S5493 Dual Hepatic Malignancies in Cirrhosis: Coexistent HCC and CD5-Positive B-Cell Lymphoma

Introduction: Hepatocellular carcinoma (HCC) commonly arises in cirrhosis, whereas hepatic involvement by CD5-positive B-cell lymphoma, such as CLL/SLL, is rare. Biopsy-proven coexistence of both malignancies in the same hepatic mass is exceptionally uncommon, with fewer than 10 reported cases. We present a diagnostically challenging case confirmed by liver biopsy, peritoneal fluid analysis, and bone marrow evaluation. Case Description/Methods: A 62-year-old man with a history of decompensated alcohol-related cirrhosis presented with progressive abdominal distension, early satiety, and bilateral lower extremity edema. Imaging revealed large-volume ascites, splenomegaly, and a 10.6 × 4.7 × 9 cm hypervascular mass in hepatic segment 4 with left portal vein tumor thrombus. Alpha-fetoprotein was markedly elevated at 2,260 ng/mL. Liver biopsy demonstrated moderately differentiated HCC with interspersed atypical lymphoid aggregates. Flow cytometry of peritoneal fluid revealed a CD5-positive monoclonal B-cell population (viability 61.9%). Bone marrow aspirate showed hypercellular marrow (90%) with CD5-positive lymphoid infiltrates occupying 40–50% of the total cellularity, consistent with CLL/SLL. PET scan demonstrated mild hypermetabolic activity throughout the left hepatic lobe. Laboratory evaluation revealed WBC 14.1 × 10⁹/L, hemoglobin 11.4 g/dL, platelets 119 × 10⁹/L, international normalized ratio 1.42, and albumin 3.5 g/dL. Liver enzymes were elevated (aspartate aminotransferase 101 U/L, alkaline phosphatase 271 U/L, gamma-glutamyl transferase 116 U/L), and total bilirubin was 2.7 mg/dL. Manual differential showed 3% atypical lymphocytes, with marked poikilocytosis, polychromasia, elliptocytes, burr cells, and decreased platelet estimate. He was not a transplant candidate due to tumor burden and stage IV lymphoma. Rituximab was initiated as monotherapy. Discussion: This case highlights a rare and clinically significant dual hepatic malignancy. While HCC is common in cirrhosis, coexisting CD5-positive B-cell lymphoma within the same liver mass, ascitic fluid, and bone marrow is exceptionally rare. Most reported cases are incidental findings during surgery or transplant. In contrast, this diagnosis was made preemptively through liver biopsy and flow cytometry, directly impacting management. The case underscores the need to consider dual pathology in cirrhotic patients with atypical cytology or fluid profiles, especially when transplant eligibility is at stake.