Intrahepatic biliary cystadenoma: a need for radical resection

Imaging features and management of focal liver lesions

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

Intrahepatic biliary cystadenoma, a challenging diagnosis and management: A case report

INTRODUCTION AND IMPORTANCE

Biliary cystadenoma (BC) is a benign hepatic cystic tumor with degenerative potential. Hepatic MRI can help guide the diagnosis. Surgical resection is recommended due to the malignant potential of biliary cystadenomas. Only anatomopathological examination of the surgical specimen can establish the definitive diagnosis of BC. The objective of this case report is to enhance our understanding of this disease and contribute to precise diagnosis for optimal management.

CASE PRESENTATION

A 55-year-old woman with a history of hypertension and atrial fibrillation presented to the surgery department with paroxysmal right hypochondrial pain. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) revealed a large septated cystic lesion occupying segments II, III, and IV of the liver. The patient underwent left hepatectomy without incident. The postoperative course was marked by a deep collection opposite the sectional area, which was successfully treated with antibiotics and radiological drainage. The pathological diagnosis confirmed BC without signs of malignancy, and no recurrence was detected post-surgery.

CLINICAL DISCUSSION

The rarity of BC, the absence of specific clinical signs and its potential for malignant transformation, underline the need for sophisticated imaging techniques. However, preoperative radiological diagnosis does not exceed 50 %. The operative decision requires a multidisciplinary discussion between radiologists and surgeons. This case highlights the unavailability of radical surgical treatment in cases of strong preoperative suspicion of BC. The cooperation of the pathologist in the histological diagnosis is crucial.

CONCLUSION

The diagnosis of BC should be considered in cases of multilocular cystic lesions in the liver, particularly in instances of recurrent cysts. Imaging aids in both positive and differential diagnoses. Complete resection is the recommended treatment for any suspected BC.

Case report: Single-operator peroral cholangioscopy system (SpyGlass) diagnosis of an extrahepatic biliary cystadenoma (video)

Biliary cystadenoma is a type of rare liver cystic tumor. Intrahepatic biliary cystadenomas are the most common, while extrahepatic biliary cystadenomas are rarely seen. Biliary cystadenoma tends to occur in middle-aged to older women and there is a lack of specific preoperative diagnostic markers. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. Herein, we report a patient in whom a space-occupying lesion was found in the bile duct by SpyGlass, and who later underwent radical surgery. The pathology report indicated that the final diagnosis was biliary cystadenoma. SpyGlass cholangioscopy may be a novel and effective diagnostic method for biliary cystadenoma.

Intrahepatic biliary cystadenoma: Confusion, experience, and lessons learned from our center

Background

Intrahepatic biliary cystadenoma (IBC) is a rare benign cystic tumor of the liver. So far, it has not been comprehensively understood, which causes incorrect diagnosis, treatment confusion, and even inappropriate treatment. Here, we reviewed clinical data of IBC patients in our center, shared our experiences and lessons learned, and improved the level of diagnosis and treatment.

Methods

The clinical data of 10 patients with pathologically diagnosed IBC, admitted to the Department of Hepatobiliary Surgery of the Affiliated Hospital of Guangdong Medical University from January, 2007, to January, 2022 were retrospectively analyzed.

Results

10 patients underwent surgery and were discharged successfully. Cyst morphology: multiple cysts: 6 cases (6/10), monocular cyst: four cases(4/10). Six patients (6/10) were diagnosed as IBC preoperatively and received hepatectomy. Four patients with monocular cyst IBC underwent intraoperative frozen section examination, except one case showed IBC; the rest were misdiagnosed as simple liver cyst. In three misdiagnosed patients, one underwent open left hepatectomy seven days after the initial operation. The other patient refused to undergo reoperation and required follow-up observation. The last patient could not tolerate hepatectomy due to insufficient residual liver volume and chose follow-up observation

Conclusion

For IBC, especially monocular IBC, it is easy to be misdiagnosed as simple hepatic cyst, which brings great confusion to clinical treatment. We propose strengthening communication with pathologists to deepen understanding of IBC. Attention should be paid to the cyst wall’s shape and the cyst fluid’s properties during the operation to avoid the missed diagnosis, misdiagnosis, or even improper operation. For suspicious cases, directly choose hepatectomy to avoid reoperation after thoroughly evaluating the patient’s condition.

Mucinous cystic neoplasm of the liver (MCN-L): a rare presentation and review of the literature

Mucinous cystic neoplasms of the liver (MCN-L, (previously referred to as cystadenomas or cystadenocarcinoma) are rare cystic tumors that occur within the liver parenchyma, or less frequently, in the extrahepatic bile ducts. They are reported to account for <5% of all liver cysts. The differential diagnosis of MCN-L includes intraductal papillary neoplasm of the bile duct (IPNB), intrahepatic cholangiocarcinoma with cystic change, echinococcal cyst, and a simple cyst. Invasive MCNs can only be differentiated from non-invasive MCNs by microscopic evaluation for the presence of ovarian-type stroma. Intraoperative biopsy and frozen section(s) are essential to differentiate MCNs from other cystic liver lesions. The treatment of choice is complete excision and can result in excellent survival with initial correct diagnosis. But its rare presentation and insufficient recognition frequently lead to an incorrect initial or delayed diagnosis or misdiagnosis.

Case Report: Low-Dose Apatinib in the Treatment of Intrahepatic Biliary Cystadenoma With Recurrence and Malignant Transformation

Apatinib is a new oral tyrosine kinase inhibitor that targets vascular endothelial growth factor receptor-2. It has been proven effective in treating multiple solid tumors. Herein, we report the case of a 67-year-old Chinese patient who was diagnosed with recurrent and malignant transformation of intrahepatic biliary cystadenoma. After multidisciplinary team discussion, the team considered that the remaining liver volume was insufficient for surgical resection. The patient refused chemotherapy and radiotherapy and was willing to take apatinib. Initially, the patient experienced severe tongue ulcers and difficulty eating. The dose of apatinib was then adjusted to 250 mg/day. To date, he has been taking apatinib for 48 months. Regular re-examination showed that the tumor had significantly decreased in size. On January 16, 2021, a CT scan revealed a tumor diameter of 4.5 cm. In our case, the patient achieved partial response and progression-free survival(PFS) of 48.0 months. During treatment, the patient’s appetite and mental state were expected. The treatment did not induce hypertension, fatigue, hand-foot syndrome, or liver and kidney damage. Apatinib may be an option for the treatment of advanced intrahepatic biliary cystadenocarcinoma. Its toxicity is controllable and tolerable. The exact curative effect still needs to be evaluated in more cases.

Intrahepatic biliary cystadenoma: A case report

BACKGROUND

Biliary cystadenoma (BCA) is a rare benign tumor, accounting for only 5% of reported cystic lesions of the liver. Given its potential for malignancy and high rate of recurrence, surgical resection is the preferred treatment. Therefore, early and accurate preoperative diagnosis is critical to the choice of treatment. We here report the first male case of BCA in our hospital, diagnosed by our team and confirmed by pathological biopsy. This article aims to improve the understanding of this disease and help make a correct diagnosis to better manage it.

CASE SUMMARY

A 58-year-old man with irregular abdominal discomfort came to our clinic and was found to have a distended abdomen during physical examination. Computed tomography and magnetic resonance imaging both showed a huge cystic mass in the liver. The patient underwent left hepatic lobectomy, cholecystectomy, and liver cyst fenestration, and most of the masses had decreased in size as of the 6-mo follow-up. The pathological diagnosis was consistent with BCA, and no recurrence was detected after the surgery. BCA occurred mainly in middle-aged women. To the best of our knowledge, this patient is the 11th male case of BCA reported in the literature.

CONCLUSION

The combination of magnetic resonance imaging and magnetic resonance cholangiopancreatography is of great significance for the early accurate diagnosis of the disease and the choice of surgical methods.

Cystic liver neoplams: A single centre experience and literature review

INTRODUCTION

The hepatic cystic tumour is a very rare neoplasm, representing about 5% of all cystic liver neoplasms. The preoperative diagnosis is difficult and can lead to confusion. The aim of this study is to analyze a number of cases operated at our centre with an histologic diagnosis of liver cystic neoplasms and also to describe the sintomathology, diagnosis and management as per the recent classification.

METHODS

A retrospective analysis was performed including all the cystic liver neoplasms operated between January 2000 and December 2019. The study was performed based on the pre-existing pathology archives. The 2010 previous cases were reclassified following the new 2010 OMS classification.

RESULTS

The study sample was of 10 patients, identifying 6 of them as mucinous cystic liver neoplasms, and the other 4 as intraductal papillary biliary neoplasms. The majority of the patients were women (8/10) and the median age was 47 years. Regarding the treatment, 3 hepatectomy and 7 enucleations were performed. Frozen section intraoperatively was not required in any case. In one case, variable cellular atypia with areas of adenocarcinoma was observed, and the patient received neoadyuvant chemotherapy with taxol and carboplatin. In all cases the resection margins were negative.

CONCLUSION

Cystic liver neoplasms are infrequent tumours with a difficult differential diagnosis. Therefore, with a high radiological suspicious, the treatment should be a complete resection to avoid recurrences and malignancies.

Biliary Mucinous Cystadenoma: A Review of the Literature

Biliary mucinous cystadenomas are cystic neoplasms commonly mistaken for simple cysts. They are rare and generally benign tumors, often incidentally found on imaging and during unrelated surgical interventions. They tend to be slow growing though may reach symptomatic dimensions. Misdiagnosis of biliary mucinous cystadenomas may have serious consequences secondary to their potential for malignant transformation into biliary mucinous cystadenocarcinomas. Here, we review the epidemiology, etiology, pathology, diagnostic modalities, histology, and available treatment methods for mucinous cystadenomas reported in current literature.

Mucinous cystic neoplasm of the liver with biliary communication: an exception to the current classification

Cystic neoplasms of the liver are rare tumours. According to the recent WHO classification, they are classified into mucinous cystic neoplasm and intraductal papillary neoplasm based on the presence of ovarian-like stroma and biliary communication. We report two rare cases of mucinous cystadenoma of the liver with biliary communication and discuss the shortcomings of current classification.

Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

BACKGROUD

Hepatic cysts are the most frequent, innocuous, space-occupying lesions of the liver. The majority of solitary liver cysts are nonsymptomatic. When liver cysts reach a large size, there are some complications, including infection, rupture, spontaneous hemorrhage, obstructive jaundice, and neoplastic degeneration. Percutaneous aspiration, fenestration, hepatic resection, and liver transplantation have been proposed for symptomatic patients.

CASE PRESENTATION

In this case report, we describe a 41-year-old woman who presented with persistent liver dysfunction, indolent xanthochromia, and skin itching for 3 months. After a series of tests, she has a 5.0 × 5.3 cm hepatic cyst with many separations in the left medial liver lobe. The obstructive jaundice was caused by a large pedunculated lump protruding into the common bile duct from the left hepatic duct. She was treated with laparotomy and this lump was completely removed from the root by choledochoscopic needle-knife electrotomy with a good clinical response. Postoperative pathology of the lump suggested a hepatic cyst wall without heterocysts or tumor cells.

CONCLUSION

Hepatic cyst wall protruding into the common bile duct can form capsular lump and result in indolent jaundice. Choledochoscopic high-frequency needle-knife electrotomy could be considered as a simple, safe and effective complementary approach for benign mass on the bile duct wall.

Intrahepatic biliary cystadenoma mimicking hydatid cyst of liver: a clinicopathologic study of six cases

BACKGROUND

Intrahepatic biliary cystadenomas are rare hepatic neoplasms, which are usually cystic. These tumors are often misdiagnosed as simple liver cysts and hydatid cysts clinically and radiologically owing to nonspecific clinical and radiologic features. These tumors require complete resection, as recurrence and malignant transformation can occur following incomplete excision. It is essential that these tumors be diagnosed accurately so that they can be adequately excised.

METHODS

Clinical and radiological features of six cases of biliary cystadenoma are described.

RESULTS

All of these cases were resected with the clinical and/or radiological impression of simple liver cysts and/or hydatid cysts. Out of the six patients, five were female and one was male. Ages of the patients ranged from 28 to 60 years (mean 45 years). The patients presented with nonspecific symptoms. Internal septations were seen on preoperative imaging (when available). On gross examination, all tumors were cystic; their sizes varied from 5.5 to 14 cm, mean size was 9.0 cm. On histopathologic examination, cystic spaces were lined by cuboidal to columnar mucin-secreting epithelium with underlying ovarian-type stroma. In one case, ovarian-type stroma was not seen. Recurrence was seen in three cases at 1 to 5 years of follow up.

CONCLUSIONS

Owing to their malignant potential and high recurrence rate following incomplete resection, an aggressive surgical approach is recommended. Prognosis is excellent after complete resection.

Uncommon neoplasms of the biliary tract: radiological findings

OBJECTIVE

To report our cancer centre experience in the biliary tumours incidence other than cholangiocellular-carcinoma, emphasizing the radiological features.

METHODS

197 patients with biliary disease undergoing Gd-EOB-DTPA-enhanced MRI were reviewed. Four radiologists evaluated retrospectively size, structure, anatomical site and signal intensity of lesions on MRI. Enhancement-pattern during the arterial-, portal- and late-phase on ultrasound, CT and MR study was assessed as well as the enhancement pattern during the hepatobiliary-phase on MRI.

RESULTS

23 patients were selected. The lesion was intraductal in 5 cases, periductal in 14 and intrahepatic in 4. 16 lesions were solid, 5 uniloculated cystic and 2 complex cystic. In five patients the lesion was simple cyst, with a signal intensity in T₁ weighted (T1W) and T₂ weighted (T2W) similar to the gallbladder. In two patients with complex cystic lesion, the solid component was heterogeneously hypointense in T₁ W, hyperintense in T₂ W with a restricted diffusion. The solid component showed heterogeneous contrast-enhancement on CT, MR and ultrasound. The tumour was intrahepatic in two patients, with signal hypointense in T₁ W and hyperintense in T₂ W. Diffusion was restricted. The lesions showed heterogeneous contrast-enhancement. The periductal lesions were hypointense in T₁ W, hyperintense in T₂ W with restricted diffusion. The lesion showed progressive contrast-enhancement. Peribiliary melanoma was hyperintense in T₁ W, hyperintense in T₂ W with restricted diffusion and progressively contrast-enhanced.

CONCLUSION

Biliary tumours can have a wide spectrum of radiologic appearances and consequently represent a diagnostic challenge for the radiologist. Advances in knowledge: MRI is the technique of choice in diagnosing biliary tumours, including rare (non-CCC) tumours.

Contrast enhanced ultrasound features of hepatic cystadenoma and hepatic cystadenocarcinoma

OBJECTIVE

Hepatic (biliary) cystic tumor (HBCT) is a rare focal cystic liver lesion, which has been rarely described in the literature. In our current multicenter, retrospective study, we aimed to analyze contrast enhanced ultrasound (CEUS) features and its diagnostic performance in histologically proved HBCT.

MATERIAL AND METHODS

Twenty-three patients with single HBCT were retrospectively analyzed. Histologically, 17 (73.9%) were benign hepatic (biliary) cystadenoma (HBCA), 6 (26.1%) were hepatic (biliary) cystadenocarcinoma (HBCAC). All CEUS examinations were assessed by two independent radiologists in consensus. Criteria of CEUS imaging evaluation included the contrast enhancement pattern of lesion (hypoenhancing, hyperenhancing, isoenhancing in comparison to the surrounding liver parenchyma) during the arterial, portal venous and late phases.

RESULTS

After injection of ultrasound contrast agents, most of the HBCTs (78.3%, 18/23) had typical honeycomb enhancement pattern of the cystic wall, septa or mural nodules. Comparing between HBCA and HBCAC, hyperenhancement of the honeycomb septa during the arterial phase was more common in HBCA (p = .047). However, hypoenhancement during the portal venous and late phases was the characteristic of HBCAC (p = .041).

CONCLUSIONS

The EFSUMB algorithm for CEUS for characterization of solid focal liver lesions is also applicable to HBCT. CEUS evaluation can avoid further diagnostic investigations or invasive biopsy procedure.

[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.

Imaging of Rare Primary Malignant Hepatic Tumors in Adults With Histopathological Correlation

Hepatocellular carcinoma and cholangiocarcinoma are the most common primary liver malignancies in adults (comprising >85%); however, liver is also host to some unusual primary malignant tumors. Some of these tumors show distinct demographic, clinicopathologic, and imaging features. Imaging features of these uncommon primary malignant liver tumors are presented with an attempt to correlate them with histopathology.

Clinicopathological characteristics and prognostic factors of intrahepatic biliary cystadenocarcinoma

Background:

Surgical resection is generally considered the main curative treatment for intrahepatic biliary cystadenocarcinoma (IBCA) or suspected IBCAs, but controversy exists regarding the prognosis for IBCAs. This study aimed to describe the clinicopathological characteristics of IBCA and identify prognostic factors that may influence the survival of patients treated with surgical procedures.

Methods:

Thirty-four patients with histologically confirmed IBCA treated between January 2000 and June 2014 were included. The clinical characteristics of patients with IBCA were compared with those of 41 patients with intrahepatic biliary cystadenoma (IBC); factors that significant difference were analyzed for prognosis analysis of IBCA using multivariate/univariate Cox proportional hazards regression models. Survival curves were constructed using the Kaplan–Meier method and compared using the log-rank test.

Results:

IBCAs had a strong female predominance, and the most common presenting symptoms were abdominal pain or discomfort. Compared with IBCs, IBCAs occurred in older patients, in more male patients, and were associated statistically significant abnormal increase in alanine aminotransferase (P = 0.01) and total bilirubin (P = 0.04). Mural nodules were more frequently seen with IBCAs and may associate with malignancy. It was difficult to differentiate between IBC and IBCA based on laboratory examination and imaging findings. Although complete resection is recommended, enucleation with negative margins also achieved good outcomes. Median overall patient survival was 76.2 months; survival at 1, 3, and 5 years was 88.0%, 68.7%, and 45.8%, respectively. Radical resection and noninvasive tumor type were independent prognostic factors for overall survival.

Conclusions:

It remains difficult to distinguish between cystadenomas and cystadenocarcinomas based on laboratory examination and image findings. Complete resection is recommended for curative treatment, and patients should be closely followed postoperatively, particularly those with invasive tumors.

Diagnosis and treatment of benign liver nodules: Brazilian Society of Hepatology (SBH) recommendations

Space-occupying lesions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenomas and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenomas are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenomas may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenomas growth, particularly of the hepatocyte nuclear factor-1alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of the liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the absence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agents are indicated.

Outcome following Resection of Biliary Cystadenoma: A Single Centre Experience and Literature Review

Background. Biliary cystadenomas (BCAs) are rare, benign, potentially malignant cystic lesions of the liver, accounting for less than 5% of cystic liver tumours. We report the outcome following resection of biliary cystadenoma from a single tertiary centre. Methods. Data of patients who had resection of BCA between January 1993 and July 2014 were obtained from liver surgical database. Patient demographics, clinicopathological characteristics, operative data, and postoperative outcome were analysed. Results. 29 patients had surgery for BCA. Male : female ratio was 1 : 28. Clinical presentation was abdominal pain (74%), jaundice (20%), abdominal mass (14%), and deranged liver function tests (3%). Cyst characteristics included septations (48%), wall thickening (31%), wall irregularity (38%), papillary projections (10%), and mural nodule (3%). Surgical procedures included atypical liver resection (52%), left hemihepatectomy (34%), right hemihepatectomy (10%), and left lateral segmentectomy (3%). Median length of stay was 7 (IQ 6.5-8.5) days. Two patients developed postoperative bile leak. No patients had malignancy on final histology. Median follow-up was 13 (IQ 6.5-15.7) years. One patient developed delayed biliary stricture and one died of cholangiocarcinoma 11 years later. Conclusion. Biliary cystadenomas can be resected safely with significantly low morbidity. Malignant transformation and recurrence are rare. Complete surgical resection provides a cure.

Diagnosis and treatment of intrahepatic biliary cystadenoma: experience with 14 cases in a single center

Intrahepatic biliary cystadenoma (IHBCA) is a rare type of liver tumor. There are no specific diagnostic methods for IHBCA, so its preoperative diagnostic rate is still fairly low. The aims of this study were to evaluate the clinical manifestations, diagnosis, and treatment of IHBCA. We retrospectively analyzed data from 14 patients treated in our hospital from January 2004 to April 2014. Eleven patients (78.6 %) were female, and the average age was 48.0 years (range 16-77 years). The most common clinical symptoms were abdominal discomfort (i.e., abdominal pain), reported in seven cases (50 %), and fullness after eating, reported in two cases (14.3 %). Jaundice was a less common symptom reported in one case (7.1 %). Four patients (28.6 %) were asymptomatic. Enhanced computed tomography (CT) scan showed multilocular or internal septations in 11 cases (78.6 %) and papillary projections or mural nodules on the cyst wall in one case (7.1 %). After injection of a contrast agent, the cyst walls or septations were slightly enhanced in nine cases (64.3 %). All 14 patients underwent surgical resection. Only one case showed recurrence (2 years postoperatively); the remaining 13 patients were recurrence-free. Intrahepatic biliary cystadenoma often occurs in middle-aged women. The main clinical symptoms are abdominal fullness with a sense of pain and jaundice. Enhanced CT is the main preoperative diagnostic method. Radical resection is the best treatment for IHBCA and can effectively prevent recurrence.

ACG clinical guideline: the diagnosis and management of focal liver lesions

Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.

Rare cystic liver lesions: A diagnostic and managing challenge

Cystic formations within the liver are a frequent finding among populations. Besides the common cystic lesions, like simple liver cysts, rare cystic liver lesions like cystadenocarcinoma should also be considered in the differential diagnosis. Thorough knowledge of each entity’s nature and course are key elements to successful treatment. Detailed search in PubMed, Cochrane Database, and international published literature regarding rare cystic liver lesions was carried out. In our research are included not only primary rare lesions like cystadenoma, hydatid cyst, and polycystic liver disease, but also secondary ones like metastasis from gastrointestinal stromal tumors lesions. Up-to date knowledge regarding diagnosis and management of rare cystic liver lesions is provided. A diagnostic and therapeutic algorithm is also proposed. The need for a multidisciplinary approach by a team including radiologists and surgeons familiar with liver cystic entities, diagnostic tools, and treatment modalities is stressed. Patients with cystic liver lesions must be carefully evaluated by a multidisciplinary team, in order to receive the most appropriate treatment, since many cystic liver lesions have a malignant potential and evolution.

Current management of noninfectious hepatic cystic lesions: A review of the literature

Nonparasitic hepatic cysts consist of a heterogeneous group of disorders, which differ in etiology, prevalence, and manifestations. With improving diagnostic techniques, hepatic cysts are becoming more common. Recent advancements in minimally invasive technology created a new Era in the management of hepatic cystic disease. Herein, the most current recommendations for management of noninfectious hepatic cysts are described, thereby discussing differential diagnosis, new therapeutic modalities and outcomes.

Evaluation of hepatic cystic lesions

Hepatic cysts are increasingly found as a mere coincidence on abdominal imaging techniques, such as ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI). These cysts often present a diagnostic challenge. Therefore, we performed a review of the recent literature and developed an evidence-based diagnostic algorithm to guide clinicians in characterising these lesions. Simple cysts are the most common cystic liver disease, and diagnosis is based on typical USG characteristics. Serodiagnostic tests and microbubble contrast-enhanced ultrasound (CEUS) are invaluable in differentiating complicated cysts, echinococcosis and cystadenoma/cystadenocarcinoma when USG, CT and MRI show ambiguous findings. Therefore, serodiagnostic tests and CEUS reduce the need for invasive procedures. Polycystic liver disease (PLD) is arbitrarily defined as the presence of > 20 liver cysts and can present as two distinct genetic disorders: autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (PCLD). Although genetic testing for ADPKD and PCLD is possible, it is rarely performed because it does not affect the therapeutic management of PLD. USG screening of the liver and both kidneys combined with extensive family history taking are the cornerstone of diagnostic decision making in PLD. In conclusion, an amalgamation of these recent advances results in a diagnostic algorithm that facilitates evidence-based clinical decision making.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A PubMed and Medline literature review was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy, followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can be effectively treated by aspiration or drainage.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

Filling Defect on ERCP: Biliary Cystadenoma, a Rare Tumor

Biliary cystadenomas are rare tumors of the bile ducts most commonly presenting as large right liver lobe lesions. These are usually slow-growing and mostly benign. They commonly present with abdominal pain. On physical exam an abdominal mass can be identified occasionally. Walls of biliary cystadenomas appear thicker than simple cysts, with soft tissue nodules and enhancing septations on CT or MRI. Radiographic images can vary with the amount of protein content in the fluid on CT or MRI. Due to the risk of malignant transformation, complete surgical resection is advised. Hereby, we describe a 37-year-old lady who presented to the outpatient clinic with bloating and abdominal discomfort with intermittent elevated liver enzymes and hyperbilirubinemia. Ultrasound of the liver and bile ducts followed by CT scan and magnetic resonance cholangiopancreatography confirmed the presence of biliary cystadenoma of the intra- and extrahepatic ducts. It was seen as a filling defect of the intra- and extrahepatic ducts (common hepatic duct) on endoscopic retrograde cholangiopancreatography. Involvement of the intra- and extrahepatic bile ducts simultaneously is a rare presentation of this tumor. She later on underwent exploratory laparotomy with extrahepatic bile duct resection, left hepatic lobe resection and reconstruction with hepaticojejunostomy. Pathology confirmed the presence of biliary cystadenoma with ovarian-like stroma. She had recovered uneventfully from the surgery when seen 2 weeks later in the clinic. Biliary cystadenoma is a rare, mostly benign neoplasm of the biliary tract that should be considered in the differential diagnosis of cystic lesions of the biliary tract.

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.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

Intra and extra-hepatic cystadenoma of the biliary duct. Review of literature and radiological and pathological characteristics of a very rare case

Painless obstructive jaundice is often associated with a malignant disease of the common bile duct or head of the pancreas. The authors present a unique case of a 62-year-old woman affected by an intrahepatic cystadenoma that extended into the common biliary duct. To our knowledge no previous case reports have been published on similar cases. After undergoing an en-block hepatic and bile duct resection, this patient is doing well without signs of recurrent disease.

Biliary cystadenoma: short- and long-term outcome after radical hepatic resection

The intrahepatic biliary cystadenoma is a rare benign tumor of the liver, originating from an intrahepatic bile duct: it becomes symptomatic only when it causes obstruction of the bile duct itself. Regardless of the various diagnostic modalities available, it is difficult to distinguish preoperatively the cystadenoma both from a simple liver cyst, and from a cystic carcinoma of the bile duct. An incomplete surgical removal of the cyst often results in a higher risk of size increase and recurrence, even considering that the lesion may degenerate into a cystadenocarcinoma. Between January 2004 and May 2011, 1,173 liver resections were carried out at the Hepatobiliary Surgery Unit of San Raffaele Hospital: 12 of these were performed for cystadenoma. Forty-six patients underwent laparoscopic liver cysts deroofing: definitive histological examination in six of these patients revealed instead the diagnosis of cystadenoma. In 50% of cases, the diagnosis of cystadenoma was therefore acquired as a result of an incidental finding. The patients were all female, median age 45 years. The liver resection included six cases of left hepatectomy, three left lobectomies, and three of the right hepatectomy. The operations were performed by laparotomy, with the exception of two left lobectomies completed laparoscopically. In all cases, the postoperative course was without major complications. The resection was radical in all cases and the median hospital stay was 5 days. At a median follow-up of 16 months (range 7-30), all patients are alive and disease free. Biliary cystadenomas can easily be misunderstood and interpreted as simple hepatic cysts. Radical surgical resection is necessary and provides good short- and long-term outcomes.

Liver transplantation for symptomatic centrohepatic biliary cystadenoma

Biliary cystadenoma is a rare benign cystic tumor of the liver. The mainstay of treatment is complete resection, either by enucleation or by formal hepatectomy, since incomplete removal entails not only constant recurrence but also the risk of malignant transformation to cystadenocarcinoma. A case of symptomatic centrohepatic biliary cystadenoma involving the main vasculobiliary structures of the liver is reported. After an unsuccessful attempt at resection resulting in an intrahepatic biliary injury, relief of jaundice and radical excision were achieved by total hepatectomy and liver transplantation. The patient is now alive and well 4 years after transplant, disease-free, with normal liver and renal function while receiving everolimus monotherapy. This is the first report of liver transplantation performed for the treatment of this tumor. With the case on the background, diagnostic aspects and available therapeutic strategies for biliary cystadenoma are reviewed and discussed.

Intrahepatic biliary cystic neoplasms: Surgical results of 9 patients and literature review

AIM: To investigate the eligible management of the cystic neplasms of the liver.

METHODS: The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution.

RESULTS: All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up.

CONCLUSION: In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Biliary Cystadenoma Causing Obstructive Jaundice: Case Report and Literature Review

Biliary cystadenomas are rare, potentially malignant neoplasms of biliary origin. Presentation is usually with vague and non-specific symptoms. Here, we describe an unusual case of biliary cystadenoma in a woman presenting with acute onset obstructive jaundice and review the relevant literature of 26 such cases reported over the last two decades.

Biliary cystadenoma

The diagnosis of cystadenoma is rare, even more so when located in the extrahepatic bile duct. Unspecific clinical signs may lead this pathology to be misdiagnosed. The need for pathological anatomy in order to distinguish cystadenomas from simple biliary cysts is crucial. The most usual treatment nowadays is resection of the bile duct, together with cholecystectomy and Roux-en-Y reconstruction.