review. Subgroup analysis of DLBCL included 15 patients. On MVA for OS, only ECOG score (p=0.02) and Lugano stage (p=0.04) remained significant. Subgroup analysis of the indolent lymphoma group included 9 patients. On MVA for OS, only age remained significant. Systemic therapy was the most common treatment modality overall (20 patients; 67%) with surgery, radiation and observation utilized in 4 patients (13%) each. Seventeen (57%) of patients were alive at the time of data collection, with 8 (27%) deceased and 5 (17%) lost to follow-up.

Conclusion

PHL are an extremely rare subtype of NHL for which there is no clear treatment consensus. Primary hepatic DLBCL appears to be treated mostly with chemotherapy with good disease control. For indolent PHL, low-dose RT appears to have good overall disease control with minimal toxicity. Our RT data is limited by the short duration of follow-up for patients receiving RT compared to those who received chemotherapy, surgery or observation. However, our results are encouraging for the use of RT for appropriate patients with indolent PHL.

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 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.

Successful ABO-incompatible living donor liver transplant for acute liver failure secondary to Hodgkin's Lymphoma in a child

We present a case of pediatric ALF, secondary to hepatic HL, who underwent a successful ABOi living donor liver transplant. We believe this is the first such case reported in academic literature. HL with liver involvement is extremely rare and is not considered an indication for transplantation. The 12-year-old, male patient presented with a viral illness prodrome, and parvovirus was detected in pre-transplant laboratory cultures. He received an ABOi living donor liver graft followed by a course of plasma exchange and rituximab after which standard immunosuppression was used. The HL was diagnosed on hepatic biopsy post-transplant. Subsequently, the patient commenced six cycles of R-CHOP chemotherapy. During chemotherapy, we stopped tacrolimus and mycophenolate mofetil. Immunosuppression was maintained with corticosteroids in-between cycles. The patient is alive and reports good quality of life 1-year post-transplant. The HL is in remission. During the post-operative period, the patient experienced four episodes of neutropenia, a bile leak, and gram-negative sepsis. One episode of acute rejection has been treated. Although we did not initially transplant the patient for ALF secondary to HL, its subsequent diagnosis and the patient's response to management raises many issues that warrant consideration. While the findings from a single case cannot be generalized, this could be a "proof of concept" for liver transplantation in hepatic HL. We hope it will facilitate discussions and potentially expand therapeutic options available to this very small group patients.

Hepatic involvement by T-cell neoplasms: a clinicopathologic study of 40 cases

Hepatic involvement by a T-cell neoplasm is rare and often challenging to diagnose in liver biopsies. We collected 40 cases of T-cell neoplasms diagnosed in the liver from five large academic institutions to assess the clinicopathologic features. The patients included 11 women and 29 men, with a median age of 54 (range: 2-75) years and a high mortality rate (31/37, 83.8%). Fourteen (35%) patients were diagnosed with hepatosplenic T-cell lymphoma (HSTCL), 13 (32.5%) peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), and 13 (32.5%) other types of T-cell neoplasms. Patients with HSTCL were much younger and had worse survival than PTCL-NOS and other T-cell neoplasms (P < 0.05). On imaging studies, 20 cases (50%) showed abnormalities, including 10 with mass lesions that correlated with normal or cholestatic pattern enzyme elevation. Histomorphological analysis revealed four main patterns; with the exception of mass forming lesions (pattern 4; n = 8), cases with sinusoidal predominant (pattern 1; n = 12), portal predominant with sinusoidal infiltrates (pattern 2; n = 13) or lobular aggregates (pattern 3; n = 5) demonstrated small to medium lymphocytes resembling a reactive/inflammatory process. In addition, we described two cases of T-cell large granular lymphocytic leukemia that mimicked HSTCL, and a case of aggressive post-transplant lymphoproliferative disorder that developed after chronic Epstein-barr virus (EBV) infection, suggesting the importance of EBV testing in some lymphoma cases. As the largest cohort of T-cell neoplasms in liver, our study provides critical data on disease frequency, distribution, and clinicopathologic features that are essential for accurate diagnosis.

FDG-PET/CT imaging findings of hepatic tumors and tumor-like lesions based on molecular background

The usefulness of whole-body 18-fluoro-2-deoxyglucose (FDG)-fluorodeoxyglucose positron emission (PET)/computed tomography (CT) is established for assessment of disease staging, detection of early disease recurrence, therapeutic evaluation, and predicting prognosis in various malignancies; and for evaluating the spread of inflammation. However, the role of FDG-PET/CT for the liver is limited because CT and magnetic resonance imaging (MRI) can provide an accurate diagnosis of most tumors. In addition, in other potentially useful roles there are several pitfalls in the interpretation of FDG uptake in PET/CT imaging. Accurate evaluation demands knowledge of the FDG uptake of each lesion, including potential negative and positive uptakes, and requires an understanding of the underlying background of the molecular mechanisms. The degree of FDG uptake is dependent on cellular metabolic rate and the expression of glucose transporter, hexokinase, and glucose-6-phosphatase, which in turn are closely affected by biological characteristics such as pathological category (e.g., adenocarcinoma, squamous cell carcinoma, small cell cancer, transitional cell cancer, neuroendocrine tumor, sarcoma, lymphoma), tumor differentiation, histological behavior (e.g., solid, cystic, mucinous), and intratumoral alterations (e.g., necrosis, degeneration, hemorrhage). Correlation with the CT and MRI findings, which also precisely depict the pathological findings, is important to avoid misdiagnosis.

Hepatic Lymphoma Diagnosis

Systemic hematopoietic disorders may present on liver biopsy, and rare cases of primary hepatic lymphoma (PHL) may be encountered. Hepatopathologists must be familiar with the full spectrum of hematopoietic disorders involving the liver and be prepared to exclude benign mimics. PHL, which is confined to the liver without extrahepatic involvement, can present as solitary or multiple nodules, raising consideration for carcinoma on imaging, or may mimic benign inflammatory conditions, posing a diagnostic challenge. This article describes clinical, morphologic, and immunophenotypic features of some of the most common hematopoietic neoplasms involving the liver, along with differential diagnosis and recommended ancillary testing.

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.

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.