LAUSR

A 41-year-old gentleman presented with a 4-month history of abdominal pain along with a 2-month history of loss of appetite and weight. He had no co-morbidities and no history of prior illness. On careful questioning, he admitted to having intermittent bouts of high-grade fever but denied any vomiting, jaundice, chest pain, diarrhea, or blood in stools. A physical examination revealed extreme tenderness in the right upper quadrant of the abdomen. No superficial lymphadenopathywas present. Laboratory results included hemoglobin of 12.9 g/dL and a white cell count of 6.9 × 109/L, with a normal differential. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were 50 and 48 IU respectively, but alkaline phosphatase (ALP) at 333 U/L was three times the normal value. Serum alpha-fetoprotein (AFP) 3.33 ng/mL, and carcinoembryonic antigen (CEA) 1.32 ng/mL and carbohydrate antigen 19–9 < 2 U/mL were not elevated. Lactate dehydrogenase (LDH) levels were 481 U/L. Serology was negative for human immunodeficiency virus and for the hepatitis C (HCV) and B (HBV) viruses. Serum calcium was within normal limits. Contrast-enhanced computed tomographic (CECT) scan showed a heterogeneously enhancing space-occupying lesion (SOL) in the liver, involving segment IVa, IVb, VIII, and V measuring 12.2 × 12.3 × 16.3 cm with gross hepatomegaly extending up to the level of porta with encasement of the left branch of portal vein for a length of 2.3 cm with periportal lymphadenopathy(2.3 × 1.5 cm). There were no lung lesions or mediastinal lymphadenopathy (Figs. 1 and 2). In view of equivocal radiological findings and normal tumor markers, a biopsy of liver lesion was planned after discussion in multidisciplinary clinic. Histologic analysis showed unclassifiable diffuse non-Hodgkin’s lymphoma B cell phenotype (Fig. 3). On immunohistochemistry (IHC), tumor cells were diffusely positive for CD20 (Fig. 4). Also, on additional IHC testing,