A case of biliary cystadenocarcinoma with recurrent jaundice. Diagnostic evaluation of computed tomography

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.

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.

Biliary cystadenocarcinoma of the liver: the need for complete resection

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

Biliary cystadenocarcinoma of the liver. A clinicopathologic and histochemical evaluation of nine cases

Nine cases of biliary cystadenocarcinoma of the liver were studied, with emphasis on its clinicopathologic features, mucin profiles, and immunohistochemical characteristics. In general, the cystic tumors had protrusions that consisted of well-differentiated papillary adenocarcinoma cells with or without benign-appearing epithelial elements. In invading or metastatic foci, the carcinoma cells tended to show distinctive anaplastic changes. Tumor growth was confined to the cystic lesions in five cases (noninvasive type), whereas in four cases it extended to the hepatic parenchyma or neighboring organs (invasive type). There was a considerable difference between the two groups in terms of prognosis. In fact, the patients included in the group with the noninvasive type had no sign of tumor recurrence after an appropriate surgical procedure. With mucin histochemical and immunohistochemical approaches, positive reactions with carcinoembryonic antigen, tissue polypeptide antigen, carbohydrate 19-9, and Dupan-2 and the predominance of sialomucin were observed in most cases of biliary cystadenocarcinoma, indicating a similar cellular nature of cholangiocarcinoma.

Biliary cystadenoma and cystadenocarcinoma: some unusual features

Biliary cystadenoma and cystadenocarcinoma are rare tumours which have a good prognosis after complete surgical removal. Correct pre-operative diagnosis depends on the imaging characteristics of the tumours. We have observed some unusual features including multifocal tumours with attachment to other abdominal organs, tumour presenting as cholangitic abscess, and distant metastasis after apparently complete resection by hemihepatectomy.

A case of biliary cystadenocarcinoma with morphologic and histochemical features of hepatocytes

A case of biliary cystadenocarcinoma is presented in which the lesion seemed to partially differentiate into hepatocellular carcinoma. This patient had a cystic tumor in the left lobe of the liver, the interior being filled with papillary tumors. Histologic examination disclosed papillary growth of columnar tumor cells, together with tumor cells akin to hepatocytes (they had a distinct cell boundary, nuclear membrane, and nucleolus) showing a cobblestone appearance in some areas. Electron microscopic examination of this area showed bile canalicular structures. Histochemically, the tissue stained positively with the Luna-Ishak canalicular (LIC) technique; periodic acid-Schiff (PAS) staining demonstrated coexisting glycogen granulo-positive cells and mucus-producing cells. Thus, in this biliary cystadenocarcinoma, some tumor cells demonstrated the morphologic and histochemical features of hepatocytes.

Imaging diagnosis of bile duct cystadenocarcinoma

Two patients with surgically resected biliary cystadenocarcinoma are presented. Both were asymptomatic and the cancer was incidentally found by ultrasonography (US). In the first case, a huge multilocular tumor (21 X 15 cm in diameter) having many papillary projections and septa within it and small daughter lesions occupied both the right anterior and left medial areas of the liver. They were clearly demonstrated on US and computed tomography (CT). Angiography disclosed tumor vessels in some area of the lesion, these features strongly suggested cystadenocarcinoma. The second case had a solid mass (7 X 7 cm) in the left hepatic lobe, in which many septal structures within the lesion were seen on enhanced CT and light dot like stains were recognized on angiography. The former findings coincided with the internal gross feature of the resected specimen. Both patients are doing well 8 months and 1 year and 6 months after operation, respectively.

Pseudosarcomatous cystadenocarcinoma of the liver

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