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Image of the Month—Quiz Case
Raul Jiménez, MD;
Adolfo Beguiristain, MD, PhD;
Inmaculada Ruiz-Montesinos, MD;
Francisco Villar, MD;
Miguel A. Medrano, MD;
Francisco Garnateo, MD;
Manuel Vaquero, MD;
Miguel Echenique Elizondo, MD, PhD
Arch Surg. 2008;143(8):805.
INTRODUCTION
A 34-year-old woman, who was using contraceptive therapy and had no previous severe illness recorded, had a hypodense lesion on segment 6 of the liver during a routine ultrasonography examination. Physical examination results were unremarkable. Blood and liver function test results and  -fetoprotein, carcinoembryonic antigen, and cancer antigen 19-9 levels were within normal limits. Viral hepatitis serologic test results and antimitochondrial antibody levels were unavailable. A chest radiograph and whole-body bone scan showed no evidence of metastases. A computed tomography–guided needle core biopsy revealed a chronic inflammatory infiltrate. Magnetic resonance imaging showed a hyperintense T2 signaling nodular lesion and arterial phase enhancement with gadolinium injection (Figure 1). The hepatic lesion was surgically resected. The patient's postoperative course was uneventful. Grossly, the resected liver segment contained a well-circumscribed, tan, nonencapsulated, solitary nodule of rubbery consistency, measuring 2.7 x 2.0 x 1.9 cm. Microscopically, the hepatic mass was composed of polymorphic small lymphocytes forming prominent lymphoid follicles with germinal centers of varying size, containing tingible body macrophages (Figure 2). Mitoses were infrequent. No bile ducts were involved in the nodular lesion. The remainder of the resected liver parenchyma was unremarkable. Immunostaining demonstrated B lymphocytes in the follicles (CD20 and Bcl-6 positive; Bcl-2 negative) along with T lymphocytes (CD3 positive). Plasma cells were positive for  and  chains at a 3:1 ratio.
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Figure 1. Magnetic resonance imaging showed a hyperintense T2 signaling nodular lesion and arterial phase enhancement with gadolinium injection.
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Figure 2. Microscopically, the hepatic mass was composed of polymorphic small lymphocytes forming prominent lymphoid follicles with germinal centers of varying size, containing tingible body macrophages.
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What Is the Diagnosis?
A. Hepatic hemangioma
B. Reactive lymphoid hyperplasia
C. Primary liver adenoma
D. Liver metastasis from gastrointestinal tract neoplasm
Answer
Author Affiliations: Departments of Surgery (Drs Jiménez, Beguiristain, Ruiz-Montesinos, Villar, Medrano, and Garnateo) and Pathology (Dr Vaquero), Donostia Hospital, and Department of Surgery, Basque Country University School of Medicine (Dr Echenique Elizondo), San Sebastián, Spain.
 Deceased.
SECTION EDITOR: CARL E. BREDENBERG, MD
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Arch Surg. 2008;143(8):806.
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