Biliary cystadenocarcinoma of the liver: the need for complete resection

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

[Prophylactic surgery for hepatic and biliary tumors]

Benign tumors of the liver and biliary tract are rare entities, and some of them require surgical management to prevent their malignant transformation. Tumors from the biliary tract with malignant potential are treated either by hepatic resection, for mucinous cystic neoplasm and ciliated hepatic foregut cysts, or by biliary resections, for biliary papillary neoplasm and type I and IV choledochal cysts. The pathologies requiring prophylactic cholecystectomy are polyps larger than 10 mm, porcelain gallbladder and pancreaticobiliary maljunction. Finally, hepatocellular adenoma over 5cm, occurring in male patients, or exon 3 mutated beta-catenin, should lead to prophylactic resection by hepatic segmentectomy. This article describes these different pathologies and their management.

Management of Mucinous Cystic Neoplasms of the Liver

BACKGROUND

Mucinous cystic neoplasms of the liver (MCN-L) including biliary cystadenomas (BCA) and biliary cystadenocarcinomas (BCAC) are rare cystic lesions that comprise less than 5% of all liver cysts and affect only a small subset of individuals. We herein review the current evidence regarding the clinical presentation, imaging characteristics, tumor markers, pathological findings, clinical management, and prognosis of MCN-L.

METHODS

A comprehensive review of the literature was performed using MEDLINE/Pubmed and Web of Science databases. In PubMed, the terms "biliary cystadenoma," "biliary cystadenocarcinoma," and "non parasitic hepatic cysts" were queried to identify the most recent data on MCN-L.

RESULTS

US imaging, CT, and MRI, as well as consideration of clinicopathological features, are required to appropriately characterize and diagnose hepatic cystic tumors. BCA are premalignant lesions and cannot be reliably differentiated from BCAC based on imaging alone. As such, both types of lesions should be treated with margin-negative surgical resection. Following surgical resection, recurrence is fairly low among patients with BCA and BCAC. Despite having worse long-term outcomes than BCA, the prognosis following surgical resection of BCAC still remains more favorable than other primary malignant liver tumors.

CONCLUSION

MCN-L are rare cystic liver tumors that include BCA and BCAC, which can be difficult to differentiate based on imaging alone. Surgical resection remains the mainstay of management for MCN-L with recurrence being generally uncommon. Future multi-institutional studies are still required to better understand the biology behind BCA and BCAC to improve the care of patients with MCN-L.

Cystadenocarcinoma of the gallbladder: A case report

Introduction and importance

Cystadenoma and cystadenocarcinoma of the biliary duct remain a rare diagnosis, the localization is intrahepatic in 97% of the cases and extrahepatic in 3%of them [1]. Cystadenocarcinoma of the gallbladder is the rarest localization, it's usually diagnosed late because of the poor symptoms and the nonspecific lesions in the different imaging.Only hundreds of cases have been reported for cystadenocarcinoma of the gallbladder.This case report has been reported in line with the SCARE Criteria.

Case presentation

We present a 70-year-old woman, with no family or personal history, who was complaining of pain in the right hypochondrium and an altered general well-being, with no other clinical abnormalities.The imaging including abdominal sonography, CT scan, and MRI concluded at a budding lesion formed in the gallbladder wall which measured 65 × 15mm.Cancer of the gallbladder was suspected and the patient was operated. A resection of segment s4b and 5 of the liver was performed with lymphadenectomy. The post-operative clinical course was uneventful.The diagnosis of cystadenocarcinoma of the gallbladder was confirmed on an anatomopathological exam of the specimen.

Conclusion

Cystadenocarcinoma is a rare diagnosis.There are no specific symptoms or lesions at the imaging.The confirmation is obtained on an anatomopathological study of the specimen.

EASL Clinical Practice Guidelines on the management of cystic liver diseases

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.

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.

A rare case of extrahepatic biliary mucinous cystic neoplasm in a middle-aged woman: A case report

Biliary mucinous cystic neoplasms are very rare tumors of the biliary tract with malignant potential. Preoperative diagnosis is challenging, as clinical, biochemical and radiological features are not specific. Surgical resection with negative margins is the gold standard treatment for these uncommon lesions. A 55-year-old woman presented at the Third Department of Surgery (Attikon University Hospital, Athens, Greece) with a history of mild right upper quadrant (RUQ) abdominal pain and jaundice. A 2-cm lesion in the distal common bile was identified by imaging. Following discussion in our multidisciplinary board meeting the patient underwent a pylorus preserving pancreatoduodenectomy, and histopathological examination revealed an ovarian-stromal type intraductal mucinous cystic neoplasm of the extra hepatic biliary. Since biliary mucinous cystic neoplasms are characterized by malignant transformation and high rates of recurrence, surgical resection with negative margins is the treatment of choice for both non-invasive and invasive biliary mucinous cystic neoplasms.

Imaging of Benign Hepatic lesions

As abdominal imaging volumes have increased, the incidence of incidentally identified benign hepatic lesions has substantially increased. Familiarity with imaging appearances of benign hepatic tumors, both common and less commonly encountered, allows the radiologist to give an informed differential diagnosis. In addition to clinical history, awareness of imaging findings of benign hepatic lesions on ultrasound, computed tomography and magnetic resonance imaging is useful in evaluating these lesions and avoiding unnecessary diagnostic interventions or imaging surveillance.

Mucinous Cystic Adenoma of the Liver: A Thought-Provoking Case of an Uncommon Hepatic Neoplasm

Patient: Male, 70-year-old

Final Diagnosis: Liver disease

Symptoms: Asymptomatic

Medication:—

Clinical Procedure: Hepatectomy

Specialty: Gastroenterology and Hepatology

Cystic biliary tumors of the liver: diagnostic criteria and common pitfalls

With major advancements and frequent use of abdominal imaging techniques, hepatic cysts are increasingly encountered in clinical practice. Although the majority of cysts are benign, a small subset represents neoplastic precursors to cholangiocarcinoma. These cystic precursors include intraductal papillary neoplasms of the bile duct (IPNB) and mucinous cystic neoplasms of the liver (MCN-L), and bear striking pathologic resemblance to corresponding cystic neoplastic precursors within the pancreas. This review examines the salient clinical, gross, microscopic and molecular features of IPNBs and MCN-Ls, and, in particular, provides histopathologic comparison to their pancreatic counterparts. Considering these neoplasms may be diagnostically challenging, we also discuss other hepatic lesions within the differential diagnosis, and the potential for molecular methods to improve their preoperative evaluation and the early detection of cholangiocarcinoma.

A Biliary Mucinous Cystic Neoplasm with Intrahepatic and Lymph Node Metastases

A 51-year-old woman who presented with a large cystic liver tumor with mural nodules in the lateral segment developed Trousseau's syndrome. A mural nodule directly invaded her liver parenchyma. Metastatic nodules were detected in the right lobe and portal/paraaortic lymph nodes. The pathological findings showed mucin-producing adenocarcinoma cells to have invaded the fibrous stroma forming a micropapillary cluster. She developed obstructive jaundice due to tumor progression and subsequently died of hepatic failure. Invasive biliary mucinous cystic neoplasm (MCN) is a rare form of a malignant tumor with a relatively favorable prognosis. This is a very rare case biliary MCN with invasive carcinoma that showed intrahepatic and lymph node metastases.

Biliary cystadenoma in an endemic zone of hydatid cyst: A rare surgical surprise

The advancement of radiological investigations has led to the early and incidental detection of hepatic cystic lesions. These are most commonly the simple cysts but can be malignant as well. Despite the recent advances, these lesions still pose a diagnostic as well as therapeutic challenge. The biliary cystadenomas and carcinomas form around 5% of all the malignant cystic lesions of liver. These lesions are hardly diagnosed preoperatively and are usually a histopathological surprise. They warrant a surgical excision. Herewith, the authors are describing a case of cystic hepatic neoplasm initially misdiagnosed as hydatid cyst of liver and discovered to be a vascular cystic lesion intraoperatively. This patient underwent resection of the lesion and was discovered to harbour biliary cystadenoma on histopathological specimen.

Mucin-producing hepatic cystic neoplasms: an uncommon but challenging disease often misdiagnosed and mismanaged

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant.Methods: Nine MHCN were encountered in our centre for over 32 years. Patients' clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification).Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1-132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free.Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable.

The impact of imaging on the surgical management of biliary cystadenomas and cystadenocarcinomas; a systematic review

BACKGROUND

Biliary Cystadenomas (BCA) are considered to be benign but may transform to Biliary Cystadenocarcinomas (BCAC). The aim of this systematic review was to assess the diagnostic work-up and necessity of complete surgical resection.

METHOD

A systematic literature search was performed in Embase.com, Medline (Ovid), Cochrane Central, Web-of-Science and Google Scholar. Articles reporting on diagnostic work-up or outcome of various treatment strategies were included.

RESULTS

Fifty-one articles with 1218 patients were included: 971 with BCA and 247 with BCAC. Patients with BCA were more often female (91% vs 63.8%, p < 0.001). On radiologic imaging BCAC more often had calcifications (p = 0.008), mural nodules (p < 0.001) and wall enhancement (p < 0.001). Reported treatment strategies were resection, enucleation, or fenestration/marsupialization. Recurrence was reported in 5.4% after resection for BCA and 4.8% after resection for BCAC. Recurrence after fenestration/marsupialization varied from 81.6% to 100% for both BCA as BCAC. Mortality rate was 0 in patients with BCA and 24% in BCAC.

CONCLUSION

Due to the difficulty in accurately diagnosing these biliary cystic lesions and the availability of different surgical approaches, patients with suspected BCA or BCAC should be treated in a center specialized in liver surgery with state-of-the-art imaging and all surgical techniques to prevent mismanagement of this rare disease.

Case report of hepatic pseudocyst: A rare manifestation of liver metastasis from an anal squamous cell carcinoma

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Liver metastasis of anal squamous cell carcinoma with a presented pseudocyst is very rare.

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Some hepatic diseases such as infections, simple biliary cysts, and neoplasms demonstrate a cystic change of the liver.

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Metastasis should be suspected when CT findings in patients with a history of gastrointestinal cancer show cystic changes involving the liver.

Introduction

Liver metastasis of an anal squamous cell carcinoma (SCC) with a pseudocyst is uncommon. There are many diseases which form hepatic cystic lesions and sometimes it is difficult to arrive at an accurate diagnosis.

Presentation of case

A 69-year-old woman visited our hospital with complaints of bloody stool and difficult defecation. A palpable mass in the anal canal was found on digital examination. The laboratory tests revealed anemia and raised levels of SCC antigen. On endoscopy a type 2 tumor was identified in the anal canal and biopsy revealed SCC. The patient was diagnosed with advanced anal SCC (cT2N1aM0, cStage IIIA) as a result of the examination and underwent chemoradiotherapy (CRT); unfortunately the tumor persisted after CRT. A salvage abdominoperineal resection with D2 and left lateral lymph node dissection was conducted. Histopathologically, the tumor was diagnosed as poorly differentiated SCC. She was readmitted for fever 3 weeks after surgery, and the abdominal CT showed multiple low density areas with enhancement at the edge of the liver, suggesting abscess or metastasis. The metastatic SCC was revealed by cytology of liver drainage and liver biopsy.

Discussion

Anal cancers are sometimes encountered however; a pseudo cystic presentation of a liver metastasis is very rare which makes it difficult to distinguish from other diseases.

Conclusion

We present a case of SCC in the anal canal with liver metastasis presenting as a hepatic pseudocyst.

Biliary mucinous cystic neoplasm mimicking a hydatid cyst: a case report and literature review

Background

Biliary mucinous cystic neoplasms are rare cystic lesions of the liver which carry pre-malignant potential. Given the scarcity of reports in the literature, they pose a considerable challenge to clinical management, particularly with regards to accurate pre-operative diagnosis.

Case presentation

We present the case of a 37-year-old Tunisian woman who presented with subacute right upper quadrant pain and a large multi-loculated cystic lesion, most consistent with a hydatid cyst. She underwent an open right hepatectomy, and pathology surprisingly revealed a biliary mucinous cystadenoma. Herein, we review the current literature on biliary mucinous cystic neoplasms, with a particular emphasis on diagnostic investigations, key radiological features and optimal treatment modalities.

Conclusion

Biliary mucinous cystic neoplasms require a high index of suspicion and should be managed with complete surgical resection, as conservative techniques are associated with high recurrence rates. Considering the potential for malignant transformation, periodical surveillance imaging is recommended in the post-operative period.

Diagnostic and Therapeutic Challenges of Intrahepatic Biliary Cystadenoma and Cystadenocarcinoma: A Report of 10 Cases and Review of the Literature

The objective of this study was to present our experience with intrahepatic biliary cystadenomas and cystadenocarcinomas in 10 patients surgically managed in our department. Intrahepatic biliary cystadenomas and cystadenocarcinomas are rare cystic tumors that are often misdiagnosed preoperatively as simple cysts or hydatid cysts. They recur after incomplete resection and entail a risk of malignant transformation to cystadenocarcinoma. A retrospective review was conducted of patients with histologically confirmed intrahepatic biliary cystadenomas and cystadenocarcinomas between August 2004 and February 2013 who were surgically managed in our department. A total of 10 patients, 9 female and 1 male (mean age, 50 years), with cystic liver were reviewed. The size of the cysts ranged between 3.5 and 16 cm (mean, 10.6). Five patients had undergone previous interventions elsewhere and presented with recurrences. Liver resections included 6 hepatectomies, 2 bisegmentectomies, 1 extended right hepatectomy, and 1 enucleation due to the central position and the large size of the lesion. Pathology reports confirmed R0 resections in all cases. All patients were alive after a median follow-up of 6 years (range, 1-10 years), and no recurrence was detected. Intrahepatic biliary cystadenoma and cystadenocarcinoma should be considered in differential diagnosis in patients with liver cystic tumors. Because of the high recurrence rate and difficult accurate preoperative diagnosis, formal liver resection is mandatory. Enucleation with free margins is an option and is indicated where resection is impossible.

Mucobilia: An Unusual Cause of Persistent Jaundice

Mucobilia is defined as the abnormal secretion of copious amounts of mucus from within the bile ducts, manifesting as obstructive jaundice or cholangitis. A spectrum of mucin-producing hepatobiliary and pancreatic neoplasms have been associated with mucobilia. We report the case of a 63-year-old male with an intestinal type of intraductal papillary neoplasm of the intrahepatic bile duct.

Multifocal Biliary Cystadenocarcinoma of the Liver: CT and Pathological Findings

Biliary cystadenocarcinoma is a rare tumor that originates from the hepatobiliary epithelium. Although this tumor can affect any portion of the biliary tree, intrahepatic location is more common. It is usually a slow growing tumor and often asymptomatic until it reaches a considerable size. The lesion is most often solitary and large when discovered; multiple lesions or metastases within the liver are very rare. A 63-year-old man was referred to our institute for weight loss, abdominal discomfort, worsening bulky symptoms in the right upper abdominal quadrant, and an increase in serum aminotransferases that had been present for several months. Spiral CT of the abdomen demonstrated two lesions, a larger one and a distant intrahepatic lesion, with a multiloculated cystic aspect, a thin peripheral capsule, multiple solid peripheral portions, and irregular septa enhancing in the portal phase after intravenous administration of iodinated contrast medium. The diagnosis of multifocal cystadenocarcinoma of the liver was confirmed by surgical laparoscopy and biopsy of the lesion. The patient was treated with chemotherapy.

Hepatobiliary Cystadenoma and Cystadenocarcinoma: A Single Center Experience

Aims and background

Hepatobiliary cystadenoma and cystadenocarcinoma are rare cystic lesions of the liver. The aim of the study was to discuss the clinical features, diagnostic methods and surgical treatment of hepatobiliary cystadenoma and cystadenocarcinoma in our hospital.

Methods

Six patients with hepatobiliary cystadenomas and four with hepatobiliary cystadenocarcinomas were evaluated. We collected detailed clinical data, and all patients were followed.

Results

Three patients of the 6 with cystadenomas and 2 patients of the 4 with cystadenocarcinomas had marked elevation of CA19-9 (average, 707.0 U/ml and 1078.5U/ml, respectively). CT scan with contrast revealed typical lesions in all 10 cases, i.e., cyst-occupying lesions with separations in the liver. All patients with hepatobiliary cystadenoma were treated by partial hepatectomy. None of them recurred at a mean follow-up of 40 months. Three patients with hepatobiliary cystadenocarcinoma underwent hepatectomy, without recurrence or metastasis at a mean follow-up of 32 months.

Conclusions

Tumor markers (CA19-9) and imaging findings may be helpful for an early diagnosis. Complete resection is still the best choice. Even for hepatobiliary cystadenocarcinoma, considering the low malignant grade, we suggest that for the best prognosis radical excision should be attempted.

Contrast enhanced ultrasound features of hepatic cystadenoma and hepatic cystadenocarcinoma

OBJECTIVE

Hepatic (biliary) cystic tumor (HBCT) is a rare focal cystic liver lesion, which has been rarely described in the literature. In our current multicenter, retrospective study, we aimed to analyze contrast enhanced ultrasound (CEUS) features and its diagnostic performance in histologically proved HBCT.

MATERIAL AND METHODS

Twenty-three patients with single HBCT were retrospectively analyzed. Histologically, 17 (73.9%) were benign hepatic (biliary) cystadenoma (HBCA), 6 (26.1%) were hepatic (biliary) cystadenocarcinoma (HBCAC). All CEUS examinations were assessed by two independent radiologists in consensus. Criteria of CEUS imaging evaluation included the contrast enhancement pattern of lesion (hypoenhancing, hyperenhancing, isoenhancing in comparison to the surrounding liver parenchyma) during the arterial, portal venous and late phases.

RESULTS

After injection of ultrasound contrast agents, most of the HBCTs (78.3%, 18/23) had typical honeycomb enhancement pattern of the cystic wall, septa or mural nodules. Comparing between HBCA and HBCAC, hyperenhancement of the honeycomb septa during the arterial phase was more common in HBCA (p = .047). However, hypoenhancement during the portal venous and late phases was the characteristic of HBCAC (p = .041).

CONCLUSIONS

The EFSUMB algorithm for CEUS for characterization of solid focal liver lesions is also applicable to HBCT. CEUS evaluation can avoid further diagnostic investigations or invasive biopsy procedure.

Rare biliary cystic tumors: a case series of biliary cystadenomas and cystadenocarcinoma

Cystic lesions of the liver are common and a major proportion is formed by parasitic cysts and simple cysts. Biliary cystic tumors (BCTs), namely biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC), are rare tumors which usually arise from the intrahepatic biliary tree. BCAs have malignant potential and are difficult to differentiate from BCAC pre-operatively on radiological imaging. Here we have presented 4 patients with BCTs and reviewed the literature pertaining to them.The data of four patients with BCA/BCAC diagnosed and treated at our institute were retrieved from our database and records were reviewed for age, sex, history, imaging, surgery, pathology and follow-up. Mean age of the patients was 53.5 years (range 30-71 years). Two male and two female patients presented with abdominal pain, of which one male patient had pancreatitis at diagnosis. Characteristic features were seen on pre-operative imaging (cystic lesions with internal septations) and biliary communication was identified in the patient with pancreatitis. Three patients were diagnosed with a BCA on final histology, while one patient had a BCAC. Following surgical resection, all the patients are asymptomatic and disease free with a mean follow-up of 24 months (range 10-40 months). In conclusion, BCTs should be suspected in the presence of a well-encapsulated, cystic hepatic lesion with internal septations. Although pre-operative distinction between BCA and BCAC is difficult, the lesion, whenever possible, should be completely resected as long-term outcomes are good, especially with BCA.

Arrangements of hepatobiliary cystadenoma complicated with congenital choledochal cyst: a case report and literature review

Hepatobiliary cystadenoma complication with congenital choledochal cyst is extremely rare and has never been reported in literatures so far.The aim of the study was to investigate the disease arrangements by analyzing the case and performing a systematic review of the literature.This case report documents the details and clear patterns of the patient. A 65-year-old woman with fever (39.2°C), nausea, vomiting, and chronic hepatitis B imaging demonstrated a left hepatic multilocular cystic mass and cystic dilated common bile duct.A regular left hemihepatectomy was performed with resection of the entire tumor and choledochal cyst.The surgical margins were negative and a final diagnosis of hepatobiliary cystadenoma complicated with congenital choledochal cyst was established. The patient had an uneventful postoperative recovery and liver function returned to normal levels.Main lessons learned from this case are: the awareness should be raised about the disease to avoid misdiagnosis; preoperative ultrasonography, computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography play an important role in detecting the lesion; the scope and timing of the surgery should be determined, which provide the chance of cure to complete resection of the tumor.

Preoperative differential diagnosis between intrahepatic biliary cystadenoma and cystadenocarcinoma: A single-center experience

AIM: To investigate preoperative differential diagnoses made between intrahepatic biliary cystadenoma and intrahepatic biliary cystadenocarcinoma.

METHODS: A retrospective analysis of patient data was performed, which included 21 cases of intrahepatic biliary cystadenoma and 25 cases of intrahepatic biliary cystadenocarcinoma diagnosed between April 2003 and April 2013 at the General Hospital of PLA. Potential patients were excluded whose diagnoses were not confirmed pathologically. Basic information (including patient age and gender), clinical manifestation, duration of symptoms, serum assay results (including tumor markers and the results of liver function tests), radiological features and pathological results were collected. All patients were followed up.

RESULTS: Preoperative levels of cancer antigen 125 (12.51 ± 9.31 vs 23.20 ± 21.86, P < 0.05) and carbohydrate antigen 19-9 (22.56 ± 26.30 vs 72.55 ± 115.99, P < 0.05) were higher in the cystadenocarcinoma subgroup than in the cystadenoma subgroup. There were no statistically significant differences in age or gender between the two groups, or in pre- or post-operative levels of alanine aminotransferase, aspartate aminotransferase, total bilirubin (TBIL), and direct bilirubin (DBIL) between the two groups. However, eight of the 21 patients with cystadenoma and six of the 25 patients with cystadenocarcinoma had elevated levels of TBIL and DBIL. There were three cases in the cystadenoma subgroup and six cases in the cystadenocarcinoma subgroup with postoperative complications.

CONCLUSION: Preoperative differential diagnosis relies on the integration of information, including clinical symptoms, laboratory findings and imaging results.

Obstructive jaundice caused by a biliary mucinous cystadenoma in a woman: a case report

INTRODUCTION

Mucinous cystadenoma of the liver is a rare (less than 5%) neoplasm. This condition is more common in young women and accounts for non-specific symptoms. Cyst adenomas commonly affect the intrahepatic system (90%) and are rarely found in the extrahepatic biliary system or affecting both the systems.

CASE PRESENTATION

A 39-year-old Sinhalese woman presented with features of obstructive jaundice and was found to have a biliary neoplasm on imaging. In the absence of a definitive diagnosis despite extensive imaging she underwent preoperative endoscopic biliary drainage followed by a left hemihepatectomy with Roux-en-Y hepaticojejunostomy. A pathological examination of the specimen revealed an obstruction of the bile duct caused by a biliary mucinous cystadenoma affecting both the intrahepatic and extrahepatic systems.

CONCLUSIONS

Biliary mucinous cystadenoma rarely present with obstructive jaundice affecting both intrahepatic and extrahepatic ducts. Exhaustive investigation might not help in the diagnosis and may need to be treated based on clinical judgment. The definitive treatment modality is surgery due to its malignant potential. The operative procedure is technically demanding and is best performed at specialist centers to minimize complications.

Current management of noninfectious hepatic cystic lesions: A review of the literature

Nonparasitic hepatic cysts consist of a heterogeneous group of disorders, which differ in etiology, prevalence, and manifestations. With improving diagnostic techniques, hepatic cysts are becoming more common. Recent advancements in minimally invasive technology created a new Era in the management of hepatic cystic disease. Herein, the most current recommendations for management of noninfectious hepatic cysts are described, thereby discussing differential diagnosis, new therapeutic modalities and outcomes.

Evaluation of hepatic cystic lesions

Hepatic cysts are increasingly found as a mere coincidence on abdominal imaging techniques, such as ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI). These cysts often present a diagnostic challenge. Therefore, we performed a review of the recent literature and developed an evidence-based diagnostic algorithm to guide clinicians in characterising these lesions. Simple cysts are the most common cystic liver disease, and diagnosis is based on typical USG characteristics. Serodiagnostic tests and microbubble contrast-enhanced ultrasound (CEUS) are invaluable in differentiating complicated cysts, echinococcosis and cystadenoma/cystadenocarcinoma when USG, CT and MRI show ambiguous findings. Therefore, serodiagnostic tests and CEUS reduce the need for invasive procedures. Polycystic liver disease (PLD) is arbitrarily defined as the presence of > 20 liver cysts and can present as two distinct genetic disorders: autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (PCLD). Although genetic testing for ADPKD and PCLD is possible, it is rarely performed because it does not affect the therapeutic management of PLD. USG screening of the liver and both kidneys combined with extensive family history taking are the cornerstone of diagnostic decision making in PLD. In conclusion, an amalgamation of these recent advances results in a diagnostic algorithm that facilitates evidence-based clinical decision making.

Inferior vena cava obstruction and collateral circulation as unusual manifestations of hepatobiliary cystadenocarcinoma

BACKGROUND

Hepatobiliary cystadenocarcinoma represents a rare epithelial malignant tumor derived from the intrahepatic bile duct.

METHODS

A 71-year-old woman, who had undergone laparoscopic drainage of a cystic lesion of the right hepatic lobe, was misdiagnosed as having hepatic echinococcal disease, and received intracystic infusion of 95% ethanol four years ago. She was admitted to our hospital for further treatment.

RESULTS

Physical examination revealed dilated superficial veins across the right abdominal wall. After mapping the direction of blood flow in these vessels, we assumed that this was a sign of inferior vena cava obstruction. Abdominal ultrasound, computed tomography, magnetic resonance imaging combined with magnetic resonance angiography showed a large cystic mass in the right upper quadrant and epigastrium, displacing the adjacent structures, adherent to the inferior vena cava, which was not patent, resulting in dilation of superficial epigastric veins. The patient underwent an exploratory laparotomy. Total excision of the huge mass measuring 16X15 cm was possible under selective vascular exclusion of the liver. Removal of the tumor resulted in immediate restoration of flow in the inferior vena cava. On the basis of the pathology and findings of immunohistochemical analysis, a hepatobiliary cystadenocarcinoma was diagnosed.

CONCLUSIONS

In the present case, hepatobiliary cystadenocarcinoma was accompanied by dilated superficial venous collaterals due to inferior vena cava obstruction. Selective vascular exclusion of the liver allowed a safe oncological resection of the tumor.

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.

Clinical outcome and long term results after surgical treatment of biliary cystadenoma and cystadenocarcinoma

Backgrounds/Aims

Biliary cystadenoma (BCA) and cystadenocarcinoma (BCCA) are rare cystic hepatic neoplasms. Prior reports concerning the proper surgical treatment and long-term survival are scarce. We report our experience and survival outcome of 30 patients over the last 25 years.

Methods

We retrospectively reviewed the clinicopathologic data of the pathologically confirmed 18 BCA and 12 BCCA patients, who underwent operations from 1983 to 2006, at the Seoul National University Hospital.

Results

The patients consisted of 8 men and 22 women with a mean age of 51 years. With abdominal computed tomography scans, 73.3% (n=22) were preoperatively diagnosed as BCA or BCCA, and differentiating BCCA from BCA was accurate in 58.3% patients. R0 resection was achieved in 90% (n=27). The differentiating factors included the presence of mural nodule (4/18 vs. 8/12; p=0.009) and mucinous content (2/9 vs. 8/1; p=0.005), and tumor size tending to be larger in BCCA (11.7 cm vs. 7.9 cm; p=0.067). Overall 5-year and 10-year survival rates of BCCA were 72.9% and 60.9%, respectively. Of patients with BCCA, 4 experienced recurrence. In case of recurrence, patients tended to be younger than 50 years (p=0.061) and the lesions tended to be larger than those without recurrence (p=0.088).

Conclusions

Preoperative differentiations of BCA from simple cyst, and BCCA from BCA are still difficult. Complete removal of the tumor, via major hepatectomy, should be considered, especially in the younger age group with large tumor.

[Benign non-parasitic hepatic cystic tumours]

Hepatic cystic tumours are a heterogeneous group of diseases with different aetiology and incidence, and with similar clinical signs and symptoms. They are classified as congenital, traumatic, parasitic, or neoplastic cysts. The congenital cystic tumours are the most prevalent, and include the simple cyst and polycystic hepatic disease. Other less common lesions are, hepatic cystadenoma, ciliated embryonic cyst, and a miscellaneous group. We have carried out a review of all benign non-parasitic hepatic cystic tumours, placing special emphasis on therapeutic strategies.

Successful surgical management of an extrahepatic biliary cystadenocarcinoma

Extrahepatic bile duct cancer is an uncommon disease, and few cases are curable by surgery. We report a case of extrahepatic biliary cystadenocarcinoma (BCAC) associated with atrophy of the left hepatic lobe. A 54-year old male was admitted with painless obstructive jaundice and a hepatic palpable mass noticed one month before presentation. Liver functions tests were consistent with cholestatic damage and serum carbohydrate antigen 19.9 (CA 19-9) was increased before treatment. Magnetic resonance imaging (MRI) disclosed dilatation of the left hepatic bile duct with irregular wall thickening close to the hepatic confluence, and atrophy of left hepatic lobe. The patient was submitted to en bloc extended left hepatectomy with resection of caudate lobe, hilar lymphadenectomy, and suprapancreatic biliary tree resection. All surgical margins were grossly negative, and postoperative course was uneventful, except for a minor bile leak. The patient was discharged on the 15th postoperative day; he is alive without tumor recurrence one year after primary therapy. Although technically challenging, extended en bloc resection is feasible in adults with extrahepatic BCAC and can improve survival with acceptable and manageable morbidity.

Tumors of the liver and intrahepatic bile ducts: radiologic-pathologic correlation

Primary tumors of the liver can be classified pathologically based on their cell of origin into epithelial tumors, arising from hepatocytes or biliary epithelium, and nonepithelial tumors, including mesenchymal tumors and lymphoma. Characteristic findings on MR imaging can be seen in many cases. This article reviews the MR imaging appearance of these tumors with pathologic correlation.

Intrahepatic biliary cystic neoplasms: Surgical results of 9 patients and literature review

AIM: To investigate the eligible management of the cystic neplasms of the liver.

METHODS: The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution.

RESULTS: All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up.

CONCLUSION: In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Successful left hemihepatectomy and perioperative management of a patient with biliary cystadenocarcinoma, complicated with MELAS syndrome: report of a case

Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke-like syndrome (MELAS) is a rare, fetal disease caused by a mutation in mitochondrial DNA that leads to impaired oxidative metabolism in skeletal muscle, the central nervous system, and liver function. This report presents the case of a 50-year-old woman with biliary cystadenocarcinoma complicated by MELAS who underwent a successful left hemihepatectomy. In this case, the diagnostic key for the malignant tumor was an (18)F-fluorodeoxyglucose positron emission tomography study, which was useful even in a patient with MELAS, which causes abnormal glucose metabolism. The perioperative management of such patients includes special precautions to prevent lactic acidosis and deterioration of the reserved liver function after a hepatectomy, since the mitochondrial function in MELAS patients is abnormal. The patient in this report has remained free of liver dysfunctions and cancer recurrence for 2 years following the hepatectomy. This is the first report of a successful major hepatectomy for a patient with MELAS.

Biliary cystadenocarcinoma diagnosed with real-time contrast-enhanced ultrasonography: Report of a case with diagnostic features

Biliary cystadenocarcinoma is a very rare malignant cystic tumor of the liver, which is often misdiagnosed due to a poor recognition of it. We report a case of a 60-year-old man with biliary cystadenocarcinoma with his real time contrast enhanced ultrasound (CEUS) characteristics compared to those of computed tomography (CT) and magnetic resonance imaging (MRI), which were correlated with the surgical and pathologic findings. Cystic wall enhancement, internal septations and intra-cystic solid portions in the arterial phase were observed on CEUS after contrast agent injection. The enhancement was washed out progressively and depicted as hypo-enhancement in the portal and late phases. CT revealed a large irregular cystic lesion in the left liver lobe with no clear septations and solid components. MRI showed an irregular cystic occupying lesion with septations.

Biliary Cystadenoma Causing Obstructive Jaundice: Case Report and Literature Review

Biliary cystadenomas are rare, potentially malignant neoplasms of biliary origin. Presentation is usually with vague and non-specific symptoms. Here, we describe an unusual case of biliary cystadenoma in a woman presenting with acute onset obstructive jaundice and review the relevant literature of 26 such cases reported over the last two decades.

Mucobilia: current aspects in the management of a rare cause of malignant biliary obstruction

Mucobilia is a rare pathologic condition characterized by the abnormal secretion and accumulation of abundant mucus within the biliary tree. It is usually seen in association with mucin-producing hepatobiliary and pancreatic tumors. Neoplastic transformation of these tumors can range from low-grade dysplasia to invasive adenocarcinoma. Mucobilia usually presents with signs and symptoms of biliary obstruction, which may span from jaundice to cholangitis with progression to septic complications in severe cases. Occurrence of hepatolithiasis has also been attributed to mucobilia, which raises the concern of an increased risk for the development of cholangiocarcinoma. Precise radiological evaluation and detailed histopathological tissue diagnosis followed by execution of appropriate surgical therapy is vital in the integrated management of mucin-producing biliary neoplasms. This review will address the etiologies and symptomatology of mucobilia as well as discuss current aspects in the management of mucobilia and its causative etiologies.

Diagnosis and treatment of benign focal liver lesions

BACKGROUND

With the routine use of improved imaging modalities, more benign liver lesions are detected nowadays. An accurate characterization of these incidental lesions may be a challenge, and frequently a biopsy or even unnecessary surgery is being performed. However, these interventions are not always to the benefit of the patient.

METHODS

A Medline search of studies relevant to imaging diagnosis and management of the most common, benign, solid and non-solid liver lesions was undertaken. References from identified articles were handsearched for further relevant articles. The authors' own experiences with benign liver lesions were also taken into account.

RESULTS

Although atypical imaging features are the exception rather than the rule, it is sometimes difficult to differentiate between benign and malignant lesions, and knowledge of their imaging features is essential if unnecessary work-up is to be avoided. The use of tissue-specific contrast media, which has clearly improved the accuracy of highly advanced radiological techniques, may be helpful during differential diagnosis. Once having established an accurate diagnosis, surgery is rarely indicated for a benign liver lesion because of its asymptomatic nature.

CONCLUSION

Knowledge of imaging features and a clear management strategy during diagnostic work-up, emphasizing the indications for surgery, will minimize the number of patients who have to undergo biopsy or unnecessary surgery.

Case of biliary cystadenocarcinoma with intracystic bleeding

Biliary cystadenocarcinomas are rare cystic tumors arising from the biliary epithelium. Symptoms vary and are sometimes absent. Most lesions are found incidentally during diagnostic radiologic procedures or surgical exploration for unrelated conditions. We describe an 80-year-old man with anemia due to intracystic bleeding. A computed tomographic scan showed a low-density hepatic lesion with thick, irregular walls and septa. Left lobectomy with cholecystectomy was performed. Histological examination revealed that the surgical specimen was a biliary cystadenocarcinoma. The concentrations of both carcinoembryonic antigen and CA19-9 were high in the cyst contents. The patient died of pneumonia 1 year 4 months after the operation, without the recurrence of cystadenocarcinoma.

Hepatobiliary cystadenocarcinoma with rapid growth: report of a case

We describe a case of histologically proven hepatobiliary cystadenocarcinoma with an emphasis on the longterm clinical course. The patient was a 75-year-old man who had been diagnosed as having a simple hepatic cyst at our hospital and had been followed up by abdominal sonography (US) for about 10 years. However, the lesion subsequently showed a sudden increase in size and a marked change in US findings, i.e., from a benign hepatic cyst to a complete solid lesion. Contrast-enhanced US revealed the lesion to be filled with fine vessels. This rapid change led us to strongly suspect a hepatobiliary cystadenocarcinoma and, thus, left lateral segmentectomy was performed. The patient is doing well 6 months after the surgical treatment.

Inflammatory pseudotumour of the liver: the residuum of a biliary cystadenoma?

Inflammatory pseudotumour is a rare form of a liver mass. We report the case of a 28-year-old man presenting with obstructive jaundice, in whom an inflammatory pseudotumour arose with the resolution of a mucus secreting cystic liver lesion. The initial features suggested an intrahepatic cystadenoma or cystadenocarcinoma, which on its involution left a solid mass. Histopathology showed an inflammatory pseudotumour with no evidence of malignancy. A similar case has been reported recently, with the development of an inflammatory pseudotumour following collapse of a liver cyst seen on imaging. These two cases may shed some light on the origins of these rare liver lesions.

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.