Hepatic Intracystic Organizing Hematoma Mimicking Biliary Cystadenocarcinoma in a Patient with Polycystic Liver Disease

Hepatic hemangioma in a simple liver cyst mimicking biliary cystic neoplasm

BACKGROUND

Follow-up is recommended for an asymptomatic unilocular hepatic cystic lesion without wall-thickness and nodular components. A few liver cystic lesions represent biliary cystic neoplasms, which are difficult to differentiate from simple cysts with benign mural nodules on imaging alone.

CASE PRESENTATION

An 84-year-old woman with a history of simple liver cyst diagnosed one year prior was admitted for evaluation of a developed mural nodule in the cystic lesion. She had no specific symptoms and no abnormalities in blood tests except for carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (43.5 U/mL) levels. Contrast-enhanced computed tomography revealed a well-defined, low-attenuation lesion without a septum that had enlarged from 41 to 47 mm. No dilation of the bile duct was observed. A gradually enhancing mural nodule, 14 mm in diameter, was confirmed. MRI revealed a uniform water-intense cystic lesion with a mural nodule. This was followed by T2-enhanced imaging showing peripheral hypointensity and central hyperintensity. Enhanced ultrasonography revealed an enhanced nodule with a distinct artery within it. A needle biopsy of the wall nodule or aspiration of intracystic fluid was not performed to avoid tumor cell spillage. The possibility of a neoplastic cystic tumor could not be ruled out, so a partial hepatectomy was performed with adequate margins. Pathologically, the cystic lesion contained a black 5 mm nodule consisting of a thin, whitish fibrous wall and dilated vessels lined by CD31 and CD34 positive endothelial cells. The final diagnosis was a rare cavernous hemangioma within a simple liver cyst.

CONCLUSIONS

Cavernous hemangiomas mimicking well-enhanced mural nodules can arise from simple liver cysts. In less malignant cases, laparoscopic biopsy or percutaneous targeted biopsy of the mural nodules, together with needle ablation, may be recommended to avoid unnecessary surgery.

Clinicopathological features and management of biliary cystic tumors of the liver: a single-center experience

BACKGROUND

Biliary cystic neoplasms (BCNs) of the liver are rare pathologies encountered in hepatobiliary surgeries. Till now, there is a lack of definitive criteria used to differentiate biliary cystadenoma (BCA) from biliary cystadenocarcinoma (BCAC).

METHODS

In the period between 2005 and 2018, the data of consecutive patients diagnosed with BCA and BCAC were retrospectively reviewed.

RESULTS

A total of 62 patients underwent surgical management for BCNs. BCA was diagnosed in 50 patients while 12 patients had BCAC. Old age, male gender, smoking, and abdominal pain were strongly associated with BCAC. Left lobe location, small size, with the presence of mural nodule, and solid component were significantly noticed with BCAC. A novel pre-operative score was developed to predict the susceptibility for BCAC and help us to identify the optimal surgical strategy. Blood loss, operative time, and complications were comparable between the two study groups.

CONCLUSION

Mural nodules or solid components are suggestive of BCAC. Complete surgical resection of cystic tumors of the liver is mandatory due to malignant potential of the lesion and for prolonged survival.

Laparoscopy-assisted extended right hepatectomy for giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma: a case report

BACKGROUND

Hemorrhagic hepatic cysts infrequently involve several iconographic changes requiring a differential diagnosis, primarily with a cystic malignancy. We herein report a case of laparoscopy-assisted extended right hepatectomy for a giant hemorrhagic hepatic cyst with an enhancing mural nodule that was clinically suspected of being biliary cystadenocarcinoma.

CASE PRESENTATION

A 73-year-old woman was followed up for giant hepatic cyst occupying the right lobe of the liver. During the follow-up, an enhancing mural nodule was newly noted on computed tomography in 2016. Based on additional clinical examinations, biliary cystadenocarcinoma was undeniable, and laparoscopy-assisted extended right hepatectomy was performed for diagnostic and therapeutic purposes. She had no perioperative complications and was discharged on postoperative day 13. A histological examination of the mural nodule showed neovascularization within an organized hematoma.

CONCLUSION

We herein report a rare case of giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma that was successfully treated with laparoscopy-assisted extended right hepatectomy. Laparoscopic surgery in our case was an effective procedure performed with the utmost care.

Useful technique for draining a large cystic tumor through the round ligament in laparoscopic left hemihepatectomy

INTRODUCTION

Some cystic liver tumors are huge when the diagnosis is made or surgery is needed. Although reducing tumor size by preoperative aspiration or drainage of the contents of the cystic tumor is helpful for liver resection, such procedures have a risk of tumor dissemination.

MATERIALS AND SURGICAL TECHNIQUE

After the round ligament was dissected, a 12-Fr drainage catheter was inserted into the tumor via the round ligament under ultrasonography. At that time, close attention was paid to avoid having the catheter deviate outside the round ligament. Through the inserted catheter, fluid was drained from the cystic lesion, and the stump of the round ligament was clipped to avoid fluid leakage. The left Glissonian pedicle was then taped. Laparoscopic left hemihepatectomy was performed under a good operative field because of tumor shrinkage.

DISCUSSION

Three cases underwent these procedures without any spillage of the contents of the cystic tumor. This method is useful for the reduction of tumor size and has a low risk of intra-abdominal leakage of the contents, resulting in a secure and good operative field.

Imaging findings of hemorrhagic hepatic cysts with enhancing mural nodules

PURPOSE

This study aimed to evaluate the clinical and radiological findings of hemorrhagic hepatic cysts with enhancing mural nodules.

METHODS

The radiology databases of five facilities were retrospectively searched for reports indicating hemorrhagic hepatic cysts or hepatic cystic tumors. Cases of hemorrhagic hepatic cysts with enhancing mural nodules based on pathological or radiological findings were identified and reviewed.

RESULTS

We included 14 cases (11 female and 3 male) with a mean patient age of 72.6 years. Up until the enhancing mural nodules were detected, the cysts had decreased in size in all ten cases for which radiological imaging was available for a period of > 3 years previous to detection. Dynamic contrast-enhanced CT or MRI showed focal enhancement in the early phase and progressive centrifugal enhancement in the delayed phase in all 16 mural nodules ≥ 10 mm in diameter. Thirteen of 14 MRI assessable enhancing mural nodules ≥ 10 mm in diameter showed a hypointense rim with central hyperintensity on T2-weighted imaging. All cases showed calcification of the cyst wall. In the three referred cases, ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/CT demonstrated no intense FDG uptake in the enhancing mural nodules. In the four resected cases, histopathology of the enhancing mural nodules revealed neovascularization within an organized hematoma, including extensive dilated vessels and hemangioma-like lesions.

CONCLUSIONS

Features including a decrease in cyst size, a progressive centrifugal enhancing pattern on dynamic contrast-enhanced CT or MRI, a hypointense rim with central hyperintensity on T2-weighted MRI, and cyst wall calcification may indicate a hemorrhagic hepatic cyst.

Clinicopathological features and post-resection outcomes of biliary cystadenoma and cystadenocarcinoma of the liver

Backgrounds/Aims

Biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC) account for 5%-10% of liver cystic diseases. In this study, we analysed the clinical presentation and surgical management of patients with BCA and BCAC.

Methods

We retrospectively analysed the medical records of 23 BCA and 7 BCAC cases diagnosed between January 2007 and December 2013.

Results

There was a statistically significant difference in age (p=0.044) and sex (p=0.048) between BCA and BCAC groups. In the BCA group, 17 patients showed no symptoms (74%), 5 had abdominal pain (22%) and 1 showed abdominal distension (4%). In the BCAC group, two patients were without any symptoms (29%), three had abdominal pain (43%), one showed abdominal distension (14%) and one had fever and chills (14%). The cystic lesion size was widely variable; thus, there was no statistical difference (p=0.84). Complete resection was performed in all patients with BCA and BCAC. No tumour recurrence developed in patients with BCA. In patients with BCAC, 1-, 3- and 5-year disease-free survival rates were 100%, 85.7% and 57.1%, respectively, and 1-, 3- and 5-year overall patient survival rates were 100%, 100% and 75.0%, respectively.

Conclusions

It is difficult to distinguish between BCA and BCAC via clinical manifestations and diagnostic imaging findings. Surgical resection is the treatment of choice for BCA and BCAC, and patient prognosis after complete resection was very favourable.