Diagnostic approach in hepatic lymphoma: radiological imaging findings and literature review

Abstract

Purpose: Imaging manifestations of hepatic lymphoma, both primary (PHL) and secondary (SHL), are extremely variable and non-specific, but some features are useful diagnostic clues in an appropriate clinical setting. Through a PubMed search, we found several published reviews focused on PHL and SHL diagnosis. However, to the best of our knowledge, few of them encompass a comprehensive analysis of all the diagnostic tools and relative radiological findings. The aim of this review is to provide a description of the radiological features of both PHL and SHL, by critically analyzing the available literature.

Materials and methods: An extensive review of published literature along with a description of personal case series of both PHL and SHL has been conducted.

Results: SHL can be easily diagnosed with imaging techniques, as it is usually associated with node disease. On the contrary the diagnosis can be a challenge in PHL, often mimicking HCC or liver metastasis of adenocarcinoma. In this context, multiparametric MRI plays a fundamental role in the differential diagnosis. Both for PHL and SHL, liver involvement presents as solitary or multiple lesions or as diffuse infiltrative disease.

Conclusion: PHL and SHL may be correctly characterized using different radiological techniques. Both CT and MRI have showed a good correlation with histology, as they permit to distinguish between lymphomatous tissue, and necrotic and fibrotic areas.

Keywords: Computed tomography; Magnetic resonance imaging; Primary hepatic lymphoma; Secondary hepatic lymphoma; Ultrasound.

Fig. 1

Liver biopsy displaying monotonous sheets of small lymphocytes replacing normal hepatic parenchyma. Lymphocytes have scant cytoplasm with a clumped chromatin pattern and round nuclei (magnification 10 × 40) Noronha et al. (2005)

Fig. 2

CT scan of a 55-year-old male patient with diagnosis of PHL before and after intravenous injection of iodine contrast agent. a Unenhanced scan of a single mass located in S4, characterized by small hypoattenuating areas. b Arterial hepatic phase confirms the presence of an inhomogeneous lesion with peripheric hyperattenuating areas and hypoattenuating intralesional foci. c Portal-venous phase shows wash-out of hyperattenuating areas. d Delayed phase confirmed wash-out with peripheral rim enhancement (pseudocapsule)

Fig. 3

MRI images of a 47-year-old male patient with diagnosis of PHL. a, b In- and out-phase T1W images of a hypointense mass located in the left lobe. c, d T2W images with and without fat suppression of PHL characterized by inhomogeneous signal hyperintensity with well-defined margins and a hyperintense central fibrous scar that should be differentiated from focal nodular hyperplasia. e DWI image confirms restricted diffusion of the lesion (b = 800). f The lesion appears hypointense on ADC map, due to real diffusion restriction

Fig. 4

MRI images of PHL shown in Fig. 3, before and after injection of hepatospecific contrast agent (Gd-EOB-DTPA). a Unenhanced T1 3D fat-sat scan shows a hypointense mass in the left lobe characterized by diffuse enhancement in arterial phase b with peripheral wash-out confirmed in portal-venous c—transitional phase d and peripheral rim enhancement. In hepatobiliary phase e, it is possible to appreciate the lesion’s signal hypointensity

Fig. 5

Follow-up CT scans before and after intravenous injection of iodine contrast media of PHL shown in Figs. 3 and 4. Arterial and portal-venous phase during chemotherapy respectively after 3 (a, b) and 6 months (c, d) with dimensional reduction of the mass located in the left lobe

Fig. 6

CT scan after intravenous injection of iodine contrast media acquired in portal-venous phase of a 62-years old female patient with diagnosis of Hodgkin Lymphoma and secondary liver involvement. Portal-venous phase shows multiple hypoattenuating lesions located in S4 (left image), S2 (middle), and S7 and S8 (right)

Fig. 7

FDG-PET imaging in a 70-year-old male patient with diagnosis of Non-Hodgkin Lymphoma. a Maximal intensity projection (MIP) image shows extensive sites of involvement visualized as areas of increased FDG uptake. b, c Fused PET-CT images show sites of liver involvement (S7), peripancreatic pathological nodes, and splenic uptake of FDG