A CASE OF HEPATIC LOW GRADE B LYMPHOMA
IN A PATIENT WITH HEPATITIS C
Guido Bonoldi*, Ciro Gallo*, Roberta Lovati*, Manuela Adele Bramerio°, Marcello Gambacorta°, Gianfranco Rondinara §
*SC Medicina 1; °SC Anatomia Istologia Patologica e Immunogenetica; § SC Chirurgia Generale 2 - AO Ospedale Niguarda Ca’ Granda
72-year-old lady, hospitalized at our hospital because of a persistent backache.
The painful symptomatology, radiated down the lower limbs, appeared about a month before; due to those disorders the patient underwent a lumbar NMR at another hospital, that detected a deformity of L-4 vertebral body and the presence of a pathological tissue which infiltrated the vertebral canal (images not available).
When the patient arrived to our emergency room she underwent an urgent lumbosacral CAT which confirmed the collapse of L-4 vertebra with lytic modifications and substitutive parenchymatous tissue that invaded the spinal canal almost completely and obliterated both the conjugation foramens at the level of L4-L5 vertebrae (figure1).
Fig.1
CAT image: L-4 body is characterized by irregular osteostructural, mainly lytic alteration, spread to the right, vertebral pedicle, showing a partial break of the posterior bone cortex. Click here to enlarge fig. 1
To be mentioned in anamnesis: hepatosis connected to viral hepatitis C, with cryoglobulinemia IgG-IgM, and surgical operations: urethral polypectomy, hysterectomy, appendectomy and bilateral saphenectomy.
At the physical examination at the time of hospitalization the patient’s mind was clear and she was orientated to place and time, she presented cutaneous dyschromia due to previous purpura, no lymphadenopathies were palpable at typical sites; at mammary palpation presence of diffuse micronodulation; no neurological deficiency nor any other pathological findings at the level of the other systems.
Among the hematochemical tests carried out, the following have to be mentioned: leukocytes 6,000/mm3 with relative neutrophilia (72%), Hb 12.8gr/dl, platelets 259,000/mm3, ESR 39, C-reactive protein 1.9mgr/dl (values within the norm: 0-0.5), gamma-GT 60U/l, cholinesterase 3,528U/l, albumin 3.36gr/dl, transaminase, alkaline phosphatase, renal function parameters, electrolyte pattern, calcemia, LDH, ferritin within the norm. To be mentioned among further laboratory tests carried out during the hospitalization: serumal beta-2-microglobulin 4.37 microgr/ml (values within the norm:0.6-2.6), CA-125:50U/ml (values within the norm: 0-35), CA-19.9:56.2 U/ml (values within the norm: 0-37), CA 15-3: 31.6 U/ml ( values within the norm: 0-25), other tumorous markers, such as CEA, alpha-phetoprotein and neuron-specific enolase were within the norm, instead; C42.7 mgr/dl (values within the norm: 10-40), Ig A 438 mgr/dl (values within the norm: 70-372), C3, Ig G, IgM and angiotensin-converting enzyme within the norm; eventually ANA,ENA and ANCA were negative.
We held it good to proceed to palliative radiotherapy (24Gy in all), even in the absence of biopsy of the infiltrating process, in order to stabilize quickly L-4 partial collapse before neurological complications turned up; besides the patient underwent a chest and a upper and lower abdomen CAT looking for a possible primary tumor and/or further metastases: the CAT revealed two hepatic hypodense lesions characterized by enhancement, one located at the level of the 6th segment (dameter:50mm) and the other one at the level of the 4th segment (diameter:25mm) (figure2 and 3).
Fig.2 and fig.3
At the level of the liver two hypodense images,characterized by enhancement and having unclear meaning, are reported: the smaller one (diameter 25 mm) is located in the 4th segment (fig.2), the bigger one (diameter 50mm) is placed in the 6th segment (fig.3). Click here to enlarge fig. 2 Click here to enlarge fig. 3
The patient also underwent a bone scintigraphy (figure 4), that showed an area of fixation only at the level of L-4, mammography and mammary ultrasound scan turned out to be negative for productive processes and bone-marrow biopsy that didn’t detect any localization due to lymphoma. The patient also underwent a chest and abdomen NMR, that confirmed the hepatic lesions (figure 5) and the vertebral one, showing also the presence of lymphadenopathy with supra and subclavicular laterocervical and right axillary lymph nodes whose maximum diameters was 2 cm .
Fig.5
The NMR confirms an evident area characterized by spreading altered signal at the level of the 6th hepatic segment. Click here to enlarge fig. 5
Fig.4
The bone scintigraphy shows intense tracer fixation at the level of L-4, the remaining bone segments turn out to be undamaged. Click here to enlarge fig. 4
All attemps to make a histological diagnosis of the hepatic lesions, through echo-guided biopsy first and biopsy during laparoscopy then, failed, because in both cases a definitive histological diagnosis wasn’t made, so the differential diagnosis between a lymphoproliferative process and vasculitis remained to be decided. So we decided to carry out an exploratory laparotomy, during which the patient underwent a partial resection of the 4th hepatic segment: the following histological test enabled to make the diagnosis of B immunophenotype, polymorphous lymphoblastic non-Hodgkin lymphoma,which is equivalent to low grade B lymphoma, according to the latest WHO classification (figure 6, 7, 8, 9).
Fig.6 Lymphoid cells in sclerotic tissue; at the periphery (below right) hepatic residues can be noticed.Click here to enlarge fig. 6
Fig.8 Stain that binds CD20, highlighting lymphoid cells characterized by B.
Click here to enlarge fig. 8
In accordance with the haematologist, the patient underwent a first course of oral chemotherapy, consisting of cyclophosphamide (400mgr/day for 5 days) and prednisone (25 mgr/day for 5 days), that was well tolerated.
References
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