Malignant transformation of biliary cystadenoma: a difficult diagnosis

Intraductal papillary mucinous neoplasm of biliary ducts: Literature review and a case report with emphasis on radiological manifestation

Intraductal papillary mucinous neoplasm of the biliary tract (B-IPMN) is an intraductal growing mucin producing tumor that is precursor of cholangiocarcinoma. Dilation of both upstream and downstream biliary ducts is the radiological key feature that is respectively caused by intraductal obstructive growth and massive mucin production. Although B-IPMN is rare, if the radiologist is familiar with its manifestation, can lead to early diagnosis when surgical resection can be curative. Here, we report a long standing pathologically proved case of B-IPMN with emphasis on radiological manifestation during a long time of 13 years across different imaging modalities.

[Mucinous cystic liver tumors: diagnosis and surgical treatment]

AIM

To optimize diagnostics and treatment of cystic liver tumors.

MATERIAL AND METHODS

The analysis included outcomes of 46 patients with liver cystic tumors.

RESULTS AND DISCUSSION

The use of abdominal Doppler-sonography (37 patients), abdominal contrast-enhanced CT (44 patients) and MRI of abdominal cavity with MR-cholangiography (24 patients) defined radiological semiotics of cystic liver diseases. The most important features of cystic tumors are intraluminal septums with blood flow (82% of patients), solid component (6.8%), daughterly cysts (11.3%), as well as biliary hypertension (39.2% of patients). Research of oncomarkers (CEA, SA 19-9, AFP) in 40 patients showed increased level of SA 19-9 only in case of cystadenocarcinoma and intraductal papillary mucinous neoplasm of biliary type. Benign and malignant cystic tumors had increased contents of oncomarkers in all cases. Surgical treatment was used in 42 patients. Extended liver resections were performed in 10 (23.8%) patients, atypical and anatomical resections (removal of less than 3 segments) - in 31 (73.8%) patients. In one case we applied cryoablation of CA in segment I of the liver in view of invasion into the wall of inferior vena cava and hepatoduodenal ligament. In 2 cases surgery was carried out laparoscopically. Also robot-assisted technique was used in 3 patients. Immunohistochemical study was performed in 22 (44.8%) patients. The diagnosis of CAC and biliary type of IPMN was confirmed in case of high expression of CK7, SK19, MUC1, S100p, SDH2, p53 antibodies. Cystadenomas were associated with moderate expression of ER, PR and p53 antibodies by stroma and CK7, SK19, CDX2, MUC1, S100p antibodies by epithelium.

CONCLUSION

There are considerable difficulties of differential diagnosis of liver cystic tumors. Therefore, the use of single algorithm of diagnostics and treatment is necessary to confirm accurately the diagnosis at the perioperative stage. Cystic tumor is more likely to be assumed in women with solitary cyst in segment IV of liver. If the diagnosis is suspected or confirmed anatomical liver resection with complete tumor removal is necessary to prevent the recurrence.

Biliary cystadenoma: an unusual cause of acute pancreatitis and indication for mesohepatectomy

The classic presentation of cystic hepatobiliary lesions is usually nonspecific and often identified incidentally. Here we describe the case of a patient presenting with acute pancreatitis resulting from a large centrally located biliary cystadenoma compressing the pancreas. Determination of the origin of the cystic lesion was difficult on imaging studies. Due to the difficult location of the lesion, a complete surgical resection was achieved with mesohepatectomy and the suspected diagnosis confirmed by pathology. The patient continues to do well 2 years post-op with no signs of recurrence.

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.

Cystic tumors of the liver: a practical approach

Biliary cyst tumors (cystadenoma and cystadeno-carcinoma) are an indication for liver resection. They account for only 5% of all solitary cystic lesions of the liver, but differential diagnosis with multiloculated or complicated biliary cysts, atypical hemangiomas, hamartomas and lymphangiomas may be difficult. The most frequent challenge is to differentiate biliary cyst tumors from hemorrhagic cysts. Computerized tomography (CT) and magnetic resonance imaging (MRI) are often not diagnostic and in these cases fine needle aspiration (FNA) is used to confirm the presence of atypical biliary cells. FNA, however, lacks adequate sensitivity and specificity and should always be used in conjunction with imaging. Pre-operative differentiation of cystadenoma from cystadenocarcinoma is impossible and surgery must be performed if a biliary cyst tumor is suspected. When multiple cystic lesions are observed throughout the liver parenchyma, it is important to exclude liver metastasis, of which colonic cancer is the most common primary site. Multiple biliary hamartomas (von Meyenburg complex) can appear as a mixture of solid and cystic lesions and can be confused with cystic metastasis. Strong and uniform T2 hyperintensity on MRI is usually diagnostic, but occasionally a percutaneous biopsy may be required.

Emergency laparotomy for misdiagnosed biliary cystadenoma originating from caudate lobe

Background

Biliary cystadenoma is a rare benign neoplasm, which is often misdiagnosed for a hepatic abscess or a hydatid cyst that tends to recur and is at risk for progression to malignant neoplasm.

Case presentation

This case describes a 30-year-old woman admitted to our institution in an emergency setting. The patient was originally misdiagnosed as affected by a hepatic hydatid cyst at another hospital, and then emergently treated at our Institution for severe abdominal pain. Histologic evaluation of the cyst showed that it was a biliary cystadenoma and, therefore, the patient underwent a hepatic resection in order to completely remove the lesion.

Conclusion

Complete excision of any suspicious hepatic cystic lesion remains the best method for diagnosis and treatment of cystadenoma. Incomplete excision of most biliary cystadenoma results in a higher rate of recurrence and the risk of malignant transformation. We report this case to elucidate the clinical presentation, preoperative evaluation, and surgical treatment of these rare lesions.

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.