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Special Feature
July 20, 2009

Image of the Month—Diagnosis

Author Affiliations



Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(7):691-692. doi:10.1001/archsurg.2009.119-b
Answer: Primary Splenic High-Grade Lymphoma

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.

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system ( Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery ( 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.

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Article Information

Correspondence:John Brems, MD, Department of Surgery, Loyola University, 2160 S First Ave, Bldg 110, Room 3268, Maywood, IL 60153 (

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.

Isaacson  PG Primary splenic lymphoma. Cancer Surv 1997;30193- 212
Takeshita  MSakai  HOkamura  S  et al.  Splenic large B-cell lymphoma in patients with hepatitis C. Hum Pathol 2005;36 (8) 878- 885
Hurley  LJBurke  CRShetty  SKSakr  OEPrevite  SRLibertino  JA Elevated alpha-fetoprotein secondary to Hodgkin's lymphoma. Urology 1996;48 (6) 936- 938