Biliary cystadenocarcinoma arising in a congenital cyst

Outcome following Resection of Biliary Cystadenoma: A Single Centre Experience and Literature Review

Background. Biliary cystadenomas (BCAs) are rare, benign, potentially malignant cystic lesions of the liver, accounting for less than 5% of cystic liver tumours. We report the outcome following resection of biliary cystadenoma from a single tertiary centre. Methods. Data of patients who had resection of BCA between January 1993 and July 2014 were obtained from liver surgical database. Patient demographics, clinicopathological characteristics, operative data, and postoperative outcome were analysed. Results. 29 patients had surgery for BCA. Male : female ratio was 1 : 28. Clinical presentation was abdominal pain (74%), jaundice (20%), abdominal mass (14%), and deranged liver function tests (3%). Cyst characteristics included septations (48%), wall thickening (31%), wall irregularity (38%), papillary projections (10%), and mural nodule (3%). Surgical procedures included atypical liver resection (52%), left hemihepatectomy (34%), right hemihepatectomy (10%), and left lateral segmentectomy (3%). Median length of stay was 7 (IQ 6.5-8.5) days. Two patients developed postoperative bile leak. No patients had malignancy on final histology. Median follow-up was 13 (IQ 6.5-15.7) years. One patient developed delayed biliary stricture and one died of cholangiocarcinoma 11 years later. Conclusion. Biliary cystadenomas can be resected safely with significantly low morbidity. Malignant transformation and recurrence are rare. Complete surgical resection provides a cure.

Invasive biliary mucinous cystic neoplasm: a review

OBJECTIVES

Biliary mucinous cystic neoplasms (BMCNs) are recently redefined rare liver tumours in which insufficient recognition frequently leads to an incorrect initial or delayed diagnosis. A concise review of the subtle, sometimes non-specific, clinical, serologic and radiographic features will allow for a heightened awareness and more comprehensive understanding of these entities.

METHODS

Literature relating to the presentation, diagnosis, treatment, pathology and outcomes of BMCNs and published prior to March 2012 was reviewed.

RESULTS

Biliary mucinous cystic neoplasms most commonly occur in females (≥60%) in the fifth decade of life. Clinical symptoms, serologic markers and imaging modalities are unreliable for diagnosis of BMCNs, which leads to misdiagnosis in 55-100% of patients. Perioperative cyst aspiration is not recommended as invasive BMCNs can only be differentiated from non-invasive BMCNs by microscopic evaluation for the presence of ovarian-type stroma. Intraoperative biopsy and frozen section(s) are essential to differentiate BMCNs from other cystic liver lesions. The treatment of choice is complete excision and can result in excellent survival with initial correct diagnosis.

CONCLUSIONS

A low threshold for considering BMCN in the differential diagnosis of cystic liver lesions and increased attentiveness to its subtle diagnostic characteristics are imperative. The complete surgical resection of BMCNs and the use of appropriate nomenclature are necessary to improve outcomes and accurately define prognosis.

Hepatobiliary cystoadenoma: a wolf in sheep's clothing

Hepatobiliary cystoadenoma is a rare cystic tumor of the liver that can undergo malignant change and become lethal. Accurate diagnosis of such lesions, even though not always possible, is of importance as the management is totally different from that of other nonneoplastic cysts. We report a case of a 60-year-old woman with aspecific symptoms, which was diagnosed using ultrasound scan and CT scan and treated with hepatic resection, and review the main features of this tumor.

Hepatobiliary cystadenoma: a case report and a review of the literature

BACKGROUND

Hepatic cystic lesions are rare; however, their management and treatment is dependent on early recognition and diagnosis.

METHODS

In this report, the authors discuss a 72-year-old woman who presented to their clinic for treatment of a hepatocystadenoma.

RESULTS

The history, physical examination, and diagnostic modalities lead to surgical intervention despite an unclear diagnosis.

CONCLUSIONS

This case illustrates an unusual hepatic lesion in which the diagnosis was not known until the time of laparotomy. However, diagnostic modalities were important in establishing the need for surgical intervention. The authors offer a pertinent review of the literature and discuss current treatment modalities.

Cystadenocarcinoma of the gallbladder

Biliary cystadenocarcinomas are a very rare set of neoplasms that occur in the liver, the extrahepatic bile duct system, and occasionally in the gallbladder. We report on a 75-year-old man with a cystadenocarcinoma of the gallbladder who presented with mild abdominal discomfort and a palpable mass in the right upper abdomen. The diagnostic workup included ultrasound, magnetic resonance tomography, and fine needle core biopsy and revealed a multicystic tumor 16 cm in diameter. The patient underwent multivisceral resection of the tumor with a resection of the right colon, a partial resection of the stomach and the liver, and a lymph node dissection. The resected specimen weighed 2500 g and the final histopatholical diagnosis was a primary, moderately differentiated cystadenocarcinoma of the gallbladder with two lymph node metastases and invasion of the right colon. The patient remains without evidence of recurrence 12 months after surgery. The clinical presentation, diagnosis, therapeutic options, and classification of hepatobiliary cystadenocarcinomas are discussed.

Biliary cystadenoma with mesenchymal stroma: Report of a case and review of the literature

Biliary cystadenomas are rare, cystic neoplasms of the biliary ductal system that usually occur in middle-aged women. They cannot be safely differentiated from cystadenocarcinomas before operation and should always be considered for resection. Cystadenomas have a strong tendency to recur, particularly following incomplete excision, and a potential of malignant transformation. Therefore, complete resection is the therapy of choice and thorough histopathologic evaluation is imperative. A case of benign biliary cystadenoma with mesenchymal stroma is presented along with a review of the relative literature addressing the clinical presentation, histology, histogenesis, differential diagnosis, imaging features, treatment and prognosis of this interesting and rare entity.

Ultrasonographic evaluation of biliary cystadenomas in cats

The purpose of this study was to describe the ultrasonographic appearance of biliary cystadenomas in cats and compare the findings to a similar rare form of liver tumor in humans. Biliary cystadenomas are uncommon, benign liver tumors of older cats that may occur as focal or multifocal cystic lesions within the liver. The records of 10 cats which had abdominal ultrasonography and histologic diagnosis of biliary cystadenoma were reviewed. The average age of affected cats was 13.3 years (range 10-16 years). Eight cats were neutered males and two were neutered females. In three cats, the tumors were not seen ultrasonographically due to their small size or from being obscured by near-field reverberation echoes. The remaining seven cats had solitary (4 cats) or multifocal (3 cats) masses corresponding to variable ultrasonographic patterns: multilocular masses containing thin-walled cysts, hyperechoic masses with cystic components, or masses of mixed echogenicity with cystic components. The masses had variable ultrasonographic patterns when multifocal disease was present. Recognizable cysts were evident somewhere within the tumors seen ultrasonographically, although sometimes the cysts appeared very small. The biliary cystadenomas were thought to be clinically silent. Although liver enlargement or a cranial abdominal mass was palpable in 4 cats, no consistent trend of clinical signs, CBC or serum biochemical abnormalities could be directly attributed to biliary cystadenoma. The treatment of choice is surgical resection of the tumor, as continued growth may compress adjacent vital structures within the liver. The differential diagnosis of biliary cystadenomas from other cystic liver lesions such as hepatic cysts, hematomas, abscesses, parasitic cysts, or other liver tumors is discussed.

Biliary cystadenocarcinoma of the liver: the need for complete resection

We report on a patient with biliary cystadenocarcinoma and review 112 previously published cases of this rare cystic hepatic neoplasm. This tumour mainly occurs in women at a ratio of 62% (female) to 38% (male), and at an average age of 56.2 years (range 18-88 years). The origin of these neoplasms is intrahepatic in 97% of cases and extrahepatic in the remaining 3%. The clinical symptoms are nonspecific and are not distinctive from benign cystic liver lesions unless invasive growth of the tumour occurs or distant metastases are present. Sonography and computed tomography (CT), as well as magnetic resonance imaging (MRI) demonstrate the multilocular nature of the tumour with septal or mural nodules. Discrete soft tissue masses, thick and coarse calcifications and varying density on CT or intensity on MRI within the loculi are additional non-specific imaging findings. The best therapeutic result with a 5-year survival rate of 100% and a recurrence rate of only 13% was achieved by complete excision (n = 16). Surgical removal of the tumour by complete excision is, therefore, the treatment of choice for biliary cystadenocarcinomas.

Biliary cystadenoma of cats

Published surveys of feline neoplasia have not specifically included biliary cystadenoma, and there is only one case report in the literature. This report is a compilation of 13 feline cases and provides a description of clinical, pathologic, immunohistochemical, and ultrastructural aspects of biliary cystadenoma as well as a discussion of comparative pathology of biliary cystadenoma in human beings and speculative histogenesis.

Mucinous cholangiocarcinoma featuring a unique microcystic appearance

An autopsy case is presented of a peculiar type of intrahepatic mucinous adenocarcinoma with microcyst formation arising in a 78 year old Japanese man who died of hepatic coma and renal failure 4 months after onset. Macroscopically, the cut surface of the lesion revealed a characteristic honeycomb-like appearance, consisting purely of microcysts, 0.2-0.4 cm in diameter, lined by prolific mucin-producing adenocarcinoma cells. The lesion did not have large cystic space, fibrous capsule, or benign cystadenomatous component other than neoplastic microcyst formation. The carcinoma cells showed various proliferating patterns, such as irregularly shaped nest-like, trabecular, papillary and tubular ones, directly invaded the hepatic parenchyma and portal tract with loose or thick fibrosis, and infiltrated extensively into both intrahepatic and extrahepatic stroma along the vascular structures. From these clinicopathological findings, we consider the present tumor to be a variant of mucinous cholangiocarcinoma with characteristic microcyst formation rather than a type of cystadenocarcinoma.

Cystic disease of the liver and biliary tract

The widespread availability of ultrasound imaging has led to more frequent recognition of cystic disease affecting the liver and biliary tract. There is a wide range of possible causes. Cystic disease of infective origin is usually caused by an Echinococcal species, or as the sequel of a treated amoebic or pyogenic abscess. The clinical and radiological features are often then distinctive and will not be dwelt upon in this review, except in respect of their contribution to the differential diagnosis of non-infective disorders. The principal non-infective cysts can be conveniently divided between the simple cyst, the polycystic syndromes (usually with coexistent renal disease), Caroli's syndrome, and choledochal cysts. The overlap between constituent members of these groups, and the association of cystic disease with hepatic fibrosis (especially with congenital hepatic fibrosis) has attracted considerable attention, and it has been suggested that they may all be considered to belong to a hepatobiliary fibrocystic continuum. In addition there are a variety of cystic neoplasms and a miscellany of unusual forms.

Hepatobiliary cystadenoma with mesenchymal stroma

In a detailed review of cystic hepatobiliary neoplasms, we identified a subset of 50 cases in which tumors were characterized by the presence of a mesenchymal cell layer interposed between an inner epithelial lining and an outer connective tissue layer. We have recently seen three such patients, making a total of 53 patients reported in the English literature. All of the patients were female, 44 of whom, with an average age of 41 years, had benign tumors. The average age of the remaining nine patients was 57 years and these patients had malignant tumors. In seven patients, the malignancy arose from the epithelial layer, but in two patients sarcomatous changes were identified in the mesenchymal tissues. The older age of the patients with malignant tumors with adequate serial biopsies in two cases supported the thesis that malignant transformation may occur in the benign tumors. Moreover the location of the tumor in one of our patients in whom the resected tumor was associated with anomalous right hepatic ducts and portal veins supported the theory that these tumors develop embryologically from nests of primitive hepatobiliary endodermal and mesodermal cells. Although surgical treatment was performed in all patients, 25% of the patients with benign hepatobiliary cystadenoma with mesenchymal stroma (CMS), and 33% of the patients with malignant CMS had tumor recurrence after primary resection. Ninety per cent of these patients had an incomplete resection at the time of their initial operations. Forty-four per cent of the patients with malignant CMS died after a mean follow-up of 17 months. We conclude that CMS (Edmonson's tumor) occurs uniquely in young female patients, develops from nests of primitive embryonal cells, has the potential for malignant transformation, and should be completely resected at primary operation to avoid recurrence.

Cystadenoma of the common bile-duct with malignant transformation

A case of cystadenoma of the common bile-duct with areas of carcinoma in situ in a 61 year old woman is presented. Pre-operative investigations may confuse this rare tumour with the more common choledochal cyst although this case raises the possibility that this neoplasm may have arisen within a longstanding choledochal cyst. Due to the risk of malignant transformation, complete excision of any cystic lesion of the bile-duct is recommended.

Pseudosarcomatous cystadenocarcinoma of the liver

A case of papillary cystadenocarcinoma with spindle (pseudosarcomatous) metaplasia of the liver is described in a 64-year-old woman. This tumor was solitary, multiloculated, and had a fibrous pseudocapsule. It was composed of undifferentiated malignant epithelial cells, which lined cystic spaces, with sarcomatous cells underneath. Immunohistochemical studies showed no detectable alpha-fetoprotein in the tumor; keratin was present in epithelial and spindle tumor cells, and alpha 1-antitrypsin was present in cytoplasm of many tumor cells. Intracytoplasmic periodic acid--Schiff-positive, diastase-resistant globules, some of them reactive for alpha 1-antitrypsin, were seen. A primary liver tumor with this histology has not been described previously in the literature.