Primary splenic lymphoma is rare, representing less than 2% of all lymphomas.1However, B-cell lymphomas are seen with increasing frequency in patients with chronic hepatitis C. This patient was known to have a splenic mass that was being followed up with serial CT scans because the working diagnosis at the time was a hepatoma metastatic to the spleen. Recently, the mass increased in size and the patient underwent a splenectomy. The patient also had a corresponding rise in his α-fetoprotein level. After the splenectomy, the α-fetoprotein level decreased significantly. However, it did not return to the normal range.
Several epidemiologic studies suggest that hepatitis C virus may be involved in the pathogenesis of B-cell lymphomas.2These may range from low-grade to high-grade non-Hodgkin's lymphomas. This patient had a known mass in his spleen that suddenly increased in size. Therefore, it is possible that he had a low-grade, marginal-zone lymphoma that became transformed by the hepatitis C into a high-grade lymphoma.
α-Fetoprotein is a tumor marker that is used to evaluate patients for hepatocellular carcinoma. Also, elevated α-fetoprotein levels are frequently seen with certain germ cell tumors. However, to our knowledge, there is only 1 case report in the literature that reports a correlation between an elevated α-fetoprotein level and a lymphoma.3Therefore, it is of uncertain significance that the α-fetoprotein level rose in conjunction with an increase in size of the lymphoma and then decreased once the lymphoma was removed. It is conceivable that the rise in the α-fetoprotein level is related to the hepatitis C virus inflammatory response. However, we would not have expected it to decrease after the splenectomy.
Further studies and a better understanding of hepatitis C viral infection will help us explain the association between B-cell lymphomas and hepatitis C. However, any patient who has hepatitis C should undergo close surveillance for both hepatomas and lymphomas.
Return to Return to Quiz Case.
The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.
Correspondence:John Brems, MD, Department of Surgery, Loyola University, 2160 S First Ave, Bldg 110, Room 3268, Maywood, IL 60153 (email@example.com).
Accepted for Publication:November 11, 2008.
Author Contributions:Study concept and design: Maglione and Brems. Acquisition of data: Maglione, Yong, and Brems. Analysis and interpretation of data: Yong, Velankar, and Brems. Drafting of the manuscript: Maglione and Yong. Critical revision of the manuscript for important intellectual content: Maglione, Yong, Velankar, and Brems. Administrative, technical, and material support: Maglione, Yong, Velankar, and Brems. Study supervision: Yong and Brems.
Financial Disclosure:None reported.
Image of the Month—Diagnosis. Arch Surg. 2009;144(7):691-692. doi:10.1001/archsurg.2009.119-b