Figures
Figure 1. Non-contrast MRI sequences of the liver showing lesions in both lobes. (a) Lesions appear hypointense (white bold arrow) on T1-weighted sequence of non-contrast MRI. (b) Lesions appear hyperintense on T2-weighted sequence (bold white arrow). (c) Lesions show restriction (bold white arrow) on diffusion weighted images.
Figure 2. Dynamic contrast-enhanced MRI (CEMRI) T1-weighted fat suppressed sequence using hepatocyte specific contrast gadobenate dimeglumine (Gd BOPTA) showing lesion enhancement pattern. (a) Lesion in the right lobe (white bold arrow pointing down) shows mild enhancement in the hepatic arterial phase (HAP). (b) Lesion appears relatively hypointense with better visualization of the lesion (white bold arrow pointing down) on the portal venous phase (PVP). (c) Lesion appears iso-hypointense compared to rest of the liver parenchyma (white bold arrow pointing down) on the equilibrium phase.
Figure 3. CEMRI T1-weighted fat suppressed sequence performed with gadolinium BOPTA showing lesion extent on the coronal sequences. (a) Coronal image of the dynamic CEMRI T1-weighted fat suppressed sequence performed with Gd BOPTA in the equilibrium phase showing lesion extension to the porta hepatis (bold white arrow with black margins) and encasement of the right portal vein (white outlined arrow). (b) Coronal 3D MRCP shows non-visualized primary biliary confluence with resultant moderate left lobe and mild right lobar ductal dilatation (bold white arrow pointing at the confluence).
Figure 4. MRI coronal FIESTA (a) and coronal post contrast T1-weighted fat suppressed images after 1 h (b). (a) MRI coronal FIESTA sequence shows striking areas of capsular retraction (white arrow) along the right lobe of liver abutting the mass. (b) MRI post contrast (Gd BOPTA) coronal T1-weighted fat suppressed sequence images acquired after 1 h delay reveal delayed enhancement within few central areas of the mass (bold white arrow with black margins).
Figure 5. Post contrast MRI sequences describe the loss of fat planes between the tumour and right kidney. (a) Axial late arterial phase post contrast MRI T1-weighted fat suppressed sequence showing the loss of fat planes between right renal upper cortex and the liver mass in the right lobe of liver showing mild enhancement but relatively hypointense to the liver (bold white arrow with black outline). (b) Axial portal venous phase post contrast MRI T1-weighted fat suppressed sequence showing the loss of fat planes between right renal upper cortex and the liver mass in the right lobe of liver (bold white arrow with black outline). (c) Coronal equilibrium phase post contrast MRI T1-weighted fat suppressed sequence showing the loss of fat planes between right renal upper cortex and the liver mass in the right lobe of liver appearing enhanced, however hypointense compared to the liver parenchyma (bold white arrow with black outline). Note is made of another target like lesion in the liver (white arrow). (d) Coronal delayed (1 h) phase post contrast MRI T1-weighted fat suppressed sequence showing the loss of fat planes between right renal upper cortex and the liver mass in the right lobe of liver showing areas of enhancement, however appearing hypointense compared to the liver parenchyma (bold white arrow with black outline).
Figure 6. Coronal post contrast MRI T1-weighted fat suppressed sequence showing few prominent (approximately 1 cm in diameter), para-caval and para-aortic lymph nodes were seen in the retroperitoneum.
Figure 7. Hematoxylin and eosin (H&E) staining of liver tissue. (a) Liver biopsy showing portal and parenchymal diffuse infiltration by monomorphic large atypical lymphoid cells (H&E), magnification × 40. (b) Sheets of singly lying atypical large lymphoid cells with intervening sclerosis (blue) on Masson’s trichrome stain, magnification × 40.
Figure 8. Immunohistochemistry of the liver tissue. (a, b) Strong diffuse membranous staining of atypical cells with leukocyte common antigen (magnification × 100) and CD20 (B-cell marker) (magnification × 200) respectively. (c, d) Tumor cells are negative for CD3 (T-cell marker) and CD30 (× 40).
Figure 9. Immunohistochemistry of the liver tissue. (a, b, d) Atypical lymphoid cells are negative for CD5, CD10 and Bcl2 (× 100). (c) Ki67 immunohistochemistry shows positive nuclear staining in > 80% of the tumor cells.
Tables
Table 1. Investigation Chart
| Investigation | Results |
|---|
| Hemoglobin | 9.3 g/dL (normal: < 1.0) |
| Total leukocyte count | 15,900/mm3 (normal: 4 - 11 × 109) |
| Platelet count | 3.16 lakh (normal: 1.5 - 4 lakh) |
| Prothrombin time/INR | 14.7/1.24 corrected, received vitamin K |
| Total serum bilirubin | 15.9 mg/dL (normal: 0.3 - 1.2 mg/dL) |
| Direct bilirubin | 9.24 mg/dL (normal: 0 - 0.2 mg/dL) |
| Indirect bilirubin | 6.66 mg/dL (normal: 0.2 - 0.8 mg/dL) |
| AST | 174 IU/L (normal: 5 - 40 IU/L) |
| ALT | 121 IU/L (normal: 10 - 40 IU/L) |
| SAP | 1,106 IU/L (normal: 32 - 92 IU/L) |
| GGTP | 474 IU/L (normal: 7 - 64 IU/L) |
| Alb/Glob | 0.5 (normal: 1.5 - 2.5) |
| AFP | 4.03 ng/mL (normal: 0 - 8.5 ng/mL) |
| CEA | 5.68 U/mL (normal: 0 - 37 U/mL) |
| Serum CA 19-9 | 428.3 U/mL (normal: 0 - 37 U/mL) |
| Serum creatinine | 0.91 mg/dL (normal: 0.2 - 1 mg/dL) |
| Serum LDH | 889 IU/dL (normal: 265 - 400 IU/L) |
Table 2. Immunohistochemistry Results
| Positive | Negative |
|---|
| CD45 (leukocyte common antigen) | CD3 (T lineage marker) |
| CD20 (B lineage marker) | HepPar-1, glypican-3 (hepatocellular carcinoma) |
| CD10 | Vimentin(mesenchymal cell marker) |
| CD5 | Synaptophysin chromogranin (neuroendocrine markers) |
| Bcl2 | CK7, CK19 (markers for mmetastatic carcinoma and cholangiocarcinoma) |
| Ki67 | Pancytokeratin |