Primary Hepatic Lymphoma Mimicking a Hepatocellular Carcinoma in a Cirrhotic Patient: Case Report and Systematic Review of the Literature

Introduction. Primary hepatic lymphomas (PHLs) are rare liver tumors, frequently misdiagnosed preoperatively. As these tumors could be successfully treated with chemotherapy, their early recognition is essential, potentially, to avoid useless surgery. We report on the case of a cirrhotic patient with hemochromatosis who presented a PHL, initially diagnosed as a hepatocellular carcinoma (HCC), and we analyze recent data from the literature on this subject. Case Presentation and Review of the Literature. A 45 mm liver tumor was found is a 68-year-old man with alcohol cirrhosis and hemochromatosis. At imaging, the diagnosis of HCC was suspected according to vascular characteristics and the presence of cirrhosis. FDG PET scan showed a solitary hypermetabolic liver tumor. Tumor markers were negative. Surgery consisted in left lateral hepatectomy. At pathology, the diagnosis of the primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) type was demonstrated. Twenty-two articles reporting 33 cases of true PHL of MALT type were found. Presentation lacked specific symptoms (70% asymptomatic). Half of patients were suspected to have other etiologies of liver mass (HCC, intrahepatic cholangiocarcinoma), and thus diagnosis was established postoperatively. In the patient, diagnosis was made by preoperative biopsy, and chemotherapy was first-line treatment. Discussion. Preoperative diagnosis of PHL, and particularly of primary hepatic MALT lymphoma, is challenging. This case illustrates that PHL remains to be considered among the differential diagnosis of isolated solid liver tumors. Further, it indicates that biopsy could be still indicated in case of suspected HCC in cirrhotic patients, particularly in the presence of unusual findings such as the combination of a FDG PET scan positive tumor in the absence of elevated alpha-fetoprotein.

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Risk-Adapted Dose-Dense Immunochemotherapy Determined by Interim FDG-PET in Advanced-Stage Diffuse Large B-Cell Lymphoma

Journal of Clinical Oncology ◽

10.1200/jco.2009.26.5942 ◽

2010 ◽

Vol 28 (11) ◽

pp. 1896-1903 ◽

Cited By ~ 205

Author(s):

Craig H. Moskowitz ◽

Heiko Schöder ◽

Julie Teruya-Feldstein ◽

Camelia Sima ◽

Alexia Iasonos ◽

...

Keyword(s):

Fdg Pet ◽

Progression Free Survival ◽

B Cell Lymphoma ◽

Pet Scan ◽

Free Survival ◽

Large B Cell Lymphoma ◽

Positive Biopsy ◽

Fdg Pet Scan ◽

Dose Dense ◽

Pet Scans

Purpose In studies of diffuse large B-cell lymphoma, positron emission tomography with [18F]fluorodeoxyglucose (FDG-PET) performed after two to four cycles of chemotherapy has demonstrated prognostic significance. However, some patients treated with immunochemotherapy experience a favorable long-term outcome despite a positive interim FDG-PET scan. To clarify the significance of interim FDG-PET scans, we prospectively studied interim FDG-positive disease within a risk-adapted sequential immunochemotherapy program. Patients and Methods From March 2002 to November 2006, 98 patients at Memorial Sloan-Kettering Cancer Center received induction therapy with four cycles of accelerated R-CHOP (rituximab + cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by an interim FDG-PET scan. If the FDG-PET scan was negative, patients received three cycles of ICE (ifosfamide, carboplatin, and etoposide) consolidation therapy. If residual FDG-positive disease was seen, patients underwent biopsy; if the biopsy was negative, they also received three cycles of ICE. Patients with a positive biopsy received ICE followed by autologous stem-cell transplantation. Results At a median follow-up of 44 months, overall and progression-free survival were 90% and 79%, respectively. Ninety-seven patients underwent interim FDG-PET scans; 59 had a negative scan, 51 of whom are progression free. Thirty-eight patients with FDG-PET–positive disease underwent repeat biopsy; 33 were negative, and 26 remain progression free after ICE consolidation therapy. Progression-free survival of interim FDG-PET–positive/biopsy-negative patients was identical to that in patients with a negative interim FDG-PET scan (P = .27). Conclusion Interim or post-treatment FDG-PET evaluation did not predict outcome with this dose-dense, sequential immunochemotherapy program. Outside of a clinical trial, we recommend biopsy confirmation of an abnormal interim FDG-PET scan before changing therapy.

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Improved survival for relapsed diffuse large B cell lymphoma is predicted by a negative pre-transplant FDG-PET scan following salvage chemotherapy

British Journal of Haematology ◽

10.1111/j.1365-2141.2010.08162.x ◽

2010 ◽

pp. no-no ◽

Cited By ~ 2

Author(s):

Michael Dickinson ◽

Rosemary Hoyt ◽

Andrew W. Roberts ◽

Andrew Grigg ◽

John F. Seymour ◽

...

Keyword(s):

B Cell ◽

Fdg Pet ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Salvage Chemotherapy ◽

Pet Scan ◽

Large B Cell Lymphoma ◽

Fdg Pet Scan ◽

Large B Cell

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SUVmax on Pre-Treatment FDG PET Scan Is Not Predictive of Outcome in Follicular Lymphoma after R-CHOP Threapy

Blood ◽

10.1182/blood.v124.21.1629.1629 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1629-1629 ◽

Cited By ~ 4

Author(s):

Mohamed Amin Ahmed ◽

Nathan Fowler ◽

Long Ma ◽

Mansoor Noorani ◽

Karishma Phansalkar ◽

...

Keyword(s):

Fdg Pet ◽

Cell Lymphoma ◽

Histological Grade ◽

B Cell Lymphoma ◽

Risk Groups ◽

Complete Response ◽

Pet Scan ◽

Ki 67 ◽

Large B Cell Lymphoma ◽

Fdg Pet Scan

Abstract Introduction: High standardized uptake value (SUV) on FDG PET scan in follicular lymphoma (FL) suggests aggressive disease and possible transformation to diffuse large B-cell lymphoma. Schoder et al, J Clin Oncol, 2005, reported that SUV >10 predicted aggressive lymphoma with >80% certainty and SUV >13 with >90% certainty. However, it is unknown whether the maximum SUV (SUVmax) on FDG PET scan at baseline, suggesting the possibility of focal aggressive or transformed disease, has prognostic value in FL. Here, we determined the prognostic value of SUVmax on baseline FDG PET scan in patients with advanced stage FL treated uniformly with R-CHOP chemoimmunotherapy at initial diagnosis. Methods: We reviewed medical records of all patients with stage III or IV FL who had FDG PET scan at initial diagnosis and were treated with R-CHOP chemoimmunotherapy at MD Anderson Cancer Center between January 2001 and December 2012. Patients with histological diagnosis of concurrent diffuse large B-cell lymphoma were excluded. Results: For the 225 patients studied, the median age was 57 years (range, 20-82). 83 (37%) patients were >= age 60, 137 (61%) had grade 1 or 2 FL, and 88 (39%) had grade 3A (n=57, 25%) or 3B (n=31, 14%). The Ki-67 score was <=40% for 85 (60%) patients and >40% for 56 (40%) patients. FLIPI risk groups were 54 patients (24%) low, 74 (33%) intermediate, and 97 (43%) high. GELF criteria were met in 133 (59%) patients. Tumor bulk of >= 6 cm was seen in 97 (43%) patients. The absolute lymphocyte count (ALC) was normal or high in 155 (69%) patients and low in 70 (31%). Sixty-nine (31%) patients received rituximab maintenance. There was no correlation between baseline SUVmax on FDG PET scan and Ki-67 score (Pearson correlation co-efficient of 0.168). The overall and complete response rates were 96% and 87%, respectively. The median follow-up time was 66 months. At 5 years, progression-free survival (PFS) was 85% and overall survival (OS) was 90%. Male gender, stage IV, high risk FLIPI, presence of GELF criteria, high beta-2 microglobulin, and low ALC were associated with significantly inferior PFS and OS (p<0.05). Histological grade was not associated with PFS or OS. Age >= 60 was associated with inferior OS but not PFS. Rituximab maintenance was associated with improved PFS but not OS. On baseline FDG PET scan, median SUVmax was 13.7 and the SUVmax range was 1.5-42.1. 105 (47%) patients had SUVmax <=13 and 120 (53%) had SUVmax >13. Patient characteristics including age, gender, histological grade, Ki-67 score, and FLIPI risk groups were not significantly different between the two SUVmax populations (p>0.05). The overall response rates were 94% and 96% for the SUVmax <=13 and SUVmax >13 groups, respectively. The complete response rate was 87% in both groups. At 5 years, the PFS and OS were not significantly different between the low and high SUVmax groups (61% vs 63% for PFS, p=0.98 and 90% vs 89% for OS, p=0.63). PFS and OS were not significantly different even when the patients were grouped into SUVmax <=10 vs >10 (p=0.9 and 0.61, respectively) or when other cut-offs were used. SUVmax was also not predictive of PFS and OS when only the patients meeting GELF criteria were analyzed. Conclusions: In this large cohort of advanced stage FL patients treated uniformly with R-CHOP chemoimmunotherapy, SUVmax on baseline FDG PET scan was not predictive of clinical outcome or correlated with other features. It is possible that the doxorubicin-based chemotherapy regimen may have benefited patients with high SUVmax who may have underlying aggressive or undiagnosed transformed disease. It remains to be determined whether SUVmax is predictive of clinical outcome in FL patients treated with other commonly used therapies such as rituximab monotherapy, rituximab and bendamustine, or R-CVP. Figure 1 Figure 1. Disclosures Wang: Pharmacyclics, Janssen: Honoraria, Research Funding. Westin:Novartis: Research Funding.

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Sequential Dose-Dense RCHOP Followed by ICE Consolidation (MSKCC protocol 01–142) without Radiotherapy for Patients with Primary Mediastinal Large B Cell Lymphoma

Blood ◽

10.1182/blood.v116.21.420.420 ◽

2010 ◽

Vol 116 (21) ◽

pp. 420-420 ◽

Cited By ~ 14

Author(s):

Craig Moskowitz ◽

Paul A Hamlin ◽

Jocelyn Maragulia ◽

Jessica Meikle ◽

Andrew D Zelenetz

Keyword(s):

Radiation Therapy ◽

B Cell ◽

Fdg Pet ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Pet Scan ◽

Large B Cell Lymphoma ◽

Fdg Pet Scan ◽

Dose Dense ◽

Large B Cell

Abstract Abstract 420 Introduction: Primary Mediastinal Large B cell lymphoma (PMBL) is a distinct subtype of diffuse large B cell lymphoma (DLBCL) that is more common in women and presents at a similar age as classical Hodgkin lymphoma (HL); and in fact gene expression profiling suggests it is more similar to HL (Blood 102: 3871–3879, 2003) than DLBCL. Patients (pts) typically present with bulky mediastinal disease and combined modality therapy (CMT) has been the mainstay of treatment; however given the risk of secondary breast cancer and coronary artery disease associated with the 36–40Gy radiation therapy to the mediastinum, programs that use chemotherapy alone are desirable provided that the favorable progression-free (PFS) and overall survival (OS) rates can be maintained. Methods: We evaluated our dose-dense R-CHOP/ICE consolidation chemotherapy program (MSKCC protocol 01–142, J Clin Oncology 28:1896-1903, 2010) for pts with PMBL. The initial 28 pts were treated on study and the subsequent 26 were treated as per protocol. No radiation therapy was permitted. All pts underwent CT and FDG-PET imaging as well as bone marrow evaluation. Therapy was administered every 2 weeks. Induction chemotherapy: four cycles of accelerated R-CHOP (rituximab 375 mg/m2; cyclophosphamide 1000 mg/m2; doxorubicin 50 mg/m2 vincristine 1.4 mg/m2 (uncapped) IVP; and prednisone 100 mg/day orally for 5 days); growth factor support was required. Consolidation chemotherapy: three cycles of ICE+/−Rituximab (J Clin Oncology 12: 3776–3785, 1999). Pt characteristics: Fifty-four pts receive treatment. Median age was 34 (range 19–59); 30 were female (56%). An elevated LDH, Karnofsky Performance Status (KPS) <80 and stage IV disease was seen in 87%, 24% and 52% respectively. Extranodal disease (ENS) was present in 74% of pts; 21 (39%) pts had lung involvement. Bulky disease defined as a mediastinal mass of at least 10 cm. was present in 36 pts (67%) of which 16 (30%) had clinical evidence of superior vena cava obstruction at presentation; the median SUV uptake in the mediastinum on the FDG-PET scan was 19. No patient had bone marrow or CNS involvement at diagnosis. Positive Immunohistochemistry markers were as follows: CD10 (6.7%), BCL6 (72.7%), BCL2 (51.2%) and MUM1 (50%). The median Ki-67 [MIB-1] expression was 60%, of which 26.7 % was ≥80%. Outcome: At a median followup for surviving pts of 3 years, the Kaplan-Meier estimates of the proportion of patients alive and progression-free are 88% and 78% respectively. Eleven pts failed therapy. Five are now progression-free after a salvage autotransplant that included radiation therapy to the mediastinum. Six pts have died; one from transplant-related mortality, one from secondary AML and 4 from PMBL, two of which had CNS disease at relapse despite intrathecal prophylaxis. None of the standard clinical or immunohistochemical risk factors predicted for PFS including: KPS (p=.79), LDH (p=.92), Stage (p=.25), ENS (p=.36), IPI (p=.18) or bulky disease (p=.42), Ki-67 [MIB-1] expression ≥80 (.34). An interim FDG-PET scan was performed on 51/54 pts; 24 (47%) of these scans were abnormal; however, this did not predict for PFS (p=.42). We also evaluated the change in SUV between the initial and interim scan with a positive cutoff of >66% (J Nucl Med 48:1626-1632, 2007) as being favorable; this also did not predict outcome (p=.21). Conclusion: This is the largest reported series of pts with PMBL treated with a uniform chemotherapy-only strategy. The MSKCC dose-dense R-CHOP/ICE program is highly effective in these pts, it avoids radiotherapy, and importantly 50% of pts who fail can be salvaged with a radiation-based transplant. Based upon these results an interim FDG-PET scan is not warranted in pts with PMBL. Disclosures: Zelenetz: GSK: Consultancy; CTI:.

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