Solitary nonparasitic cysts of the liver: the Boston Children's Hospital experience

Symptomatic giant solitary bile cyst with intracystic bleeding in a 13-year-old girl: a case report and literature review

Background

Simple hepatic cyst is a rare disease in childhood. They occur in the general population with a prevalence of up to 5%. The incidence and size of cysts increase dramatically in adults older than 50 years. We performed a systematic literature review of all cases of simple hepatic cysts in the pediatric population undergoing surgical treatment. We found 52 cases reported in literature with a mean age of 2.54 years, 15% were pedicled cysts and only one case reported intracystic bleeding, detected only in the anatomopathological examination. We report a case of a 13-year-old girl who was presented with a symptomatic giant solitary bile cyst, the second biggest simple hepatic cyst reported in pediatric population, the biggest pedicled cyst and the only case of intracystic bleeding detected in pre-operative image examination in this group. This case brings important considerations about this complication and its pre-operative diagnosis.

Case presentation

We report a case of a 13-year-old girl with a giant solitary biliary cyst in the left hepatic lobe, symptomatic and with intracystic bleeding noted on magnetic resonance imaging. Diagnosis was difficult due to nonspecific symptoms and the non-typical images of simple hepatic cyst due to intracystic bleeding. The patient underwent a laparotomy, showing a large pedicled cyst, linked to segments II and III without adherence to other organs. Complete excision of the lesion was performed because the risk of torsion. The postoperative period passed without complications.

Conclusions

Although intracystic bleeding is the most common complication in adults, this is not reported in the pediatric population according to our review. Knowing how to recognize intracystic bleeding is important, because this complication predisposes the cyst to rupture and changes the appearance of the lesion on imaging tests, which can be more easily confused with cystadenoma or a cystadenocarcinoma. The magnetic resonance imaging is essential in the intracystic bleeding investigation. Comparisons between ultrasound and computed tomography findings associated with anemia history can prove the probability of this complication.

Laparoscopic complete excision of an enormous simple hepatic cyst occupying the entire abdomen in a child: a case report and literature review

Background

Simple hepatic cysts are common lesions in adults, but rare in children. Because of their benign nature, simple hepatic cysts may not be detected until they grow too large to be diagnosed and resected in a minimally invasive manner.

Case presentation

An 18-month-old girl presented with an enormous cyst occupying the entire abdomen. The beak sign on computed tomography revealed the hepatic origin of the cyst. The cyst was decompressed through the umbilicus, which was opened by the three-triangular-skin-flap technique, thus creating a working space that enabled laparoscopic surgery. The cyst was excised en bloc together with the attached hepatic parenchyma.

Conclusions

Giant simple hepatic cysts occupying the entire abdomen are rare in children. Of 14 reported cases, only 1 underwent laparoscopic treatment. We have herein reported another case of a giant simple hepatic cyst in which the beak sign on imaging and the three-triangular-skin-flap umbilical opening technique were useful for its diagnosis and laparoscopic excision, respectively. Complete excision is desirable because there is a possibility of recurrence or other diseases that require total removal, including hydatid cysts and mesenchymal hamartomas.

Laparoscopic Excision of Solitary Dysontogenetic Liver Cysts in Young Children: Technical Aspects and Outcome

Background: Solitary dysontogenetic liver cysts are rare in young children. However, large cysts can cause symptoms and require therapy. Cyst excision is the therapeutic method least associated with cyst recurrence. Only limited data are available on cyst excision performed laparoscopically in this age group. We present our experience using this surgical approach. Methods: Since 2005, 7 children including 5 newborns and infants with solitary dysontogenetic liver cysts have undergone minimally invasive excision of the cyst at our institution. Patient data were analyzed retrospectively. Results: Median age of the patients at surgery was 8 months (3 days to 6 years); 5 of them were younger than 1 year. The cysts had varying locations in the segments IV-VIII, and median size was 5.4 cm (3.8-7.9). Complete excision was realized in all cases. Median duration of surgery was 120 minutes (60-171). All procedures could be completed laparoscopically. One intraoperative complication occurred (injury of a bile duct that could be sutured laparoscopically). Median follow-up was 29 months (14-173). Cyst recurrence was not observed in any of the cases. Conclusion: Laparoscopic excision of solitary dysontogenetic liver cysts is an effective treatment in young children. Resection is not limited to cysts in anterior and lateral liver segments.

Congenital Epidermoid Cyst of the Liver: A Rare Entity Characterized by Antenatal Onset, Slow Postnatal Growth, and Consistent Histologic and Immunohistologic Features

BACKGROUND

There are only 15 reported hepatic epidermoid cysts; they include patients presenting congenitally through adulthood, with varied speculations about pathogenesis. Aside from recently reported pancytokeratin staining, no other descriptions have included immunohistochemistry. Splenic epidermoid cysts were recently characterized as positive for HBME-1, p63, CEA, CK7 (luminal), and CK19. We interrogate 2 hepatic epidermoid cysts with a broad panel of immunohistochemistry, with the aim of elucidating histogenesis.

METHODS

Archives were searched for "liver," "hepatic," and "cyst." Hepatic cysts lined by squamous epithelium were included. Clinical records, macroscopic findings, and hematoxylin and eosin and immunohistochemically stained slides were reviewed.

RESULTS

We identified 2 patients with epidermoid cysts of the liver, first detected on antenatal ultrasound. Both were females and asymptomatic; neither had other congenital abnormalities. Cysts enlarged slowly after birth. Resection was at ages 2 and 6 months, done to avoid potentially more difficult surgery in the future. Cysts were unilocular (4.8 cm) and multilocular (7.0 cm). Both were lined by stratified nonkeratinizing squamous to focally transitional-like epithelium and surrounded by paucicellular fibrous stroma. In the multilocular cyst, hepatocytes and fibrous stroma populated septa. Epithelium was positive for HBME-1, p63, CK19, CEA, Cam5.2, and CK7, negative for EMA, D2-40, WT-1, calretinin, and Ca19-9. Cytogenetic analysis of one showed a normal female karyotype. During the study period, 22 other pediatric liver cysts were diagnosed.

CONCLUSION

Hepatic epidermoid cyst is a distinct entity, rare but nevertheless constituting 8% of pediatric hepatic cysts at our institution. It is characterized by intrauterine onset and growth roughly commensurate with that of the fetus/infant; it is apparently unsyndromic. It may be unilocular or multilocular. It stains for an array of epithelial markers as well as HBME-1. Strong immunohistochemical overlap with splenic epidermoid cyst points to a shared pathogenesis and detracts from hypotheses that hepatic epidermoid cysts derive from hepatic elements.

Laparoscopic Treatment of Congenital Nonparasitic Liver Cysts in Newborns

Background: Congenital nonparasitic liver cysts in newborns are rare. Surgical excision of these formations is necessary to prevent complications. Reports of laparoscopic treatment of simple liver cysts in children are sporadic. We present a series of 3 patients with liver cysts treated laparoscopically in a single center. We added a short review of the literature. Methods: Data of 3 patients with nonparasitic liver cysts were collected at our center, from 2014 to 2019. Early and long-term results of laparoscopic operations were studied. Results: All patients were newborns, and of these, 2 were girls and 1 boy. The primary diagnosis was established during prenatal ultrasound examination. The laparoscopic approach was used in all patients. Complete resection of the cysts was achieved laparoscopically in all cases. Pathology reports were consistent with nonparasitic liver cysts. The early postoperative period was uneventful with prompt discharge. In the long-term follow-up period, there were no recurrences of the disease. Conclusions: The study presents one of the largest series of laparoscopic excision of nonparasitic liver cysts in newborns. We conclude that laparoscopy is a safe and effective method of treating of congenital hepatic cysts.

Giant congenital solitary nonparasitic cyst of the liver causing respiratory distress in a neonate

A 3-day-old male neonate delivered at 34 weeks of gestational age was brought with breathing difficulty since birth. The abdomen was massively distended. A soft cystic mass was occupying almost the entire abdomen and causing obvious respiratory distress. On exploration, a huge, solitary, unilocular cyst was found between the two lobes of the liver. Growing extrahepatically between the two lobes, it had displaced them laterally on either side. Enucleation of the cyst and marsupialization of its base was done. Histopathology showed evidence of congenital solitary nonparasitic cyst of the liver. Symptomatic presentation of CSNCL in children, especially in a neonate is extremely rare and not considered as a differential diagnosis of an abdominal mass. Hence, the case report.

Congenital hepatic cyst with antenatal diagnosis: a case report and literature review

Congenital hepatic cysts are rare lesions of infancy. While operative management and outcomes have been extensively studied in adult patients with hepatic cysts, data in pediatric patients are limited. We discuss our experience in an infant and review relevant literature regarding operative technique and surgical outcomes.

Systemerkrankungen

Systemerkrankungen als Ursache einer Lebererkrankung sind häufig, ohne dass man genaue Zahlen angeben kann. Die verschiedenen Grunderkrankungen sind für sich betrachtet zwar selten, nur dadurch, dass viele Erkrankungen in Betracht gezogen werden müssen, ergibt sich eine relative Häufung. Durch Fortschritte auf dem Gebiet der molekularbiologischen Diagnostik insbesondere bei den Stoffwechselerkrankungen lassen sich heute bereits viele der in Frage kommenden Grunderkrankungen eindeutig nachweisen. Allerdings ist bei keiner der Erkrankungen ein hundertprozentiger molekularbiologischer Nachweis möglich. Damit ergibt sich eine sichere Diagnose nur bei einem positiven Nachweis. Bei fehlendem Nachweis einer bisher bekannten für die Erkrankung spezifischen Mutation bleibt die Zuordnung entweder enzymatischen Tests oder klinischer Diagnose vorbehalten. Insbesondere bei der Manifestation als akutes Leberversagen ist die für die Diagnosesicherung erforderliche Zeit damit oft nicht vorhanden.

Laparoscopic excision of an antenatally diagnosed large simple hepatic cyst in the newborn

Non-parasitic hepatic cysts are rare in infants and children. Advances in antenatal imaging have improved their detection, while development of laparoscopic techniques has expanded options for treatment. We present a case of an antenatally diagnosed non-parasitic hepatic cyst in a neonate, which was successfully excised laparoscopically with no recurrence.

Mesothelial cyst of the liver in a neonate

Mesothelial cysts are very rare congenital cystic lesions that are derived from coelomic remnants. We report a neonate with a mesothelial cyst of hepatic origin. On routine antenatal ultrasound study, an intra-abdominal mass was seen. After birth, the cystic lesion's size increased to 8 cm and became symptomatic. Surgical resection was performed. Preoperative diagnostic imaging studies, including CT and MRI, did not identify the etiology, but the cyst appeared to be of hepatic origin. Intra-operatively, the cystic lesion was confirmed to have originated from the liver. Based on immunohistological analysis, the final diagnosis was mesothelial cyst of the liver.

Rapidly enlarging solitary nonparasitic cyst of the liver in a child presenting as acute abdomen

Symptomatic solitary nonparasitic cysts of the liver (SNCL) are rarely encountered in children, especially rapidly enlarging cysts presenting as acute abdomen. Therefore, it is difficult to establish the pre-operative diagnosis and to determine the treatment protocol of SNCL. While imaging techniques such as ultrasonography and computed tomography are modalities for diagnosis of SNCL, making a pre-operative diagnosis in the case of very large cysts remains difficult. We present a child with SNCL who initially presented with a rapidly enlarging cyst presenting as acute abdomen, and also provide a review of the literature. Moreover, we evaluate the surgical procedures and conclude that total excision of the cysts when possible is a suitable treatment procedure in children.

Accessory liver lobe with mesothelial inclusion cysts in an omphalocele: a new malformative association

Mesothelial inclusion cysts represent benign lesions that have been reported in a wide variety of locations. Peritoneal cysts are observed and visceral involvement has been described, notably of intraperitoneal organs such as the spleen and the testis. We report the cases of 2 neonates who underwent surgical management of an omphalocele. The hernial sac contained an accessory liver lobe, displaying in both cases multilocular mesothelial inclusion cysts. The hobnail cells lining the cysts exhibited calretinin and cytokeratin immunohistochemical reactivity, as well as focal D2-40 reactivity. One of the cases occurred in the setting of a Beckwith-Wiedemann syndrome (MIM 130650), an overgrowth disorder notably associated with omphalocele and hepatic anomalies and tumors. However, no hepatic mesothelial cyst has been described in this syndrome. In the 2nd case the omphalocele and the hepatic cysts were the sole lesions observed in the neonate. To the best of our knowledge, these 2 cases represent the first description of such an association.

Solitary liver cysts in children: not always so simple

AIM

Liver cysts in children are uncommon. Many are simple and solitary and do not require intervention. However, this series demonstrates a broad range of potential pathologies, some of which are life-threatening.

METHODS

All children referred to our unit during an 8-year period (1998-2005) and found to have a solitary liver cyst were prospectively recorded. Clinical, radiologic, and pathologic features were analyzed. Children with an isolated extrahepatic choledochal cyst and polycystic disease were excluded.

RESULTS

Twenty-one children with a liver cyst were identified. Two had undergone unsuccessful surgical intervention before referral. There were 11 prenatally detected cysts. Median gestational age at detection was 22 weeks (19-35 weeks); only 1 was specifically characterized as a liver cyst prenatally. Six of these required surgery: 2 large simple cysts, 2 intrahepatic choledochal cysts, 1 giant complex biliary cyst causing respiratory distress, and 1 ciliated hepatic foregut cyst. Of the 5 cysts remaining under ultrasound surveillance, 4 decreased in size or resolved. In 10 children presenting between birth and 15.8 years, a liver cyst was diagnosed postnatally: 3 huge cystic mesenchymal hamartomas, 1 type V choledochal cyst, 1 hydatid cyst, and 5 simple cysts. Four of these required surgical resection. Simple cysts tended to be small and could be distinguished from other pathologies using a combination of imaging techniques (ultrasound, magnetic resonance imaging/magnetic resonance cholangiopancreatography [MRCP], radionuclide scan). Only 2 of 12 children with "simple" cysts required surgery for symptoms. However, a wide range of other cyst pathologies were found in 9 children, and although none was malignant, some were life-threatening and 7 required resection.

CONCLUSIONS

Simple solitary nonparasitic liver cysts rarely cause symptoms or require surgery, but the pediatric surgeon should be aware of the wide range of other types of liver cyst in children to ensure appropriate treatment.

Laparoscopic Resection of Solitary Congenital Liver Cyst in a Neonate

Solitary congenital liver cysts are a rare finding and present a challenge in the diagnosis. Routine prenatal ultrasounds confirmed the presence of an isolated cystic mass in the upper abdominal cavity of a fetus during the third trimester of gestation. Ultrasound examination performed after birth confirmed the presence of a floating cyst in the upper abdomen. Laparoscopy was performed on the 12th day to confirm the diagnosis using a 2.7 mm scope and instruments. Using a monopolar hooked cautery, the cyst was resected free from the liver surface without any complication. The postoperative course was uneventful. Histopathologic analysis demonstrated a true liver cyst with a mesothelial lining and hepatic residues. To our knowledge, this is the first case reported in literature where a solitary liver cyst was resected using minimal invasive techniques in a newborn.

Secretion and expression of epithelial markers supports the biliary origin of solitary nonparasitic cyst of the liver in infancy

Solitary nonparasitic cyst of the liver (SNPCL) is rare in children. Although there are several hypotheses regarding the pathogenesis, the true origin of SNPCL remains unknown. The authors present an infant with a huge SNPCL in whom the epithelial markers, CA19-9, DU-PAN-2, and SPan-1, were elevated in the serum and cystic fluid. The presence of CA19-9 and DU-PAN-2 was shown by immunohistochemistry in the cystic epithelia. These indicate that the classical idea of biliary origin of SNPCL is supported.

Unusual hepatic tumor with features of mesenchymal hamartoma and congenital solitary nonparasitic cyst

We report a hepatic tumor in an adolescent that does not fit into any of the described categories of liver tumors. The patient presented with hepatomegaly, abdominal pain, and normal liver function test; the tumor was cystic in imaging studies. The resected specimen, result of a partial hepatectomy, measured 21 cm and was multicystic with solid areas. Microscopically, the cysts were lined by a mucous-producing or intestinal-type epithelium, associated with smooth muscle and small mucous-producing glands. The solid component contained fibrous and adipose tissue, smooth muscle and thick-walled vessels. Aneuploidy was demonstrated by flow cytometry. We interpreted the tumor as having features of a mesenchymal hamartoma and congenital solitary nonparasitic cyst. It is conceivable that the lesions originated with small peribiliary glands with dilatation and intestinal metaplasia.

Liver tumors

Liver tumors in children are rare, potentially complex, and encompass a broad spectrum of disease processes. Any age group may be affected, including the fetus. Most present with abdominal distension and/or a mass. Accurate preoperative diagnosis is usually possible using a combination of ultrasound scanning and cross-sectional imaging techniques (CT and/or MR), supplemented by liver biopsy and measurement of tumor markers. The most common benign tumors are hemangiomas, but mesenchymal hamartoma, focal nodular hyperplasia, and adenoma also are found. In Western countries, hepatoblastoma is the most common primary malignant liver tumor; disease-free survival is now possible in more than 80% of affected patients because of advances in combination chemotherapy, improved techniques of surgical resection, and the selective use of liver transplantation. In contrast, there has been less progress in the management of hepatocellular cancer, which still poses many therapeutic challenges.

Case report: primary cystic keratinizing squamous cell carcinoma of the liver in a patient with treated nasopharyngeal carcinoma

Primary squamous cell carcinoma of the liver is very rare; only 18 cases have been recorded. In the present report we document an additional case who had a unique history of stage III non-keratinizing nasopharyngeal carcinoma treated with a full course of radiotherapy in July 1993. Two small hypoechoic cyst-like lesions in the left hepatic lobe were identified at the same time. In July 1995 the 50-year-old patient reported to be suffering from abdominal fullness and tenderness. A large hypodense tumour was demonstrated in the left hepatic lobe by abdominal echography. The patient was diagnosed as having metastatic carcinoma and received two courses of pre-operative chemotherapy followed by left lobectomy of the liver and resection of adherent tissues on 9 August 1995. Pathological study demonstrated a larger hepatic cystic keratinizing squamous cell carcinoma, which most likely arose from a solitary hepatic cyst. Tumour seedings, probably secondary to tumour rupture, were also revealed on the omentum, peritoneum and diaphragm. However, regional lymph nodes were fee of tumour. Systemic work-up failed to demonstrate evidence of local recurrence of nasopharyngeal carcinoma, metastatic lesion or any second primary tumour site.