Hepatic reactive lymphoid hyperplasia in a patient with primary biliary cirrhosis

Abstract

Reactive lymphoid hyperplasia (RLH) of the liver is an extremely rare lesion characterized by the proliferation of non-neoplastic lymphocytes forming follicles. Hepatic RLH is known to be associated with gastrointestinal carcinoma and autoimmune diseases including primary biliary cirrhosis (PBC). We report a case of hepatic RLH in a patient with PBC and gastric cancer. A 68 year old Japanese woman with a 10 year history of liver enzyme abnormality was admitted. Laboratory testing revealed that her anti-mitochondrial antibody was markedly elevated. Five mo after the diagnosis of PBC, she was found to have gastric cancer. Abdominal computed tomography disclosed a liver nodule in S8, suggesting metastatic gastric carcinoma. Histopathologically, the resected liver lesion comprised of a nodular proliferation of small lymphocytes with lymphoid follicles. This is the first reported case of hepatic RLH in a patient with both PBC and gastric cancer. Pre-operative diagnosis of hepatic RLH by clinical imaging is extremely difficult. Therefore, a needle biopsy could be useful to make a diagnosis of hepatic RLH, especially to differentiate from metastatic gastrointestinal carcinoma.

Keywords: Gastric cancer; Liver; Primary biliary cirrhosis; Pseudolymphoma; Reactive lymphoid hyperplasia.

Figure 1

Histopathological findings of the liver biopsy. Periportal lymphocytic infiltration with bile duct damage (arrows: damaged bile duct; hematoxylin and eosin stain, × 400).

Figure 2

Endoscopic picture of the stomach. The depressed lesion with spontaneous hemorrhage and irregular margins.

Figure 3

Contrast-enhanced abdominal computed tomography. A well-circumscribed nodule showing early arterial enhancement in S8 (arrow).

Figure 4

Histopathological findings of the gastric carcinoma and liver nodule. A: Signet ring cell carcinoma of the stomach invading into the deep submucosa (hematoxylin and eosin stain, × 40); B: A relatively well-circumscribed nodular proliferation of lymphocytes with lymphoid follicles in the liver (right: liver parenchyma, hematoxylin and eosin stain, × 40); C: Mantle zone and germinal center are sharply demarcated and a mixture of small and large lymphocytes and scattered tingible body macrophages is observed in the germinal center (hematoxylin and eosin stain, × 40).

Figure 5

Immunohistochemical findings of the liver nodule. CD3-positive T lymphocytes (left) and CD20-positive B lymphocytes (right) are regularly distributed (× 40).