Posttransplant Liver Mass

Abstract

Question: A 55-year-old man who was 7 years post liver transplant for alcohol– and hepatitis C–induced cirrhosis with a 10-mm hepatocellular carcinoma (HCC) presented with right upper quadrant discomfort. The patient had a remote history of Epstein–Barr virus (EBV). Three months before presentation, his ultrasound (Figure A) and liver function tests (LFTs) were within normal limits. At presentation the LFTs were: Aspartate aminotransferase, 145 U/L; alanine aminotransferase, 52 U/L; bilirubin total, 24.1 mg/dL; alkaline phosphatase, 149 U/L; alpha fetoprotein, 6.2 ng/mL; and white blood count, 7.4. The liver appeared diffusely heterogeneous on ultrasound with a possible large mass in the right lobe of the liver (Figure B). Computed tomography (CT) was subsequently performed (only noncontrast images were obtained owing to patient's renal insufficiency: Creatinine, 4.64 mg/dL; estimated glomerular filtration rate, 13 mL/min). CT images showed a 15 × 11-cm mass in the right lobe of the liver (Figure C, arrows). The mass was mildly hyperdense compared with the surrounding liver parenchyma, and showed a central area of lower density (Figure C, asterisk). An ultrasound-guided core biopsy of the mass was obtained (Figure D; stain: hematoxylin and eosin). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Posttransplant lymphoproliferative disease (PTLD) localized to the liver is a rare entity, with only 83 cases reported in the literature.1Izadi M. Fazel M. Saadat S.H. et al.Hepatic involvement by lymphoproliferative disorders post liver transplantation: PTLD.Survey Hepatol Int. 2011; 5: 759-766Crossref PubMed Scopus (15) Google Scholar The diagnosis is made on pathology by the characteristic cellular pattern: Liver parenchyma completely replaced by round, blue, pleomorphic cells with numerous apoptotic bodies, indicating a high turnover rate (Figure D, E; stain: hematoxylin and eosin), uniformly CD20 positive cells (Figure F), scattered cells expressing CD3 (Figure G), and nearly universal Ki-67 positivity (Figure H), confirming the high proliferative rate. The final pathology diagnosis was unclassified B-cell lymphoma, with features intermediate between diffuse large B-cell lymphoma and Burkitt's lymphoma. The diagnosis could have been suspected at imaging owing to the rapid growth of the mass in 3 months, which would have been very unusual for a HCC, even though HCC duplication size is faster among posttransplant patients.2Addley H.C. Griffin N. Shaw A.S. et al.Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation.Clin Radiol. 2011; 66: 349-356Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar PTLD has a high proliferative rate as demonstrated by pathology staining, and its incidence in post liver transplanted patients has been associated with HCV and EBV. Other reported reasons for PTLD include greater levels of immunosuppression and antibody induction therapy, including OKT3, antilymphoblast globulin, and antithymocyte globulin.3Kim R.D. Fujikawa T. Mizuno S. et al.Adult post-transplant lymphoproliferative disease in the liver graft in patients with recurrent hepatitis C.Eur J Gastroenterol Hepatol. 2011; 23: 559-565Crossref PubMed Scopus (4) Google Scholar The patient opted for palliative treatment only and died 1 month later.