Presentation
Raised gamma-glutamyl transferase (GGT) levels in an asymptomatic individual.
Patient Data
Hypoechoic spherical mass measuring approximately 8 cm in diameter, located between the right and left hepatic lobes, with a hyperechoic center and septa radiating to the periphery. There is a vessel coursing through the mass, prominent at its center.
Rounded slightly lobular hypodense hypoenhancing hepatic mass measuring ~8 cm in diameter involving segments 4a-4b-5-8, showing thin, mild peripheral enhancement and thin, enhancing septa, the latter seen best at the late (~3.5 min.) phase. A branch of the right hepatic artery courses through the mass and another one encircles its posterior margin. There is barely any mass effect on the liver and no transient hepatic attenuation differences (THAD).
Solid retroperitoneal mass measuring 3.7 x 2.7 x 3.4 cm between the left psoas muscle and the inferior renal pole, indenting the psoas, isodense to the hepatic mass and exhibiting the same contrast enhancement characteristics.
Case Discussion
Came in for a prescription renewal for hypertension and benign prostatic hypertrophy. The general practitioner noticed a GGT of almost 200 IU/L and referred him for a liver ultrasound.
After a large hypoechoic hepatic mass was discovered, he was referred for a triphasic liver CT.
At ultrasound, the combination of a large hypoechoic mass with a central scar, central vessel and radiating septa, placed focal nodular hyperplasia at the top differential diagnosis list. At CT, however, the mass showed features most compatible with hepatic lymphoma, perhaps even primary, and a single retroperitoneal node.
An ultrasound-guided biopsy was obtained.
Histopathology report:
Macroscopic description
Two cylinders of tissue measuring 0.8 cm and 1.2 cm in length and 0.1 cm in diameter each.
Microscopic description
Diffuse large B-cell lymphoma.
Comment: cores of tissue infiltrated by a population of large atypical cells. The atypical cells are positive for CD20, CD10, CD79a, BCL6, and are negative for CD3,CD5, BCL2, c-Myc, cyclin D1, CD23 and pankeratin. Ki67 index: 70-80%.
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