Primary hepatic lymphoma in liver cirrhosis: A rare case report

Primary hepatic lymphoma is rare. Clinical and radiological presentations are not specific. The diagnosis is often late. Chronic hepatitis or cirrhosis, especially post-viral C usually precedes primary liver lymphoma. The differential diagnosis arises mainly with other hepatic tumors, such as atypical hypovascular cellular hepatocellular carcinoma when there is liver cirrhosis and with hypovascular hepatic metastases, especially colorectal, stomach and lung metastases. Other differential diagnosis are tuberculosis or sarcoidosis, particularly when there is multiple lesions. We report the case of a 52-year woman, with a history of hepatitis C infection, presenting liver cirrhosis with multiple hepatic lesions. Radiological aspect was not specific which makes it difficult to distinguish from other hepatic tumors, especially hypovascular liver metastases.


Introduction
Primary hepatic lymphoma is rare. It is considered when there is no other lymph node or visceral localization. Clinical and radiological presentations are not specific. The diagnosis is often late. Chronic hepatitis or cirrhosis, especially post-viral C usually precedes primary liver lymphoma [ 1 ,2 ]. ✩ Acknowledgments: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ✩✩ Competing interest: The authors declare that there is no conflict of interest. * Corresponding author. K. Imrani.
We report the case of a 52-year woman, with a history of hepatitis C infection, presenting multiple hepatic lesions.

Case report
52-year-old woman, with a history of hepatitis C infection, was presented for abdominal pain evolving for 4 months in a con-   There was no lymphadenopathy or splenomegaly. The aspect of the nodular lesions evoked either atypical hypovascular hepatocellular carcinoma, hepatic metastasis or primary hepatic lymphoma.
Given the biological and radiological datas, the most likely diagnosis was hepatic lymphoma without being able to eliminate the possibility of hypovascular hepatic metastases.
The thoracic and abdomino pelvic CT scan showed no associated lesions.
A biopsy of the liver nodular lesions was performed using an 18 Gauge menghini needle. Anatomopathological examination was in favor of B-cell type primary liver lymphoma ( fig. 5 ).
The patient was referred to oncology department for chemotherapy with a good clinical evolution.

Discussion
Hepatic lymphomas are ususally secondary to systemic impairment. Primary hepatic lymphoma is very rare. It accounts for 0.4% extranodal non-Hodgkin lymphomas and only 0.016% of all non-Hodgkin lymphoma.
Primary hepatic non-Hodgkin lymphomas are defined by the absence of splenomegaly or lymphadenopathy on clinical examination, the absence of lymphoma cells in the blood cell account, a normal chest and abdominopelvic CT scan, with negative bone marrow biopsy and lumbar [ 2 ,3 ] Chronic hepatitis or cirrhosis, especially post-viral C usually precedes primary liver lymphoma as in our case.
Clinical features are not specific, dominated by alteration of the general state with sometimes hepatic colic or palpable hepatomegaly [4] .
Biological assessment may show cytolysis or cholestasis. Lactate dehydrogenase is often high [5] .
Imaging is not specific to the diagnosis of hepatic lymphoma which can take three appearances: a solitary nodule, multiple nodules or diffuse hepatic infiltration. According to literature, solitary lesion is the most frequent form followed by multi nodular form. The infiltrative form is not common and is it associated with worse prognosis [ 1 ,4 ,6 ].
Ultrasound shows hypoechoic lesions compared to hepatic parenchyma sometimes anechogenic.
On MRI, lesions of primary non-Hodgkin's lymphoma vary in appearance depending on the degree of inflammatory response. They can be iso-intense on T1 WS, hypo, iso or hyperintense on T2 WS. Contrast enhancement is low or absent. The most frequent appearance is a lesion isointense on T1 WS, hyperintense on T2 WS with peripheral enhancement [ 1 ,3 ,9 ].
The differential diagnosis arises mainly with other hepatic tumors, such as atypical hypovascular cellular hepatocellular carcinoma when there is liver cirrhosis and with hypovascular hepatic metastases, especially colorectal, stomach and lung metastases. Other differential diagnosis are tuberculosis or sarcoidosis, particularly when there are multiple lesions. However, in tuberculosis, lesions are small and it is often associated with necrotic lymphadenopathy. In Sarcoidosis, lesions are also small and it is usually associated with typical thoracic manifestations [ 11 ,12 ,13 ].
The diagnosis is confirmed histologically after liver biopsy. Immunohistochemistry is essential to differentiate lymphoma from other malignant tumors. The vast majority of primary lymphomas in the liver are diffuse large cell lymphomas, mainly type B [ 2 ,5 ].
The therapeutic modalities combine surgery, chemotherapy, radiotherapy or a combination of the different processes. Indications depend on tumour volume, liver function and general condition of the patient [ 10 ,14 ].

Conclusion
Primary liver lymphoma is a rare entity. The radiological aspect is not specific. The differential diagnosis arises essentially with hypovascular hepatic metastases. This is a diagnosis to keep in mind especially when there is liver cirrhosis without the typical radiological aspect of hepatocellular carcinoma.

Patient consent
Written informed consent for publication was obtained from the patient. The manuscript does not disclose the patient's private information.