Unusual Hyperechoic Appearance of Hodgkin's Lymphoma in the Liver.

during all recorded phases compared to the surrounding splenic tissue. Due to the fact that lymphoma involvement of the liver usually does not present a hyperechoic pattern in B-mode and that the contrast-enhanced examination indicated malignant lesions, we performed a biopsy of one of the liver masses using a 18-gauge needle with a throw of 33 mm. Differential diagnosis of hyperechoic liver lesions include metastatic carcinoma and multifocal hepatocellular carcinoma. Both diagnoses were less likely because there were no known primary and no signs of liver cirrhosis present. Pathological examination revealed next to the normal liver tissue a lymphocytic infiltrate associated with formation of intracellular fat in the surrounding hepatocytes. The density of vessels indicated by immunohistochemistry using antibodies against CD31 and CD34 was increased in the infiltrated areas ( ●▶ Fig. 3). Further immunohistochemical analyses confirmed liver infiltrates of Hodgkin’s lymphoma. Using the Ann Arbor Staging System with Cotswolds Modifications, the patient was staged as grade IV, BHS. Chemotherapy using the BEACOPP regimen (Cyclophsphamide, Adraimycine, Etoposide, Procarbacine, Prednisolone, Neulasta) was started. Follow-up examinations using PET-CT after two cycles of chemotherapy presented regression of all lesions including the cervical lymph nodes, liver and spleen masses. Discussion ▼ Hodgkin’s lymphoma accounts for approximately 10 % of all lymphomas. The incidence in Europe is about 2.4 cases per 100 000 persons (Sant M et al. Blood. 2010 Nov; 116(19): 3724–3734.). Liver involvement of lymphomas in general can be found in up to 50 % of cases (Castroagudin JF et al. J Ultrasound Med. 2007 Jun; 26(6): 791–796.). The vast majority of sonographic findings are lesions with a hypoechoic appearance. A small portion of cases present with a heterogeneous sonographic appearance of the focal lesions (Soyer P et al. Abdom Imaging 1993;18(4): 339–343.). Here we present the first detailed report to our knowledge of a Hodgkin’s lymphoma presenting as hyperechoic liver lesions. This case was part of a cumulative analysis of the contrast-enhanced ultrasound pattern of hepatic lymphoma (Trenker C et al. Ultraschall Med. 2014 Apr; 35(2): 142–148.). Increased echogenicity of liver lesions has been attributed to fat deposition (Caturelli E et al. Gastroenterology 1991; 100(6): 1678–1682.). One form, the fatty liver disease also known as nonalcoholic fatty liver disease, can present as patchy or focal hyperechoic areas inside the liver (Gorg C et al. Onkologie 2005; 28(12): 659–664.). Other examples of hyperechoic liver lesions include liver adenomas. Liver adenomas with a hyperechoic appearance can also reveal intratumoral fat deposition in histological analysis which is the main factor contributing to the echogenicity (Hung CH et al. Abdom Imaging. 2001 Sep-Oct; 26(5): 500–506.). Additional lesions presenting with a hyperechoic pattern are hemangiomas. Increased vessel density contributes in these cases mainly to the high echogenicIntroduction ▼ Liver lesions of Hodgkin’s lymphoma and other lymphoma types usually appear as hypoechoic lesions in grayscale abdominal ultrasound. Here we describe the unusual case of hyperechoic liver nodules caused by Hodgkin’s lymphoma.