Imaging Pearls ❯ Liver ❯ Lymphoma
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- Hepatic lymphomas are rare malignancies that are classified as either primary hepatic lymphoma (PHL) or secondary hepatic lymphoma (SHL). They can present with several CT patterns, including a solid focal lesion, multifocal lesions, a diffuse pattern, or a porta hepatis lesion. PHLs most often present as solid lesions, whereas SHLs are commonly multifocal. On CT, they typically appear as hypovascular, hypoattenuating masses that may show central low-density necrosis and demonstrate only minimal enhancement compared to the surrounding parenchyma. Rim enhancement may be seen, creating a “target sign.” These lesions often exhibit an infiltrative growth pattern, encasing vessels, and biliary structures without causing compression. Although rare, it is important to include lymphoma in the differential diagnosis of a hypodense liver lesion.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - “Hepatic lymphoma is a rare malignancy, classified into primary hepatic lymphoma (PHL) and secondary hepatic lymphoma (SHL). It often presents with variable and nonspecific imaging manifestations; however, with advances in diagnostic imaging, certain features can provide valuable clues towards the diagnosis, in the appropriate clinical context. Imaging findings play a pivotal role in early recognition and in guiding therapeutic management, which differs markedly from that of other malignant liver tumors.”
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - Primary hepatic lymphoma (PHL) is defined as lymphoma limited to the liver or perihepatic lymph nodes, without evidence of distant nodal disease, splenomegaly, splenic lesions, or bone marrow/blood involvement for at least six months after diagnosi. It is rare, accounting for < 0.1% of all NHL cases, and typically presents in the fifth decade of life with a male predominance. Lei et al. proposed a diagnostic criteria for PHL comprising: (a) clinical signs and symptoms due to liver involvement, (b) no evidence of distant lymphadenopathy, and (c) absence of leukemic features on peripheral smear .
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - The most common presentation is right upper quadrant abdominal pain (39–70%), followed by jaundice, weight loss, or nonspecific symptoms such as fever, chills, anorexia, fatigue, malaise, nausea, and vomiting. Other reported findings include hemorrhagic diatheses such as epistaxis, gingival bleeding, and hematemesis . Approximately 10% of cases are asymptomatic and detected incidentally. On physical examination, hepatomegaly is present in only 17% of the cases. Most patients demonstrate elevated LDH and β2-microglobulin levels (80–90%), and abnormal liver enzymes are found in ≥ 70% of cases.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - Characteristic CT and MRI features include the vascular/ biliary floating sign, multinodular sign, pseudocapsule, and the double-ring/target sign on delayed imaging. While imaging assists in early recognition, definitive diagnosis requires histopathology. Fine-needle aspiration and liver biopsy, supported by immunohistochemistry and cytogenetics, remains essential for diagnosis . Prognosis is relatively better than SHL, but survival is highly variable (3-123 months), influenced by comorbidities and immunosuppression. Burkitt lymphoma, though rare, is particularly aggressive and can be fatal within months if untreated, underscoring the importance of early imaging diagnosis .
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - Hepatic lymphoma may present as a solitary mass, multifocal nodules, or diffuse infiltration. The most common imaging manifestation of PHL is a solitary lesion (55–60%), followed by multiple lesions (35–40%) often with a dominant mass, while diffuse infiltration is rare. Its appearance often mimics hepatocellular carcinoma (HCC). SHL, by contrast, most commonly presents as multifocal lesions or diffuse infiltration (90%), with solitary lesions rarely seen. A dominant mass is usually absent in SHL. A combination of infiltrating and nodular patterns has also been described.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - This is the most common presentation of PHL (60%), while SHL manifests as a solid focal mass in only 10% of the cases. In a study of sixteen patients with PHL, imaging showed focal masses in 81% of the patient . The lesion is usually homogeneously hypodense on non-contrast CT scan and has soft tissue attenuation. Areas of necrosis and hemorrhage may occasionally be seen. Occasionally, a central scar may be seen in this type of hepatic lymphoma, mimicking focal nodular hyperplasia (FNH). However, the poor enhancement of the lesion across all contrast-enhanced phases helps differentiate it from FNH .
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. Epub ahead of print. PMID: 41642288. - This is the most common pattern in SHL (up to 90%), whereas PHL may also present with multifocal lesions, usually with a dominant mass. Splenic lesions accompany SHL in 30–40% of cases . The nodules are typically hypoenhancing relative to hepatic parenchyma, with patchy or rim enhancement observed in up to 15% of cases . The differential diagnosis for a multifocal pattern includes granulomatous diseases (tuberculosis, sarcoidosis), fungal microabscesses, septic emboli, and metastases. Granulomatous diseases are especially challenging to differentiate, as they may also cause hypoenhancing hepatosplenic lesions, hepatosplenomegaly, and extensive lymphadenopathy, with overlapping systemic symptoms such as fever and weight loss. Helpful differentiating features include rim-enhancing necrotic lymph nodes in tuberculosis, hypointense nodules and pulmonary involvement in sarcoidosis, however, clear distinction is often difficult on imaging.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. - Diffuse hepatic involvement is the most challenging to detect on CT, since lesions often show the same attenuation as hepatic parenchyma In SHL, tumor cell infiltration of the portal tracts and sinusoids is a common pattern of diffuse hepatic involvement. This finding is rare in PHL, but when present, it is associated with a poor prognosis . The classic sign is diffuse hepatomegaly, however, only measuring the size clinically or on imaging is insufficient for diagnosis. Assessment of liver volume using commercially available automated software and FDG-PET/CT are helpful in demonstrating diffuse uptake in liver, spleen and systemic lymphadenopathy guiding towards diagnosis of lymphoma . Zhao et al. reported a case of diffuse lymphoma with no identifiable mass on CT or MRI, however liver volume and uptake on PET/CT were increased guiding towards the diagnosis , however, clear distinction is often difficult on imaging.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5. - Periportal lymphoma is a rare presentation that may occur as soft tissue cuffing or an ill-defined mass extending into the porta hepatis (Fig. 4), which can be seen in both primary or secondary lymphoma [24–26]. This distribution of lymphoma can be explained by the presence of lymphatic vessels along the portal vein and bile ducts, which account for nearly 80% of hepatic lymphatic drainage [27]. Coakley et al. first described two cases of NHL presenting as mass-like periportal infiltration [24]. This appearance can mimic hilar cholangiocarcinoma, but several features help in differentiation. Cholangiocarcinoma typically causes biliary dilatation, infiltrates adjacent perihepatic structures such as the portal vein or hepatic artery, and can lead to vascular complications like portal vein thrombosis.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5 - PHL can mimic HCC, often demonstrating arterial enhancement and a hyperattenuating pseudocapsule. While a fibrous capsule is a characteristic feature of HCC and is typically thin (< 2 mm), lymphoma more often shows a thicker rim enhancement, hypothesized to represent peritumoral fibrosis and ductular reaction rather than a true capsule. It is important to note that delayed washout has been reported in some PHL cases, making differentiation from HCC challenging [29]. Since PHL is also associated with HBV and HCV, lesions may arise in background of cirrhosis, further complicating the diagnosis. Hepatic lymphoma may also resemble metastases (enhancement similar to primary lesion), abscess (often with surrounding edema), or hemangioma (progressive centripetal fill-in), but relative hypoenhancement can favor lymphoma. The appearance of PHL can be similar to other rare mass-forming lesions such as poorly differentiated carcinomas, embryonal sarcoma, or inflammatory pseudotumor, or granulomatous hepatitis .
- The target appearance is another characteristic manifestation, reflecting central necrosis or degeneration and rim enhancement , seen in 15% of hepatic lymphomas . Because these lesions often have a well-defined, lobulated contour with peripheral enhancement that persists into the equilibrium phase, they may be mistaken for intrahepatic cholangiocarcinoma on imaging. However, unlike cholangiocarcinoma, hepatic lymphoma typically lacks capsular retraction, biliary dilatation, or vascular displacement. Additionally, CA-19.9 levels are usually markedly elevated in cholangiocarcinoma, helping to distinguish between the two. The ‘target sign’ morphology is observed more often in EBV-positive diffuse large B-cell lymphoma, as EBV is considered to cause the necrotic changes.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5 - In PHL, the lesion often surrounds the intrahepatic bile ducts or portal vein without compressing or invading them, a finding known as the biliary/vascular floating sign. In comparison, HCC usually causes vascular displacement or invasion and can lead to portal vein tumor thrombus. A mass in the porta hepatis may also suggest post-transplant lymphoproliferative disorder (PTLD), In PHL, the lesion often surrounds the intrahepatic bile ducts or portal vein without compressing or invading them, a finding known as the biliary/vascular floating sign. In comparison, HCC usually causes vascular displacement or invasion and can lead to portal vein tumor thrombus. A mass in the porta hepatis may also suggest post-transplant lymphoproliferative disorder (PTLD),
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5 - Hepatic lymphoma is a rare entity that can closely mimic both benign and malignant liver lesions. While CT remains the primary imaging modality for initial evaluation, the diagnosis is often challenging and requires histopathological confirmation. Nonetheless, recognition of characteristic imaging features, as highlighted above, can raise early suspicion, guide timely biopsy, and facilitate appropriate management planning, thereby improving patient outcomes.
CT presentations of hepatic lymphoma: what radiologists need to know.
Arshad H, Kawamoto S, Fishman EK.
Abdom Radiol (NY). 2026 Feb 5. doi: 10.1007/s00261-025-05361-5
- Lymphomatous involvement of the liver may manifest at imaging as a discrete focal liver mass or masses, diffuse infiltrating disease, or an ill-defined mass in the porta hepatis. The most common imaging manifestation of PHL is a solitary discrete lesion, which is seen in about 60% of cases. Multiple lesions are seen in 35%–40% of patients, although one lesion is likely to be dominant . Diffuse infiltration is uncommon in PHL and indicates a poor prognosis. In contrast, multifocal lesions or diffuse infiltration is the most common pattern of secondary hepatic lymphoma (90%).
Hematologic malignancies of the liver: spectrum of disease.
Tomasian A, Sandrasegaran K, Elsayes KM, et al.
Radiographics. 2015 Jan-Feb;35(1):71-86. - Numerous small discrete nodules (in a miliary pattern) are distributed throughout the liver in about 10% of cases of Hodgkin disease and secondary non-Hodgkin lymphoma of the liver. Another point of distinction is that dominant liver masses are not typically seen in secondary lymphoma but are characteristic of PHL. In addition, untreated nodules in secondary hepatic lymphoma are usually homogeneous, even when large , while the dominant masses in PHL are typically heterogeneously enhancing. By definition, splenic lesions are not seen in patients with PHL but are seen in 30%–40% of patients with secondary non-Hodgkin lymphoma.”
Hematologic malignancies of the liver: spectrum of disease.
Tomasian A, Sandrasegaran K, Elsayes KM, et al.
Radiographics. 2015 Jan-Feb;35(1):71-86. - “At CT, lymphomatous nodules commonly have soft-tissue attenuation but enhance to a lesser degree than the liver parenchyma on arterial, portal venous, and delayed phase images. The lesions may demonstrate hemorrhage, necrosis, or a rim-enhancement pattern. Calcification is rare in the absence of treatment. A multiphase CT study is not indicated for diagnosis of hepatic lymphoma because the lesions typically are hypovascular in all phases.”
Hematologic malignancies of the liver: spectrum of disease.
Tomasian A, Sandrasegaran K, Elsayes KM, et al.
Radiographics. 2015 Jan-Feb;35(1):71-86.
- “Posttransplant malignancies can arise by means of three different mechanisms: de novo, donor-related, and recurrent cancers. De novo malignancies are new cancers arising in transplant recipients that originate separately from the transplanted organs, such as NMSC and Kaposi sarcoma. Donor-related cancers can either be from direct transmission of tumors that preexisted in the donor or de novo development of cancer in the transplanted organ without a preexisting history.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “Direct oncogenic effects of immunosuppressive drugs, impaired immunosurveillance of neoplastic cells, and increased incidence of virally induced malignancies are also mechanisms in the pathogenesis of malignancies that develop in transplant recipients.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407- "Kaposi sarcoma is a multifocal angioproliferative endothelial malignancy driven by HHV-8 infection. HHV-8 is a complex DNA virus that can induce malignancy by inhibition of apoptosis, damaging antigen-processing pathways, evasion of mutated host cells from immunosurveillance, activating the mTOR pathway, and upregulating vascular endothelial growth factor receptors. Although most Kaposi sarcomas are due to reactivation of HHV-8 in recipients because of prolonged immunosuppression, infection can also be transmitted from the donor. There is a 400- to 500-fold greater incidence of Kaposi sarcoma in solid organ transplant recipients than in the general population."
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “Visceral Kaposi sarcoma can involve the gastrointestinal tract, lymph nodes, and lungs. Although rare, direct involvement of the allografts has also been described. At imaging, skin lesions can be seen as vascular nodules or masses with associated hypervascular lymph nodes. Abdominal findings of Kaposi sarcoma include nodular bowel wall thickening, enhanced masses in the liver and spleen, lymphadenopathy, and vascular mesenteric masses.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “PTLD is a spectrum of lymphoproliferative diseases that occur after organ transplantation and range from benign lymphoid hyperplasia to lymphoma. The incidence of PTLD ranges from 1% to 20%, depending on the level of immunosuppression and the presence of Epstein-Barr virus infection. Lung, heart, and pancreas transplants, which require higher doses of immunosuppressive agents, are associated with a higher risk of PTLD than are kidney or liver transplants. About 85% of PTLDs are from activation of B lymphocytes by Epstein-Barr virus, although proliferation of T-cells, natural killer cells, or plasma cells may also cause PTLD. PTLD manifests in two well-recognized forms: early-onset PTLD, which develops within the first year after transplantation (80% of cases) and late-onset PTLD, which manifests 4–5 years after transplant.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “About 85% of PTLDs are from activation of B lymphocytes by Epstein-Barr virus, although proliferation of T-cells, natural killer cells, or plasma cells may also cause PTLD. PTLD manifests in two well-recognized forms: early-onset PTLD, which develops within the first year after transplantation (80% of cases) and late-onset PTLD, which manifests 4–5 years after transplant.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “Approximately 50%–75% of PTLD cases manifest in the abdomen and primarily involve the gastrointestinal tract (more often in the distal small bowel than in the proximal small bowel). Imaging findings in gastrointestinal PTLD include irregular bowel wall thickening with eccentric mural masses, aneurysmal dilatation, luminal ulceration, and, rarely, intussusception. The liver is the most common solid organ involved in PTLD of the abdomen.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407 - “PTLD is potentially fatal, with a mortality rate between 22% and 70%, and early diagnosis is a key factor for overall survival rates. Limited levels of immunosuppression can help to prevent PTLD, and reduction in immunosuppression is the initial step in the treatment of PTLD and may result in complete regression of early lesions or polymorphic PTLD. Antibody or antiviral therapy and chemotherapy are other treatment strategies.”
Malignancy after Solid Organ Transplantation: Comprehensive Imaging Review
Katabathina VS et al.
RadioGraphics 2016; 36:1390–1407
- “Primary Hepatic Lymphoma (PHL) is an extremely rare tumor comprising only 0.016% of all cases of Non-Hodgkin's Lymphoma (NHL). PHL commonly presents in the mid-50s, with a male pre- dominance (M:F ratio of 2.3:1), and it is often associated with HCV, HBV, HIV, and Epstein-Barr Virus (EBV). Patients with PHL may present with a range of symptoms including hepatomegaly, abdominal pain, fatigue, jaundice, fever, and weight loss. Labs are typically normal with the exception of abnormal liver function tests (LFTs) and LDH; AFP and CA19–9 are normal.”
Rare primary hepatic malignancies: A case-based review
Victoria Wu et al.
Clinical Imaging 69 (2021) 196-204 - “There are several imaging features of PHL which may help to differentiate it from other more common liver malignancies. First, PHL may present with three distinct morphologic patterns; the most common being a single, well-defined lesion in 64% of cases. The other two less common forms include multiple discrete lesions or a diffuse, miliary pattern. On ultrasound, PHL most often appears as an homogeneous hypoechoic lesion with well-defined margins . On contrast enhanced ultrasound, there is washout on late phase. CT demonstrates hypoenhancement in comparison to normal liver parenchyma during both arterial and delayed phases with occasional rim enhancement. These lesions rarely contain calcification. On MR, PHL presents as homogeneous lesions which are hypo- to iso- intense on T1 weighted imaging and hyperintense on T2 weighted imaging. Due to a relatively higher nucleus to cytoplasm ratio and compacted cellularity, PHL also appears as marked restriction on DWI with low ADC values.”
Rare primary hepatic malignancies: A case-based review
Victoria Wu et al.
Clinical Imaging 69 (2021) 196-204
- "Primary hepatic lymphoma (PHL) is a rare primary liver tumor. Due to its clinical and radiological resemblance to liver metastases of adenocarcinoma, PHL is frequently diagnosed intra- or post-operatively. Since chemotherapy is the treatment of first choice for lymphoma, adjuvant chemotherapy should be given to patients for optimal treatment. The existing literature on PHL reveals the difficulties involved in diagnosis and treatment."
Primary lymphoma of the liver - A complex diagnosis
Steller EJA et al.
World J Radiol. 2012 Feb 28; 4(2): 53–57. - "Primary hepatic NHL is very rare, only 0.016% of all NHL. Of all primary extranodal NHL only 0.4% arise in the liver. 1.1% of all primary hepatic tumors in 30 years in the Johns Hopkins tumor registry consisted of PHL. The incidence of hepatic involvement in NHL is described between 16% and 22%, stressing the importance of careful investigation to disseminated disease outside of the liver."
Primary lymphoma of the liver - A complex diagnosis
Steller EJA et al.
World J Radiol. 2012 Feb 28; 4(2): 53–57. - "At initial presentation a third of patients present with a solitary liver nodule while another third have multiple lesions, and the remaining cases have diffuse infiltration of the liver."
Primary lymphoma of the liver - A complex diagnosis
Steller EJA et al.
World J Radiol. 2012 Feb 28; 4(2): 53–57. - "On tri-phasic liver CT scan PHL usually presents itself as a hypodense lesion, with possible areas of inhomogeneity. Occasionally local areas of rim enhancement or calcifications may be seen."
Primary lymphoma of the liver - A complex diagnosis
Steller EJA et al.
World J Radiol. 2012 Feb 28; 4(2): 53–57. - "Liver involvement by secondary Non Hodgkin’s lymphoma is relatively common. Primary liver lymphoma (PLL) is extremely rare. Among all extra nodal lymphomas, PLL constitutes <1% of all cases."
PRIMARY LIVER LYMPHOMA
S. Khalid et al.
JBR–BTR, 2013, 96: 84-86. - "Four of eighteen patients presented with a single focal lesion. Thirteen of eighteen patients presented with multiple well defined focal lesions. One patient presented with a diffuse hepatic involvement. On triphasic CT, three patients showed gradual progressive contrast enhancement. Lesions remained isodense to the liver on the arterial phase with mild enhancement in the portal phase and showed washout on the delayed phase in two patients. The remaining thirteen patients showed multiple hypodense non-enhancing lesions."
Multidetector CT (MDCT) Findings Of Primary Hepatic Lymphoma.
El-Badrawy A et al.
Gulf J Oncolog. 2016 Jan;1(20):64-70.