Rapidly enlarging hepatobiliary cystadenoma

Management of simple hepatic cyst

Simple hepatic cysts are typically saccular, thin-walled masses with fluid-filled epithelial lined cavities that arise from aberrant bile duct cells during embryonic development. With the development of diagnostic modalities such as ultrasonography, computed tomography and magnetic resonance imaging, simple hepatic cysts are seen with relative frequency in daily clinical examination. US is the most useful and noninvasive tool for the diagnosis of simple hepatic cysts, and can generally differentiate simple hepatic cysts from abscesses, hemangiomas and malignancies. Cysts with irregular walls, septations, calcifications or daughter cysts on US should be evaluated with enhanced CT or MRI to differentiate simple hepatic cysts from cystic neoplasms or hydatid cysts.Growth and compression of hepatic cysts cause abdominal discomfort, pain, distension and dietary symptoms such as nausea, vomiting, a feeling of fullness and early satiety. Complications of simple hepatic cysts include infection, spontaneous hemorrhage, rupture, and external compression of biliary tree or major vessels.Asymptomatic simple hepatic cysts should be observed. Treatment for symptomatic simple hepatic cysts includes percutaneous aspiration, aspiration followed by sclerotherapy, and surgery. The American College of Gastroenterology clinical guidelines recommend laparoscopic fenestration based on its high success rate and low invasiveness. Percutaneous procedures for treatment of simple hepatic cysts are particularly effective for the immediate palliation of patient symptoms; however, they are not generally recommended because of the high rate of recurrence.Management of simple hepatic cysts requires correct differentiation from neoplasms and infections, and the selection of a reliable treatment.

Mucinous cystic neoplasm of the liver communicated with intrahepatic duct exhibiting peculiar chronological change in MR imaging appearances: a case report

A 70-year-old woman has been followed up for chronic hepatitis C and hepatocellular carcinoma which had been successfully controlled by several sessions of radiofrequency ablation. A small cystic lesion in segment IV associated with adjacent intrahepatic duct dilatation was firstly noted 4 years before on MR imaging, which showed gradual increase in size and significant interval change in the MRI signal intensity of the cystic content on the follow-up examinations. The mass finally reached 4 cm in its largest dimension, associated with slightly enhancing thickened wall, suggesting its neoplastic nature. The mass was surgically resected and a final diagnosis of mucinous cystic neoplasm (MCN) of the liver was made. MCN is usually considered to have no communication with intrahepatic duct, but in this particular case, the communication with the biliary duct was suggested from its early stage of the lesion, which would be the cause of peculiar chronological change in MR appearance.

Spontaneous rupture of a simple hepatic cyst: report of a case

We describe the spontaneous rupture of a simple hepatic cyst. A 62-year-old woman was admitted for right upper quadrant pain of sudden onset. The patient denied a history of abdominal trauma. Computed tomography of the abdomen showed a 13-cm-diameter solitary hepatic cyst in the right lobe. Part of the cyst surface was irregular, and the internal echo was heterogeneous. Retained fluid was detected under the liver capsule. Ten days after admission, computed tomography revealed that the volume of fluid retained under the liver capsule had decreased but that the hepatic cyst had enlarged again. The patient was referred to our hospital for further evaluation and treatment. Physical examination revealed mild right upper quadrant pain, but no signs or symptoms of peritonitis or abnormalities of the chest or heart. Percutaneous puncture was performed with a needle and an 8-French pigtail catheter under ultrasonographic guidance. Brown serous fluid was aspirated. After the removal of approximately 1,000 mL of fluid, contrast medium was injected to check for communications between the cyst and the biliary tree and to document the absence of leakage into the peritoneal cavity. After complete aspiration of the cyst fluid, 200 mg of minocycline hydrochloride dissolved in 10 mL of saline was injected into the cyst, and the catheter was flushed with 10 mL of saline (total volume of saline, 20 mL). The catheter was then clamped for 30 minutes. After percutaneous aspiration, the patient's symptoms resolved. Minocycline hydrochloride was injected daily for 7 days, and the catheter was removed. There has been no evidence of recurrence after 2 years.

Surgical resection of cystic intraductal papillary adenocarcinoma of the bile duct: report of a case

We describe a cystic intraductal papillary neoplasm of bile duct (IPNB) of adenocarcinoma treated with surgical resection. An 82-year-old man was admitted to our hospital because of distension of the right upper quadrant of the abdomen. On admission, a huge nontender mass was palpated in the right upper abdomen. Initial laboratory tests revealed the following serum values: aspartate aminotransferase, 123 IU/L; alanine aminotransferase, 113 IU/L; alkaline phosphatase, 376 IU/L; bilirubin, 1.6 mg/dL; alpha-fetoprotein, 7.4 ng/mL; CA19-9, 39.8 U/mL; carcinoembryonic antigen, 4.1 ng/mL; and Duke pancreatic monoclonal antigen type 2, 200 U/mL. Abdominal ultrasonography revealed an anechoic mass with an elevated papillary lesion in the right paramedian section. Computed tomography showed a low-density hepatic lesion, measuring 12 × 10 cm, with thick, irregular walls. A T2-weighted magnetic resonance scan showed mural nodules with signal intensity higher than that of the liver. The cystic lesion was suspected to be a cystic IPNB, but we could not determine whether it was a carcinoma. We performed extensive right paramedian sectionectomy and cholecystectomy. The resected multilocular tumor was filled with a yellow fluid, and the cut surface showed multiple, yellowish papillary nodules lining the cystic wall. On histologic examination, the neoplastic biliary epithelium showed papillary growth in the dilated lumen. Papillary and micropapillary lesions exhibited cellular atypia: nuclear enlargement and hyperchromasia, mutilayering, and mitosis. Ovarian-like stroma was not detected. The tumor was diagnosed as an IPNB (carcinoma in situ lesion). These lesions had expanded into several intrabiliary ducts. No recurrence has been detected 2 year after operation.

Biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection

Most hepatic cysts are asymptomatic, but complications occasionally occur. We describe a patient with biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection. A 60-year-old Japanese woman was admitted to our hospital because of a nontender mass in the right upper quadrant of the abdomen. Laboratory tests revealed the following: serum total bilirubin, 0.6 mg/dL; serum aspartate aminotransferase, 100 IU/L; serum alanine aminotransferase, 78 IU/L; serum alkaline phosphatase, 521 IU/L; and serum gamma glutamic transpeptidase, 298 IU/L. Abdominal computed tomography, ultrasonography, and magnetic resonance cholangiopancreatography revealed a huge hepatic cyst, 13 cm in diameter, at the hepatic hilum, accompanied by dilatation of the intrahepatic bile duct and obstruction of the common bile duct. We diagnosed biliary obstruction due to a huge hepatic cyst at the hepatic hilum, and laparoscopic surgery was performed. A huge hepatic cyst was seen at the hepatic hilum. After needle puncture of the huge cyst, the anterior wall of the cyst was unroofed, and cholecystectomy was done. Intraoperative cholangiography through a cystic duct revealed stenosis of the duct. Subsequent decapsulation of the cyst was performed in front of the common bile duct. After this procedure, cholangiography revealed that the stenosis of the common bile duct had resolved. Histopathological examination of the surgical specimen confirmed the hepatic cyst was benign. The postoperative course was uneventful, and the results of liver function tests normalized. The patient was discharged 7 days after operation. Computed tomography 3 months after operation revealed disappearance of the hepatic cyst and no dilatation of the intrahepatic bile duct.

A case of spontaneous rupture of a simple hepatic cyst

We describe the spontaneous rupture of a simple hepatic cyst associated with a benign course. A 64-year-old woman was admitted for right upper quadrant pain. The patient denied a history of abdominal trauma. Abdominal computed tomography (CT) showed a huge solitary hepatic cyst (diameter, 10 cm) in the right lobe. Part of the cyst surface was irregular, and the interior was heterogeneous on ultrasonography. Fluid retention was detected under the liver capsule. Spontaneous rupture of a nonparasitic hepatic cyst was suspected. The patient was admitted to our hospital for further evaluation and treatment. Examination of the abdomen revealed right upper quadrant pain but no signs or symptoms of peritonitis. One week after admission, CT revealed that the volume of fluid retained under the liver capsule had decreased. Percutaneous puncture was performed with a needle and an 8-French pigtail catheter under ultrasonographic guidance. Serous, brown fluid was aspirated. After percutaneous aspiration, the patient's symptoms resolved. Minocycline hydrochloride was given daily by intravenous injection for 7 days. The catheter was then removed. There has been no evidence of recurrence after 1 year.

Intracystic hemorrhage of a large simple hepatic cyst

Spontaneous intracystic hemorrhage rarely occurs in nonparasitic hepatic cysts. We describe a patient with spontaneous intracystic hemorrhage of a large simple hepatic cyst that mimicked a malignancy. A 59-year-old man presented with right abdominal discomfort. The patient's medical history included a simple hepatic cyst that had been detected 7 years earlier but was left untreated. Three weeks before presentation, right upper abdominal pain occurred but resolved spontaneously. The serum CA19-9 concentration was 48.3 U/mL (normal<37 U/mL). Ultrasonography revealed a large cystic mass, containing many hyperechoic structures and occupying nearly the entire right hepatic lobe. Computed tomography demonstrated a homogenous low-density area, 20 cm in diameter, in the right hepatic lobe. Magnetic resonance imaging revealed a heterogeneous hypointense lesion measuring 20 cm in diameter. The lesions showed linear hyperintense areas on T1-weighted sequences and mosaic heterogeneous hyperintensity on T2-weighted sequences. We suspected a hemorrhagic simple hepatic cyst, hydatid cyst, or hemorrhagic cystadenocarcinoma. Right hepatectomy was performed, and the enlarged right lobe was removed. The mass was soft, sponge-like, and contained fluid, but was not elevated. Pathologic examination of the surgical specimen confirmed the presence of a hemorrhagic benign hepatic cyst.