Predictors of treatment response following aspiration sclerotherapy of hepatic cysts: an international pooled analysis of individual patient data. Eur Radiol. 2017;27:741-748. [PMID: 27180184 PMCID: PMC5209423 DOI: 10.1007/s00330-016-4363-x]

Differentiation between mucinous cystic neoplasms and simple cysts of the liver: a systematic review and meta-analysis

PURPOSE

Radiologic examinations frequently identify cystic liver lesions, which encompass various entities from simple benign cysts to malignant neoplasms. This work analyses the available data to compare diagnostic features of biliary cystic neoplasms and hepatic simple cysts.

METHODS

A systematic search of PubMed, Scopus, Embase, and Web of Science up to October 2024 was conducted. The characteristics were categorized into hepatic simple cysts (HSC) and mucinous cystic neoplasms (MCN), including biliary cystadenoma (BCA) and cystadenocarcinoma (BCAC) detected by imaging modalities including ultrasound, CT scans with IV contrast, or MRI. We analyzed biliary cystic neoplasms and hepatic simple cysts across multiple studies using Review Manager Ver. 5, calculating summary measures for each feature.

RESULTS

The study analyzed 577 lesions in 577 patients and 49 studies. Hepatic simple cysts were the most common finding, with 349 identified, mainly in the right hepatic lobe, presented with abdominal pain or incidentally. Intracystic septation was found in 50.1% of HSC lesions, with thick septation in 10.52% of lesions. 228 (49.9%) patients were diagnosed with MCN, with abdominal swelling and pain as the most common presentation. Septation was the most common radiological feature of MCNs, with thick septa in 50.61%. MCNs had internal septa, solid mural nodule, upstream bile duct dilation, presence in the left hepatic lobe, septal thickening, cystic wall enhancement, calcifications, and internal debris. The presence of a cyst in the left lobe was more related to MCNs.

CONCLUSION

Characterizing cystic liver lesions necessitates a comprehensive evaluation of the lesions' location, size, and complexity. Imaging and clinical findings are essential for a final diagnosis.

Complex cystic liver lesions: classification, diagnosis, and management

Cystic liver disease has been increasingly reported in the literature, with a prevalence as high as 15-18%. Hepatic cysts are usually discovered incidentally, while their characterization and classification rely on improved imaging modalities. Complex cystic liver lesions comprise a wide variety of novel, re-introduced, and re-classified clinical entities. This spectrum of disorders ranges from non-neoplastic conditions to benign and malignant tumors. Their clinicopathological features, prognostic factors, and oncogenic pathways are incompletely understood. Despite representing a heterogeneous group of disorders, they can have similar clinical and imaging characteristics. As a result, the diagnosis and management of complex liver cysts can become quite challenging. Furthermore, inappropriate diagnosis and management can lead to high morbidity and mortality. In this review, we aim to offer up-to-date insight into the diagnosis, classification, and management of the most common complex cystic liver lesions.

Percutaneous aspiration and sclerotherapy of a giant simple hepatic cyst causing obstructive jaundice: A case report and review of literature

BACKGROUND

Giant simple hepatic cysts causing intrahepatic duct dilatation and obstructive jaundice are uncommon. A variety of measures with different clinical efficacies and invasiveness have been developed. Nonsurgical management, such as percutaneous aspiration and sclerotherapy, is often applied.

CASE SUMMARY

The case is a 39-year-old female with a 5-mo history of cutaneous and scleral icterus, loss of appetite, and dark urine. Lab tests showed jaundice and liver function abnormalities. Imaging revealed a giant simple hepatic cyst obstructing the intrahepatic bile ducts. A combination of percutaneous catheter aspiration and lauromacrogol sclerotherapy was successfully performed and the effects were satisfactory with the size of cyst decreasing from 13.7 cm × 13.1 cm to 3.0 cm × 3.0 cm. Further literature review presented the challenges of managing giant simple hepatic cysts that cause obstructive jaundice and compared the safety and efficacy of a combination of percutaneous aspiration and lauromacrogol sclerotherapy with other management strategies.

CONCLUSION

Giant simple hepatic cysts can cause obstructive jaundice, and a combination of percutaneous catheter aspiration and sclerotherapy with lauromacrogol are suggested to treat such cases.

Predictive value of alarm symptoms in patients with Rome IV dyspepsia: A cross-sectional study

BACKGROUND

No studies have evaluated the predictive value of alarm symptoms for organic dyspepsia and organic upper gastrointestinal (GI) diseases based on Rome IV criteria in the Chinese population.

AIM

To evaluate the predictive value of alarm symptoms for dyspeptic patients based on Rome IV criteria.

METHODS

We performed a cross-sectional study of dyspepsia patients who met the inclusion and exclusion criteria at two academic urban tertiary-care centers from March 2018 to January 2019. Basic demographic data, dyspeptic information, alarm symptoms, lifestyle, examination results, family history and outpatient cost information were collected. Dyspepsia patients with normal findings on upper GI endoscopy, epigastric ultrasound and laboratory examination and without Helicobacter pylori-associated dyspepsia were classified as functional dyspepsia.

RESULTS

A total of 381 patients were enrolled in the study, including 266 functional dyspepsia patients and 115 organic dyspepsia patients. There were 24 patients with organic upper GI disease among patients with organic dyspepsia. We found that based on the Rome IV criteria, alarm symptoms were of limited value in differentiating organic dyspepsia and organic upper GI diseases from functional dyspepsia. Age (odds ratio (OR) = 1.056, P = 0.012), smoking (OR = 4.714, P = 0.006) and anemia (OR = 88.270, P < 0.001) were independent predictors for organic upper GI diseases. For the comparison of epigastric pain syndrome, postprandial distress syndrome and epigastric pain syndrome combined with postprandial distress syndrome, the results showed that there were statistically significant differences in anorexia (P = 0.021) and previous visits (P = 0.012). The ClinicalTrials.gov number is NCT03479528.

CONCLUSION

Most alarm symptoms had poor predictive value for organic dyspepsia and organic upper GI diseases based on Rome IV criteria. Gastroscopic screening should not be based solely on alarm symptoms.

Antenatally-detected liver cysts: Causes and characteristics, indications for intervention

AIM

The prevalence of antenatally-detected hepatic cysts is increasing owing to increased use of maternal ultrasonography (USS). Diagnostic precision, however, is challenging and subsequently there is no clear consensus on postnatal management. The aim of the study was to evaluate the natural history and long-term follow up of congenital simple hepatic cysts.

METHODS

Single-center review of prospectively-maintained dataset collected over a 25-year period. Data are quoted as median (range).

RESULTS

In the period 1991-2016, 31 infants presented with an antenatally-detected cyst which, on postnatal imaging, was likely confirmed as a simple parenchymal hepatic cyst. These together with a further infant who presented at 4 days without any antenatal imaging comprised the study group (n = 32). Gestational age at detection was 23 (13-38) weeks. Maximum antenatal cyst diameter was measured at 19 (4-120) mm. Only the largest required percutaneous aspiration at 35 weeks' gestation being associated with polyhydramnios. Postnatally, serial USS was performed alongside MRI/CT or liver scintigraphy if there was diagnostic doubt. Initial maximum cyst diameter was 30 (12-120) mm. Five infants came to surgical intervention and this included excision ± marsupialization (n = 4), and a cyst-jejunostomy en Roux in one child thought to have a connection with the biliary tract on intraoperative cholangiography. The mucosal lining in two cysts showed areas of squamous metaplasia, with one more showing an intact squamous lining probably more consistent with an epidermoid cyst. In the remaining cases (n = 27), all asymptomatic, serial USS showed volume maintenance (n = 16) actual volume regression (n = 4) and resolution (n = 7). Median follow-up in these cases was 42 (4-252) months.

CONCLUSION

This is the largest case series to date of antenatally-detected simple hepatic cysts. Most can be managed conservatively, and relative regression or resolution is likely. Surgical intervention should be reserved for those: that are large at the outset; show rapid cyst growth - these being typically exophytic in nature; wall irregularity or where there is diagnostic doubt.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

Level IV.

Giant hepatic cyst as a cause of gastric outlet obstruction

We describe the case of a 58-year-old female who presented to her primary care provider with lifelong anorexia, 6-week history of liquid only diet and new onset epigastric abdominal pain radiating to the back accompanied by nausea and abdominal distension. An initial computed tomography scan with contrast demonstrated a massive simple hepatic cyst with mass effect compression of the duodenal sweep. Repetitive treatment with aspiration sclerotherapy using hypertonic saline provided initial resolution of symptoms and led to substantial reduction of cyst diameter. Repeat imaging demonstrated complete drainage of the cyst and decompression of the duodenum. Ultimately, the patient's symptoms returned 6 weeks later at which time she opted for surgical deroofing of the cyst. Surgery provided for complete resolution. This case appears to be the first to document the compression of second portion of the duodenum by a massive simple hepatic cyst causing anorexia and mimicking gastric outlet obstruction.

Symptom relief and not cyst reduction determines treatment success in aspiration sclerotherapy of hepatic cysts

OBJECTIVE

To assess whether quantitative assessment of symptom reduction is a better outcome parameter than cyst volume reduction for treatment success in patients treated by aspiration sclerotherapy.

METHODS

We included patients with symptomatic, large (> 5 cm), hepatic cysts from a randomized controlled trial (NCT02048319). At baseline and 6 months after treatment, symptoms were assessed with the polycystic liver disease questionnaire (PLD-Q) and we measured cyst volume using ultrasonography. Patient-reported change in health was assessed on a 5-point Likert scale (much worse to much better) after 6 months. We tested whether PLD-Q scores and cyst volumes changed after aspiration sclerotherapy (responsiveness). Changes in PLD-Q scores and cyst volume were compared with change in health as a measure of treatment success (discriminative ability). As secondary analysis, we compared baseline characteristics between responders (improved) and non-responders (not improved).

RESULTS

We included 32 patients. Six months after treatment, 23 patients (72%) improved. Both PLD-Q score and cyst volume significantly decreased (median 38 to 18 points, p < 0.001, and 479 to 68 mL, p < 0.001). Larger improvement in PLD-Q score was associated with a positive change in health (p = 0.001), while larger proportional reduction in cyst volume was not significantly associated with health improvement after treatment (p = 0.136). Responders had larger baseline cyst volumes compared to non-responders (median 624 mL [IQR 343-1023] vs. 322 mL [IQR 157-423] p = 0.008).

CONCLUSION

Cyst diameter reduction does not reflect treatment success in aspiration sclerotherapy from patients' perspective, while symptoms measured with the PLD-Q can be used as a reliable outcome measure.

KEY POINTS

• Cyst diameter reduction poorly reflects treatment success in aspiration sclerotherapy. • Symptoms measured by the polycystic liver disease questionnaire (PLD-Q) is a better outcome measure than cyst volume reduction for treatment success after aspiration sclerotherapy. • Particularly patients with larger cysts (≥ 529 mL) benefit from aspiration sclerotherapy.

Differentiating Cystic Liver Lesions: A Review of Imaging Modalities, Diagnosis and Management

Hepatic cysts (HCs) are frequently discovered incidentally on abdominal imaging. The prevalence of HCs has been reported as high as 15-18% in the United States. Although most cysts are benign, some are malignant or premalignant. It is important to diagnose cystic lesions in order to properly manage them. Imaging with conventional ultrasound, computed tomography, magnetic resonance imaging, or contrast-enhanced ultrasound can be used to further characterize and diagnose HCs. Ultrasound is typically the first-line imaging modality, whereas more advanced imaging can help narrow down the specific lesion. Contrast-enhanced ultrasound is a newer modality, recently approved in the United States, which offers non-invasive evaluation in real-time. The first step in diagnosis is stratifying risk by differentiating simple and complex cysts. There are several features that can help identify HCs, including septae, mural consistency, calcifications, and quality of cystic fluid. Simple cysts are mainly congenital cysts, but also occur in polycystic liver disease. Complex cysts include mucinous neoplasms, echinococcal cysts, hemorrhagic cysts, cystic hepatocellular carcinoma and other rare lesions. Treatment is indicated in symptomatic cysts or those suspicious for malignant or premalignant features. Treatment modalities include fenestration, aspiration sclerotherapy, or surgical resection.

Pasireotide does not improve efficacy of aspiration sclerotherapy in patients with large hepatic cysts, a randomized controlled trial

OBJECTIVES

We tested whether complementary use of the somatostatin analogue pasireotide would augment efficacy of aspiration sclerotherapy of hepatic cysts.

METHODS

We conducted a double-blind, placebo-controlled trial in patients who underwent aspiration sclerotherapy of a large (>5 cm) symptomatic hepatic cyst. Patients were randomized to either intramuscular injections of pasireotide 60 mg long-acting release (n = 17) or placebo (sodium chloride 0.9 %, n = 17). Injections were administered 2 weeks before and 2 weeks after aspiration sclerotherapy. The primary endpoint was proportional cyst diameter reduction (%) from baseline to 6 weeks. Secondary outcomes included long-term cyst reduction at 26 weeks, patient-reported outcomes including the polycystic liver disease-questionnaire (PLD-Q) and safety.

RESULTS

Thirty-four patients (32 females; 53.6 ± 7.8 years) were randomized between pasireotide or placebo. Pasireotide did not improve efficacy of aspiration sclerotherapy at 6 weeks compared to controls (23.6 % [IQR 12.6-30.0] vs. 21.8 % [9.6-31.8]; p = 0.96). Long-term cyst diameter reduction was similar in both groups (49.1 % [27.0-73.6] and 45.6 % [29.6-59.6]; p = 0.90). Mean PLD-Q scores improved significantly in both groups (p < 0.01) without differences between arms (p = 0.92).

CONCLUSIONS

In patients with large symptomatic hepatic cysts, complementary pasireotide to aspiration sclerotherapy did not improve cyst reduction or clinical response.

KEY POINTS

• Complementary pasireotide treatment does not improve efficacy of aspiration sclerotherapy. • Cyst fluid reaccumulation after aspiration sclerotherapy is a transient phenomenon. • Aspiration sclerotherapy strongly reduces symptoms and normalizes quality of life.

An update on the pathophysiology and management of polycystic liver disease

Polycystic liver disease (PLD) is characterized by the presence of multiple cholangiocyte-derived hepatic cysts that progressively replace liver tissue. They are classified as an inherited ciliopathy /cholangiopathy as pathology exists at the level of the primary cilia of cholangiocytes. Aberrant expression of the proteins in primary cilia can impair their structures and functions, thereby promoting cystogenesis. Areas covered: This review begins by looking at the epidemiology of PLD and its natural history. It then describes the pathophysiology and corresponding potential treatment strategies for PLD. Expert commentary: Traditionally, therapies for symptomatic PLD have been limited to symptomatic management and surgical interventions. Such techniques are not completely effective, do not alter the natural history of the disease, and are linked with high rate of re-accumulation of cysts. As a result, there has been a push for drugs targeted at abnormal cellular signaling cascades to address deregulated proliferation, cell dedifferentiation, apoptosis and fluid secretion. Currently, the only available drug treatments that halt disease progression and improve quality of life in PLD patients are somatostatin analogues. Numerous preclinical studies suggest that targeting components of the signaling pathways that influence cyst development can ameliorate growth of hepatic cysts.

Utilization of Distilled Water Lavage for Localized Fluid Collection After Combined Hepatectomy and Cyst Fenestration for Polycystic Liver Disease

Ascites necessitating persistent drainage or paracentesis after drain removal has been found among early postoperative complications after combined hepatectomy and cyst fenestration (CHCF) for polycystic liver disease (PLD). It has been reportedly observed in 20% to 70% of cases and seemed to easily cause recurrent symptoms unless properly treated. We utilized distilled water lavage for treating localized fluid collection after combined hepatectomy and cyst fenestration for PLD. A 63-year-old female patient underwent CHCF for PLD, which caused severe abdominal fullness. Early postoperative course was uneventful until 10 days after surgery when the patient suffered sudden abdominal fullness and resultant severe anorexia because of right subphrenic massive localized monolocular fluid collection diagnosed by abdominal computed tomography—although total liver volume was reduced to less than half of that before surgery. Percutaneous drainage relieved symptoms immediately, but the drainage tube could not be removed because of massive outflow. Then we utilized distilled water lavage for treating this condition. After that, drain outflow dramatically reduced and the drainage tube was successfully removed. Total liver volume of the patient continued to reduce up to 1 year after surgery and retained less than one-third of preoperative total liver volume thereafter. Sustained reduction of total liver volume in the present case suggested a sclerosant effect of hypotonic cytocidal property of distilled water for cyst endothelium and/or retrieved effectiveness of fenestration. Hence, we consider this approach to be useful for patients with PLD receiving CHCF and thus present it here.