title: Methotrexate-associated primary hepatic malignant lymphoma following hepatectomy: A case report.
abstract: BACKGROUND
  Recently, immunosuppressant-associated malignant lymphoma (ML) cases have been increasing along with the development of several effective immunosuppressant drugs for rheumatoid arthritis (RA). Among methotrexate (MTX)-associated lymphoproliferative disorders, primary hepatic lymphoma (PHL) in patients with RA following surgical resection has not been reported previously.
  
  
  METHODS
  A 65-year-old woman who is a hepatitis B virus carrier with a history of RA was admitted. MTX was introduced seven years prior as an RA treatment. Her laboratory data showed no elevation of several tumor markers, and liver function test results were normal. On contrasted computed tomography (CT) scanning, a slightly enhanced tumor was detected at the early phase, and tumor staining was sustained at the delayed phase. Further, subsegmentectomy of the S6 was performed. The pathological diagnosis was diffuse large B-cell lymphoma. However, positron emission tomography-CT and bone marrow aspiration sample showed no resident sign of ML.
  
  
  CONCLUSIONS
  Diagnosis of PHL before surgery is difficult. If the mass lesion was solitary and had a certain degree of size, then resection could be performed for its treatment and diagnosis. The treatment for ML requires a diagnosis of the subtypes to select a therapeutic agent and determine the prognosis. Once a precise preoperative diagnosis was made, withdrawing MTX could be the first treatment in case of MTX-related ML.
  
  
  CONCLUSIONS
  Long-term usage of immunosuppressant drugs could cause proliferative ML. Considering the increasing occurrence of MTX-related ML, withdrawing MTX should be considered, especially in patients with long-term immunosuppressant usage for RA.
authors.affiliation: Department of Surgery, Onomichi General Hospital, Onomichi, Hiroshima, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Takei
authors.affiliation: Department of Surgery, Onomichi General Hospital, Onomichi, Hiroshima, Japan. Electronic address: t.abe.hiroshima@gmail.com.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Abe
authors.affiliation: Department of Surgery, Onomichi General Hospital, Onomichi, Hiroshima, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Japan.
authors.forename: Hironobu
authors.initials: H
authors.lastname: Amano
authors.affiliation: Department of Gastroenterology,Onomichi General Hospital, Onomichi, Hiroshima, Japan.
authors.forename: Naomichi
authors.initials: N
authors.lastname: Hirano
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Japan.
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Kobayashi
authors.affiliation: Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Ohdan
authors.affiliation: Kawasaki Medical School Hospital, Kurashiki, Okayama, Japan.
authors.forename: Toshinori
authors.initials: T
authors.lastname: Kondo
authors.affiliation: Department of Surgery, Onomichi General Hospital, Onomichi, Hiroshima, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Nakahara
authors.affiliation: Department of Surgery, Onomichi General Hospital, Onomichi, Hiroshima, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Japan.
authors.forename: Toshio
authors.initials: T
authors.lastname: Noriyuki
keywords: Diffuse large B cell lymphoma; Methotrexate; Primary hepatic malignant lymphoma