Hodgkin Lymphoma in Liver

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Image Description

Primary hepatic lymphomas are rare. Most occur in middle-aged or elderly patients with an underlying immunodeficiency (prior organ transplantation), chronic infection (Hepatitis B, C; HIV infection; active tuberculosis), or autoimmune disorder (SLE, Sjogren syndrome; Felty syndrome). Secondary involvement of liver by lymphomas is more common. Most are diffuse large B-cell lymphomas. Other types include MALT lymphomas, Burkitt lymphoma, follicular lymphoma, peripheral T-cell lymphoma, and Hodgkin lymphoma.

In 50% of cases, lymphomas form a solitary mass. In about 45% of cases, there are multiple small nodules scattered throughout the liver. In 5% of cases, there is diffuse hepatic enlargement without a dominant mass. The differential diagnosis includes hepatocellular carcinoma or metastatic carcinoma. Elevation of lactate dehydrogenase with normal CEA and AFP favors the diagnosis of lymphoma.

On FNA smears, lymphomas are discohesive neoplasms. Depending upon the specific type, the lymphoid cell population may be monomorphic without significant cytologic atypia (follicular lymphomas, MALT-lymphomas, and small lymphocytic lymphomas) or composed of large atypical cells (diffuse large B-cell lymphoma - the most common lymphoma secondarily involving the liver). Lymphoglandular bodies are present in the background. FNA material is usually sufficient to perform flow cytometry or gene rearrangement studies. Cell block or needle core biopsy specimen can be used for immunohistochemical studies.

The image shows Hodgkin lymphoma involving the liver. Image courtesy of Dr. Jean-Christophe Fournet, Paris, France; humpath.com; Used with permission

About the Disease

Metastasis is the most common malignancy in non-cirrhotic livers in the Western countries. About 40%-50% of patients dying from cancer have liver metastases. Liver is highly susceptible due to dual blood supply (hepatic and portal) and fenestrations in sinusoidal epithelium which allow tumor cells to escape into the parenchyma. Primary sites in adults: pancreas, stomach, colon, lung, breast, kidney, malignant melanomas, and soft tissue sarcomas. Malignancies of gall bladder, extrahepatic bile ducts, stomach, and pancreas can spread to liver by direct extension. Primary sites in children: neuroblastoma, Wilms tumor, and rhabdomyosarcoma. Presentation ranges from no symptoms to fulminant hepatic failure. Patients may develop malaise, anorexia, weight loss, abdominal pain, and obstructive jaundice. Diagnosis can be accurately made in most cases by CT- or ultrasound guided-FNA and needle core biopsies. Metastases form multiple, discrete expansive masses or ill-defined infiltrative areas. Larger nodules undergo necrosis and fibrosis producing umbilication. Liver may be greatly enlarged with an irregular surface. Malignancies of breast, stomach, lung, pancreas, and lymphomas may produce miliary involvement. Metastases are quite rare in cirrhotic livers. Microscopic features are those of the primary tumor. Metastatic adenocarcinomas may invade bile ducts and show intrabiliary growth mimicking cholangiocarcinoma. Prognosis is poor in most cases (with some exceptions). Most patients die within 1 year of presentation. Resection of isolated liver metastases from colo-rectal cancers can produce long-term disease-free survival or even cure in some cases. Patients with liver metastases from neuroendocrine tumors and Carcinoid syndrome get dramatic relief from symptoms after resection of metastatic foci. References: 1. Iacobuzio-Donahue, C. A. & Montgomery E. (2012). Gastrointestinal and Liver Pathology - 2nd Edition. Philadelphia, PA. Elsevier Saunders. 2. Feldman, M., Friedman, L. S., & Brandt, L. J. (2016). Sleisenger & Fordtran's Gastrointestinal & Liver Disease - 10th Edition. Philadelphia, PA. Elsevier Saunders. 3. Goldblum, J. R. et al (2018). Rosai and Ackerman's Surgical Pathology - 11th Edition. Philadelphia, PA. Elsevier.4. DeVita, V. T., Lawrence, T. S., & Rosenberg, S. A. (2019). Cancer - Principles & Practice of Oncology - 11th Edition. Wolters Kluwer.

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