Figure 1
The pathological findings
Clinical History
A 73-year-old woman with a history of anaemia and chronic liver disease and a positive family history of various malignancies was admitted for further evaluation of a caecal adenocarcinoma.
Imaging Findings
The extension study of thoraco-abdominopelvic CT (Figs. 1, 2, 3) revealed a hypodense nodular lesion in liver segment 6, with well defined borders, which in the clinical setting was interpreted as a metastasis. Furthermore a solid left thyroid nodule and a heterogeneous mass in the left adrenal gland were identified incidentally.
For further evaluation of those findings, a PET/CT was performed, which ruled out malignancy of the adrenal lesion, but confirmed the hepatic metastasis and resulted positive for the thyroid lesion. The latter was diagnosed as multinodular goitre by ultrasound-guided fine needle aspiration (USG/FNA).
With the diagnosis of colonic cancer and a unique liver metastasis, she underwent haemicolectomy and hepatic segmentectomy. An intra-operative ultrasound (Fig. 4) was performed to rule out additional lesions: the solid lesion was confirmed in segment 6, 3, 5 x 2 cm in diameter, hypoechoic with a hyperechoic centre and well-defined borders.
For further evaluation of those findings, a PET/CT was performed, which ruled out malignancy of the adrenal lesion, but confirmed the hepatic metastasis and resulted positive for the thyroid lesion. The latter was diagnosed as multinodular goitre by ultrasound-guided fine needle aspiration (USG/FNA).
With the diagnosis of colonic cancer and a unique liver metastasis, she underwent haemicolectomy and hepatic segmentectomy. An intra-operative ultrasound (Fig. 4) was performed to rule out additional lesions: the solid lesion was confirmed in segment 6, 3, 5 x 2 cm in diameter, hypoechoic with a hyperechoic centre and well-defined borders.
Discussion
RLH is a benign lymphoid, non-specific, but well-demarked lesion, characterised by polyclonal proliferation of lymphoid cells and non-neoplastic follicles forming a reactive germinal centre [1]. Its aetiology and pathogenesis are still unknown. Nodular lymphoid lesion or pseudolymphoma is used synonymously [2].
In the literature review we found that similar processes occur in the context of autoimmune diseases, carcinomas or states of immunodeficiency general; this reveals its reactive character [3].
These lesions are focal, well defined and located in different organs (in the gastrointestinal tract (most frequently encountered location [4]), in the orbit, the oral mucosa, lung, skin, breast and in the pancreas).
In the liver, however, it is a very rare condition.
The first case reported of hepatic RLH dates back to 1981 [5] and currently there have been 35 cases published worldwide [6] with the following characteristics:
- Women are more affected than men (male: female 1: 9.7) [5]
- Average age (59) [7]
- Hepatic nodular lesion: hypoechoic and hypodense (benign) [8]
- Average tumour size of 2.1 cm [6]
- In the context of chronic liver disease and/or autoimmune disorder [9] an/or extrahepatic tumour [10].
The present case meets all the common features described in the literature: middle-aged female patient suffering of chronic liver disease and two extrahepatic malignancies (adenocarcinoma of the caecum and thyroid carcinoma), her family history revealed a possible genetic predisposition to haematological diseases in the context of an autoimmune process. The radiologic findings of the patient did not correspond to metastasis of adenocarcinoma, but malignancy could not be ruled out in the present context.
According to literature review of magnetic resonance imaging (MRI) of RHL [4], [8], [11], [12] the respective findings are a hypointense nodule on T1-weighted and hyperintense on both T2- and on diffusion-weighted imaging (DWI).
Contrasted MRI (extra-cellular Gd compounds and hepatocyte-directed CA (godobenate and gadoxetic acid) would reveal the lesion as hyperintense in the arterial phase and hypointense in the portal phase. Until today all cases reported of RLH have been misdiagnosed on the basis of imaging findings only, because of the difficult discrimination of RLH from malignant tumours such as metastasis, HCC[9], lymphoma etc., especially in the context of an extrahepatic malignancy. Thus, definitive diagnosis often requires preoperative biopsy [13] of the lesion in question, which could also prevent its resection.
The untreated natural history of this lesion is a spontaneous regression over time [7].
The increased detection of these cases is due to technological advances in imaging devices, so hepatic RLH will probably be diagnosed more frequently in the future.
In the literature review we found that similar processes occur in the context of autoimmune diseases, carcinomas or states of immunodeficiency general; this reveals its reactive character [3].
These lesions are focal, well defined and located in different organs (in the gastrointestinal tract (most frequently encountered location [4]), in the orbit, the oral mucosa, lung, skin, breast and in the pancreas).
In the liver, however, it is a very rare condition.
The first case reported of hepatic RLH dates back to 1981 [5] and currently there have been 35 cases published worldwide [6] with the following characteristics:
- Women are more affected than men (male: female 1: 9.7) [5]
- Average age (59) [7]
- Hepatic nodular lesion: hypoechoic and hypodense (benign) [8]
- Average tumour size of 2.1 cm [6]
- In the context of chronic liver disease and/or autoimmune disorder [9] an/or extrahepatic tumour [10].
The present case meets all the common features described in the literature: middle-aged female patient suffering of chronic liver disease and two extrahepatic malignancies (adenocarcinoma of the caecum and thyroid carcinoma), her family history revealed a possible genetic predisposition to haematological diseases in the context of an autoimmune process. The radiologic findings of the patient did not correspond to metastasis of adenocarcinoma, but malignancy could not be ruled out in the present context.
According to literature review of magnetic resonance imaging (MRI) of RHL [4], [8], [11], [12] the respective findings are a hypointense nodule on T1-weighted and hyperintense on both T2- and on diffusion-weighted imaging (DWI).
Contrasted MRI (extra-cellular Gd compounds and hepatocyte-directed CA (godobenate and gadoxetic acid) would reveal the lesion as hyperintense in the arterial phase and hypointense in the portal phase. Until today all cases reported of RLH have been misdiagnosed on the basis of imaging findings only, because of the difficult discrimination of RLH from malignant tumours such as metastasis, HCC[9], lymphoma etc., especially in the context of an extrahepatic malignancy. Thus, definitive diagnosis often requires preoperative biopsy [13] of the lesion in question, which could also prevent its resection.
The untreated natural history of this lesion is a spontaneous regression over time [7].
The increased detection of these cases is due to technological advances in imaging devices, so hepatic RLH will probably be diagnosed more frequently in the future.
Differential Diagnosis List
Reactive lymphoid hyperplasia of the liver
Hepatic metastasis
Hepatocellular carcinoma
(low grade B-cell) lymphoma
Final Diagnosis
Reactive lymphoid hyperplasia of the liver
References
[1] Nagano K, Fukuda Y, Nakano I, Katano Y, Toyoda H, Nonami T,Nagasaka T, Hayakawa T (1999) Case report: Reactive lymphoid hyperplasia of liver coexisting with chronic thyroiditis: Radiographical characteristics of the disorder. J Gastroentrol Hepatol 14:163-67 (PMID: 10029298)
[2] Willenbrock K, Kriener S, Oeschger S, Hansmann ML (2006) Nodular lymphoid lesion of the liver with simultaneous focal nodular hyperplasia and hemangioma: discrimination from primary hepatic MALT-type non-Hodgkin s lymphoma. Virchows Arch 448: 223-7 (PMID: 16331470)
[3] Kubota T, Moritani S (2007) High incidence of autoinmune disease in Japanese patients with ocular adnexalreactive lymphoid hyperplasia. Am J Ophthalmol 144:148–149 (PMID: 17601445)
[4] Yoshikawa K, Konisi M, Kinoshita T, Takahashi S, Gotohda N, Kato Y, Kojima M (2011) Reactive lymphoid hyperplasia of the liver: literature review and 3 case reports. Hepatogastroenterology 58:1349-53 (PMID: 21937394)
[5] Sharifi S, Murphy M, Loda M, Pinkus GS, Khettry U (1999) Nodular lymphoid lesion of the liver: an immune-mediated disorder mimicking low-grade malignant lymphoma. Am J Surg Pathol 23:302-308 (PMID: 10078921)
[6] Hayashi M, Yonetani N, Hirokawa F, Asakuma M, Miyaji K, Takeshita A, Yamamoto K, Haga H, Takubo T, Tanigawa N (2011) An operative case of hepatic pseudolymphoma difficult to differentiate from primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue. World J Surg Oncol 9:3 (PMID: 21232116)
[7] Zen Y, Fujii T, Nakanuma Y (2010) Hepatic pseudolymphoma: a clinicopathological study of five cases and review of the literature. Mod Pathol 23:244-50 (PMID: 19915525)
[8] Takahashi H, Sawai H, Matsuo Y, Funahashi H, Satoh M, Okada Y, Inagaki H, Takeyama H, Manabe T (2006) Reactive lymphoid hyperplasia of the liver in a patient with colon cancer: report of two cases. BMC Gastroenterol 6:25 (PMID: 16965640)
[9] Okubo H, Maekawa H, Ogawa K, Wada R, Sekigawa I, Iida N, Maekawa T, Hashimoto H, Sato N (2001) Pseudolymphoma of the liver associated with Sjögren\'s syndrome. Scand J Rheumatol 117-9 (PMID: 11324789)
[10] Sato K, Ueda Y, Yokoi M, Hayashi K, Kosaka T, Katsuda S (2006) Reactive lymphoid hyperplasia of the liver in a patient with multiple carcinomas: a case report and brief review. J Clin Pathol 59:990-2 (PMID: 16935975)
[11] Okada T, Mibayashi H, Hasatani K, Hayashi Y, Tsuji S, Kaneko Y, Yoshimitsu M, Tani T, Zen Y, Yamagishi M. (2009) Pseudolymphoma of the liver associated with primary biliary cirrhosis: a case report and review of literature. World J Gastroenterol 15(36):4587-92. (PMID: 19777620)
[12] Park HS, Jang KY, Kim YK, Cho BH, Moon WS. (2008) Histiocyte-rich reactive lymphoid hyperplasia of the liver: unusual morphologic features. J Korean Med Sci 23(1):156-60. (PMID: 18303220)
[13] Matsumoto N, Ogawa M, Kawabata M, Tohne R, Hiroi Y, Furuta T, Yamamoto T, Gotoh I, Ishiwata H, Ono Y, Arakawa Y, Kinukawa N (2007) Pseudolymphoma of the liver: Sonographic findings and review of the literature. J Clin Ultrasound 35:284-8 (PMID: 17436320)
Case information
| URL: | https://www.eurorad.org/case/10000 |
| DOI: | 10.1594/EURORAD/CASE.10000 |
| ISSN: | 1563-4086 |
Figure 2
Contrast-enhanced abdominal Computed Tomography
Coronal image of contrast-enhanced CT MPR shows a nodular, hypodense and well-circumscribed lesion in liver segment 6.
Figure 3
Contrast-enhanced abdominal Computed Tomography
Coronal multiplanar reconstruction image showing a nodular, hypodense and well-circumscribed lesion in liver segment 6.
Figure 4
Intraoperative ultrasound
Intraoperative ultrasound image revealing a hypoechoic, rounded and well-defined hepatic lesion with an hyperechoic centre.
Figure 5
Pathological findings: Microscopic features of RLH.
A:panoramic-view. Inset: portal inflammation.
B:Granulomatous infiltrate(*). Inset: Multinucleated giant-cells(**)
C:Positive CD20-inmunohistochemical staining.
D:Negative BCL2-expression in reactive germinal centers.
E&F:Inmunohistochemistry for κ and λ: No evidence of light-chain-restriction.
The pathological findings
Contrast-enhanced abdominal Computed Tomography
Coronal image of contrast-enhanced CT MPR shows a nodular, hypodense and well-circumscribed lesion in liver segment 6.
Department of Radiology, University hospital of Guadalajara, Spain.
Department of Radiology, University hospital of Guadalajara, Spain.
Contrast-enhanced abdominal Computed Tomography
Coronal multiplanar reconstruction image showing a nodular, hypodense and well-circumscribed lesion in liver segment 6.
Department of Radiology, University hospital of Guadalajara, Spain.
Department of Radiology, University hospital of Guadalajara, Spain.
Intraoperative ultrasound
Intraoperative ultrasound image revealing a hypoechoic, rounded and well-defined hepatic lesion with an hyperechoic centre.
Department of Radiology, University hospital of Guadalajara, Spain.
Department of Radiology, University hospital of Guadalajara, Spain.
Pathological findings: Microscopic features of RLH.
A:panoramic-view. Inset: portal inflammation.
B:Granulomatous infiltrate(*). Inset: Multinucleated giant-cells(**)
C:Positive CD20-inmunohistochemical staining.
D:Negative BCL2-expression in reactive germinal centers.
E&F:Inmunohistochemistry for κ and λ: No evidence of light-chain-restriction.
Department of Pathological Anatomy, Hospital of Guadalajara, Spain.
Department of Pathological Anatomy, Hospital of Guadalajara, Spain.