Appropriate diagnosis of biliary cystic tumors: comparison with atypical hepatic simple cysts

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.

A paradigm shift in diagnosis and treatment innovation for mucinous cystic neoplasms of the liver

This study comprehensively explores the clinical characteristics, diagnostic approaches, and treatment methods for liver mucinous cystic neoplasms (MCN). A retrospective analysis was conducted on seven individuals diagnosed with MCN, admitted to the Fifth Medical Center of the PLA General Hospital between October 2016 and May 2023. Preoperative AFP was negative, while CA19-9 was elevated in two cases. Surgical resection was performed for all patients. The patients showed favorable postoperative recovery. Follow-up revealed an excellent overall survival rate, except for one case of invasive carcinoma resulting in tumor recurrence and metastasis 6 months after surgery. MCN poses a diagnostic challenge due to the absence of distinct clinical and radiological features, leading to potential misdiagnosis and inappropriate treatment. Patients with suspected liver cystic diseases should consider the possibility of MCN. Surgical resection has proven to be a practical approach with satisfactory therapeutic outcomes.

Management of Mucinous Cystic Neoplasms of the Liver

BACKGROUND

Mucinous cystic neoplasms of the liver (MCN-L) including biliary cystadenomas (BCA) and biliary cystadenocarcinomas (BCAC) are rare cystic lesions that comprise less than 5% of all liver cysts and affect only a small subset of individuals. We herein review the current evidence regarding the clinical presentation, imaging characteristics, tumor markers, pathological findings, clinical management, and prognosis of MCN-L.

METHODS

A comprehensive review of the literature was performed using MEDLINE/Pubmed and Web of Science databases. In PubMed, the terms "biliary cystadenoma," "biliary cystadenocarcinoma," and "non parasitic hepatic cysts" were queried to identify the most recent data on MCN-L.

RESULTS

US imaging, CT, and MRI, as well as consideration of clinicopathological features, are required to appropriately characterize and diagnose hepatic cystic tumors. BCA are premalignant lesions and cannot be reliably differentiated from BCAC based on imaging alone. As such, both types of lesions should be treated with margin-negative surgical resection. Following surgical resection, recurrence is fairly low among patients with BCA and BCAC. Despite having worse long-term outcomes than BCA, the prognosis following surgical resection of BCAC still remains more favorable than other primary malignant liver tumors.

CONCLUSION

MCN-L are rare cystic liver tumors that include BCA and BCAC, which can be difficult to differentiate based on imaging alone. Surgical resection remains the mainstay of management for MCN-L with recurrence being generally uncommon. Future multi-institutional studies are still required to better understand the biology behind BCA and BCAC to improve the care of patients with MCN-L.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

External validation of a machine learning based algorithm to differentiate hepatic mucinous cystic neoplasms from benign hepatic cysts

PURPOSE

To externally validate an algorithm for non-invasive differentiation of hepatic mucinous cystic neoplasms (MCN) from benign hepatic cysts (BHC), which differ in management.

METHODS

Patients with cystic liver lesions pathologically confirmed as MCN or BHC between January 2005 and March 2022 from multiple institutions were retrospectively included. Five readers (2 radiologists, 3 non-radiologist physicians) independently reviewed contrast-enhanced CT or MRI examinations before tissue sampling and applied the 3-feature classification algorithm described by Hardie et al. to differentiate between MCN and BHC, which had a reported accuracy of 93.5%. The classification was then compared to the pathology results. Interreader agreement between readers across different levels of experience was evaluated with Fleiss' Kappa.

RESULTS

The final cohort included 159 patients, median age of 62 years (IQR [52.0, 70.0]), 66.7% female (106). Of all patients, 89.3% (142) had BHC, and the remaining 10.7% (17) had MCN on pathology. Agreement for class designation between the radiologists was almost perfect (Fleiss' Kappa 0.840, p < 0.001). The algorithm had an accuracy of 98.1% (95% CI [94.6%, 99.6%]), a positive predictive value of 100.0% (95% CI [76.8%, 100.0%]), a negative predictive value of 97.9% (95% CI [94.1%, 99.6%]), and an area under the receiver operator characteristic curve (AUC) of 0.911 (95% CI [0.818, 1.000]).

CONCLUSION

The evaluated algorithm showed similarly high diagnostic accuracy in our external, multi-institutional validation cohort. This 3-feature algorithm is easily and rapidly applied and its features are reproducible among radiologists, showing promise as a clinical decision support tool.

Hepatobiliary mucinous cystic neoplasms and mimics

This review will provide an overview of hepatobiliary mucinous cystic neoplasms and their mimics such as complex appearing benign cysts, intraductal papillary neoplasm of bile ducts, choledochal cysts, infectious cysts, and other cystic neoplasms. Preoperative imaging, particularly abdominal MRI with MRCP, plays a key role in differentiating these entities which differ widely in management. Familiarity with the differentiating imaging features of mucinous cystic neoplasms and their mimics allows radiologists to provide management-guiding reports.

The prevalence and natural history of hepatic cysts examined by ultrasound: a health checkup population retrospective cohort study

The prevalence of hepatic cysts in the general population and their natural history are largely unknown. This study aimed to assess the prevalence and natural history of hepatic cysts by investigating health checkup participants. Ultrasonographic data of health checkup participants (n = 38,842) were retrospectively evaluated to calculate its prevalence. In addition, we assessed the changes in the size and characteristics of hepatic cysts over 10 years (n = 7709). We found the prevalence of hepatic cysts was 21.9%. Older age, female sex, and presence of kidney cysts or pancreatic cysts were associated with the occurrence of hepatic cysts. Younger age, female sex, and the existence of multiple hepatic cysts were associated with cyst enlargement. Among 126 individuals who had hepatic cysts with a diameter of 30 mm or larger at the first visit, two (1.6%) required treatment. Remain 124 cases showed four patterns: 44 cases with enlargement, 47 stable, 11 regression after enlargement, and 22 regression. Hyperechoic fluid inside the cysts was observed in 54.5% (18 of 33), which was significantly higher than 6.6% (6 of 91) of the non-regression (OR = 17.0). The appearance of intracystic hyperechoic fluid by ultrasound may predict subsequent regression of the hepatic cyst.

Differentiation of mucinous cysts and simple cysts of the liver using preoperative imaging

PURPOSE

Preoperative radiographic differentiation of mucinous cystic neoplasms (MCN) and simple cysts (SLC) of the liver is challenging. Previous data have demonstrated that the finding of septations arising from the cyst wall without indentation on cross-sectional imaging is associated with MCN. We aim to assess whether this radiographic feature is diagnostic of MCN.

METHODS

A prospectively maintained database was queried for patients with a preoperative diagnosis of a cystic liver lesion who subsequently underwent operative intervention. The feature of septations without indentation of the cyst wall was evaluated on cross-sectional imaging obtained within 3 months of operation. Imaging was independently evaluated by three radiologists blinded to pathology and interobserver agreement was compared to assess the diagnostic accuracy of this feature as well as the overall likelihood of the lesion representing a MCN.

RESULTS

There were 95 patients who met inclusion criteria; 80 (84%) had SLC on pathology, while 15 (16%) had MCN. Presence of septa without indentation of cyst wall had high sensitivity (range 80-87%), but low specificity (range 48-66%). Interobserver percent agreement (PA) was 51% [κ = 0.35 (95% CI 0.22-0.47)]. Sensitivity among the three radiologists ranged between 20 and 80% and specificity between 71 and 91% for the likelihood of the lesion representing MCN versus SLC, with an area under the curve (AUC) of 0.67-0.79; however, interobserver agreement was fair [κ = 0.40 (95% CI 0.25-0.55), PA = 67%].

CONCLUSION

The presence of septations without indentation of cyst wall demonstrates adequate sensitivity to differentiate MCN and SLC. However, there is variability for detection of this feature and therefore, it alone is of limited clinical value.

Multi-Center Follow-up Study to Develop a Classification System Which Differentiates Mucinous Cystic Neoplasm of the Liver and Benign Hepatic Cyst Using Machine Learning

RATIONALE AND OBJECTIVES

To date, no clinically useful classification system has been developed for reliably differentiating mucinous cystic neoplasm (MCN) from a benign hepatic cyst (BHC) in the liver. The objective was to use machine learning and a multi-center study design to develop and assess the performance of a novel classification system for predicting whether a hepatic cystic lesion represents MCN or BHC.

MATERIALS AND METHODS

A multi-center cohort study identified 154 surgically resected hepatic cystic lesions in 154 subjects which were pathologic confirmed as MCN (43) or BHC (111). Readers at each institution recorded seven pre-determined imaging features previously identified as potential differentiating features from prior publications. The contribution of each of these features to differentiating MCN from BHC was assessed by machine learning to develop an optimal classification system.

RESULTS

Although several of the assessed imaging features demonstrated statistical significance, only 3 imaging features were found by machine learning to significantly contribute to a potential classification system: (1) solid enhancing nodule (2) all septations arising from an external macro-lobulation (3) whether the lesion was solitary or one of multiple cystic liver lesions. The optimal classification system had only four categories and correctly identified 144/154 lesion (93.5%).

CONCLUSION

This multi-center follow-up study was able to use machine learning to develop a highly accurate classification system for differentiation of hepatic MCN from BHC, which could be readily applied to clinical practice.

CT and MRI features differentiating mucinous cystic neoplasms of the liver from pathologically simple cysts

PURPOSE

The purpose of this study was to determine if CT and MRI features can accurately differentiate mucinous cystic neoplasms (MCNs) from simple liver cysts and to compare accuracy of CT and MRI in detecting these features.

METHODS

Eighty-four surgically treated lesions with pre-operative CT or MRI were evaluated by two abdominal radiologists for upstream biliary dilatation, perfusional change, internal hemorrhage, thin septations, thick septations/nodularity, lobar location, and number of coexistent liver cysts. Odds ratios, sensitivities, specificities, and positive and negative predictive values were calculated for association of each feature with MCNs.

RESULTS

Of 84 liver lesions, 13 (15%) were MCNs, all in women, and 71 (85%) were simple cysts, in 59 women and 12 men. Thick septations/nodularity, upstream biliary dilation, thin septations, internal hemorrhage, perfusional change, and fewer than 3 coexistent liver cysts were more frequent in MCNs than in simple cysts. The combination of thick septations/nodularity and at least one additional associated feature showed high specificity for MCNs (94-98%). MRI detected significant associations of biliary dilation, thin septations, and hemorrhage/debris with MCNs which CT did not.

CONCLUSION

Surgically treated MCNs of the liver with preoperative imaging occurred at our institution only in women. Thick septations or nodularity, biliary dilation, thin septations, internal hemorrhage or debris, perfusional change, and fewer than 3 coexistent liver cysts are features that help differentiate MCNs from simple cysts. MRI has advantages over CT in detecting these features.

Cystic biliary tumors of the liver: diagnostic criteria and common pitfalls

With major advancements and frequent use of abdominal imaging techniques, hepatic cysts are increasingly encountered in clinical practice. Although the majority of cysts are benign, a small subset represents neoplastic precursors to cholangiocarcinoma. These cystic precursors include intraductal papillary neoplasms of the bile duct (IPNB) and mucinous cystic neoplasms of the liver (MCN-L), and bear striking pathologic resemblance to corresponding cystic neoplastic precursors within the pancreas. This review examines the salient clinical, gross, microscopic and molecular features of IPNBs and MCN-Ls, and, in particular, provides histopathologic comparison to their pancreatic counterparts. Considering these neoplasms may be diagnostically challenging, we also discuss other hepatic lesions within the differential diagnosis, and the potential for molecular methods to improve their preoperative evaluation and the early detection of cholangiocarcinoma.

Atypic large hepatic cyst with persistent elevated CA19.9 serum value: utility of intracystic CA72.4 dosage for a mini-invasive management

Simple hepatic cysts are very common, but may be difficult to differentiate from a biliary cystadenoma or cystadenocarcinoma. Because the surgical treatment if needed, such as a hepatic fenestration or resection, depends on the diagnosis, the assay of intracystic tumor markers is useful.We report the case of a 67-year-old woman with a large hepatic cyst responsible of pain and inflammation. The combination of imaging findings, serum, and intracystic fluid tumor markers [CA72.4 (carbohydrate hydrogen)] permitted to diagnose a simple hepatic cyst despite an unusual persistent elevated serum CA19.9 level. A laparoscopic cyst fenestration was proposed with an uneventful postoperative course. The pathological findings showed a simple hepatic cyst.In case of hepatic cysts, radiological findings can discriminate between benign and (pre)malignant lesions, but in case of doubtful diagnosis, the serum and intracystic tumor markers can be helpful.The use of serum or intracystic tumor marker allows to choose the correct therapeutic strategy and to use mini-invasive approach when feasible.

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.

The impact of imaging on the surgical management of biliary cystadenomas and cystadenocarcinomas; a systematic review

BACKGROUND

Biliary Cystadenomas (BCA) are considered to be benign but may transform to Biliary Cystadenocarcinomas (BCAC). The aim of this systematic review was to assess the diagnostic work-up and necessity of complete surgical resection.

METHOD

A systematic literature search was performed in Embase.com, Medline (Ovid), Cochrane Central, Web-of-Science and Google Scholar. Articles reporting on diagnostic work-up or outcome of various treatment strategies were included.

RESULTS

Fifty-one articles with 1218 patients were included: 971 with BCA and 247 with BCAC. Patients with BCA were more often female (91% vs 63.8%, p < 0.001). On radiologic imaging BCAC more often had calcifications (p = 0.008), mural nodules (p < 0.001) and wall enhancement (p < 0.001). Reported treatment strategies were resection, enucleation, or fenestration/marsupialization. Recurrence was reported in 5.4% after resection for BCA and 4.8% after resection for BCAC. Recurrence after fenestration/marsupialization varied from 81.6% to 100% for both BCA as BCAC. Mortality rate was 0 in patients with BCA and 24% in BCAC.

CONCLUSION

Due to the difficulty in accurately diagnosing these biliary cystic lesions and the availability of different surgical approaches, patients with suspected BCA or BCAC should be treated in a center specialized in liver surgery with state-of-the-art imaging and all surgical techniques to prevent mismanagement of this rare disease.

Biliary mucinous cystic neoplasm mimicking a hydatid cyst: a case report and literature review

Background

Biliary mucinous cystic neoplasms are rare cystic lesions of the liver which carry pre-malignant potential. Given the scarcity of reports in the literature, they pose a considerable challenge to clinical management, particularly with regards to accurate pre-operative diagnosis.

Case presentation

We present the case of a 37-year-old Tunisian woman who presented with subacute right upper quadrant pain and a large multi-loculated cystic lesion, most consistent with a hydatid cyst. She underwent an open right hepatectomy, and pathology surprisingly revealed a biliary mucinous cystadenoma. Herein, we review the current literature on biliary mucinous cystic neoplasms, with a particular emphasis on diagnostic investigations, key radiological features and optimal treatment modalities.

Conclusion

Biliary mucinous cystic neoplasms require a high index of suspicion and should be managed with complete surgical resection, as conservative techniques are associated with high recurrence rates. Considering the potential for malignant transformation, periodical surveillance imaging is recommended in the post-operative period.

Misdiagnosis of Intrahepatic Biliary Cystadenoma Located in the Caudate Lobe: A Case Report

BACKGROUND

Intrahepatic Biliary Cystadenoma (IBC) is rare but has a high incidence of misdiagnosis, especially for experienceless surgeons.

CASE

We report a case of IBC located in the caudate lobe and described a typical procedure of misdiagnosing this disease. Finally, the patient was successfully cured, but the procedure of misdiagnosis should attract attention. IBC and atypical biopsy for histological examination are the most important causes of misdiagnosis. Recurrent cystic lesions of the liver and repeated increases in CA 19-9 may suggest a "liver cyst", which is a misdiagnosis.

CONCLUSION

The experience and lessons of misdiagnosis, in this case, may help other clinicians diagnose the rare disease accurately.

Imaging findings of hemorrhagic hepatic cysts with enhancing mural nodules

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An updated review of cystic hepatic lesions

Cystic hepatic lesions are commonly encountered in daily practice. The diagnosis of these lesions ranges from benign lesions of no clinical significance to malignant and potentially lethal conditions. The prevalence of hepatic cyst (HC) has been reported to be as high as 15-18% in the United States. Imaging with conventional ultrasound, computed tomography, magnetic resonance imaging, or contrast-enhanced ultrasound can be used to characterize further and diagnose. The pre-test probability of a diagnosis is highly affected by the patient's comorbidities and the clinical and laboratory data; thus, imaging studies should be interpreted in the context of the other clinical information for that particular patient. Treatment modalities for hepatic cyst include fenestration, aspiration sclerotherapy, or surgical resection. In the current review, we discuss the pathophysiology, diagnosis, and treatment modalities for various cystic hepatic lesions.

Differentiating metastatic mucinous colorectal adenocarcinomas from simple cysts of the liver using contrast-enhanced and diffusion-weighted MRI

OBJECTIVE:

To determine the value of contrast-enhanced and diffusion-weighted (DW) MRI for differentiating metastatic mucinous colorectal adenocarcinomas from simple cysts of the liver.

METHODS:

29 patients with 47 metastatic mucinous colorectal adenocarcinomas and/or 19 simple cysts of the liver who underwent contrast-enhanced and DW MRI were included in this retrospective study. Two radiologists assessed the MRI findings by consensus. Qualitative and quantitative analyses were conducted. Significant MRI findings on univariate and multivariate analyses were assessed, and their diagnostic performances for predicting metastatic mucinous colorectal adenocarcinomas were analyzed.

RESULTS:

The presence of rim enhancement (odds ratio, 28.43; p = 0.008) and intracystic enhancement (oddsratio, 180.15; p = 0.001) were independently significant factors for predicting metastatic mucinous colorectal adenocarcinomas. The sensitivity and specificity of rim enhancement, intracystic enhancement, and their combination for detecting metastatic mucinous colorectal adenocarcinomas were 83% (39/47) and 63.2% (12/19), 87.2% (41/47) and 89.5% (17/19), and 72.3% (34/47) and 94.7% (18/19), respectively. Compared to simple cysts, metastatic mucinous colorectal adenocarcinomas showed significantly lower mean apparent diffusion coefficient (1.92 ± 0.81 vs 2.99 ± 0.75 × 10^-3 mm² s^-1; p = 0.001) and lesion-to-liver apparent diffusion coefficient ratio (1.66 ± 0.75 vs 2.44 ± 0.56 × 10^-3 mm² s^-1; p = 0.004) and higher mean signal intensity (400.3 ± 216.3 vs 222.4 ± 99.3; p = 0.039) and lesion-to-liver signal intensity ratio on hepatobiliary-phase images (0.58 ± 0.16 vs 0.30 ± 0.14; p < 0.001).

CONCLUSION:

Contrast-enhanced and DW MRI may be helpful for differentiating metastatic mucinous colorectal adenocarcinomas from simple cysts of the liver.

ADVANCES IN KNOWLEDGE:

On contrast-enhanced and DW MRI, rim and intracystic enhancement can be helpful for differentiating metastatic mucinous colorectal adenocarcinomas from simple cysts of the liver.

Long-term outcomes and quality of life after surgical or conservative treatment of benign simple liver cysts

BACKGROUND

Benign liver cysts are common and are often detected incidentally. Most patients do not require intervention. Occasionally, large dominant or multifocal small cysts cause symptoms as a result of rapid growth, secondary infection, intra-cystic bleeding or compression of adjacent organs.

AIM

To compare presenting symptoms and outcomes of a consecutive series of patients with benign liver cysts treated either conservatively or by surgical intervention. Long-term quality of life (QoL) was also assessed.

METHODS

Retrospective analysis of prospectively collected data was conducted. Long-term general and disease-specific quality of life was also documented.

RESULTS

Ninety-five patients were included in the study (46 treated operatively, 49 treated conservatively). 80% were female, and the mean age of the cohort was 58 years. Those who had surgical intervention were older (62 vs 55 years, p = 0.004), were more likely to have shortness of breath at presentation (11 vs 5%, p = 0.018) and had larger cysts (12 vs 4 cm, p < 0.001) compared with those offered conservative treatment. Laparoscopic stapled excision was the most common operative procedure (70%) and the overall complication rate was 20%. At a median follow-up of 64 months, 17% (8/46) of the surgically treated patients had radiological evidence of cyst recurrence but only 9% (4/46) were symptomatic. At median follow-up of 71 months, 37% (14/38) of conservatively treated patients had unchanged or new symptoms compared to the first presentation. Furthermore, 10% (4/38) of this group had additional radiological or surgical intervention for persistent symptoms during the follow-up period. Overall, there was no difference in long-term QoL between the two groups.

CONCLUSION

Surgical intervention for selected patients with symptomatic benign liver cysts results in low long-term recurrence rates and excellent patient-reported outcomes and quality of life. Laparoscopic-stapled excision can be done safely and reliably in carefully selected patients.

Rare biliary cystic tumors: a case series of biliary cystadenomas and cystadenocarcinoma

Cystic lesions of the liver are common and a major proportion is formed by parasitic cysts and simple cysts. Biliary cystic tumors (BCTs), namely biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC), are rare tumors which usually arise from the intrahepatic biliary tree. BCAs have malignant potential and are difficult to differentiate from BCAC pre-operatively on radiological imaging. Here we have presented 4 patients with BCTs and reviewed the literature pertaining to them.The data of four patients with BCA/BCAC diagnosed and treated at our institute were retrieved from our database and records were reviewed for age, sex, history, imaging, surgery, pathology and follow-up. Mean age of the patients was 53.5 years (range 30-71 years). Two male and two female patients presented with abdominal pain, of which one male patient had pancreatitis at diagnosis. Characteristic features were seen on pre-operative imaging (cystic lesions with internal septations) and biliary communication was identified in the patient with pancreatitis. Three patients were diagnosed with a BCA on final histology, while one patient had a BCAC. Following surgical resection, all the patients are asymptomatic and disease free with a mean follow-up of 24 months (range 10-40 months). In conclusion, BCTs should be suspected in the presence of a well-encapsulated, cystic hepatic lesion with internal septations. Although pre-operative distinction between BCA and BCAC is difficult, the lesion, whenever possible, should be completely resected as long-term outcomes are good, especially with BCA.

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.

The accuracy of pre-operative imaging in the management of hepatic cysts

BACKGROUND

Biliary cystic tumours (BCT) [biliary cystadenoma (BCA) and cystadenocarcinoma (BCAC)] warrant complete resection. Simple liver cysts (SLC) require fenestration when symptomatic. Distinguishing between BCT and atypical SLC with pre-operative imaging is not well studied.

METHODS

All patients undergoing surgery for a pre-operative suspected SLC or BCT between 1992 and 2014 were included. Peri-operative data were retrospectively reviewed. A blind radiological review of pre-operative imaging was performed.

RESULTS

Ninety-four patients underwent fenestration (n = 54) or complete excision (n = 40). Final pathology was SLC (n = 74), BCA (n = 15), BCAC (n = 2) and other primary malignancies (n = 3). A frozen section (FS) was performed in 36 patients, impacting management in 10 (27.8%) by avoiding (n = 1) or mandating a liver resection (n = 9). Frozen section results were always concordant with final pathology. Upon blind review, a solitary lesion, suspicious intracystic component, septation and biliary dilatation were associated with BCT (P < 0.05). Diagnostic sensitivity was high (87.5-100%) but specificity was poor (43.1-53.4%). The diagnostic value of imaging was most accurate when negative for BCT (negative predictive value: 92.5-100%).

CONCLUSION

Radiological assessment of hepatic cysts is relatively inaccurate as SLC frequently present with concerning features. In the absence of a strong suspicion of malignancy, fenestration and FS should be considered prior to a complete resection.

Rare benign tumors of the liver: still rare?

Background

Benign liver tumors are common. They do not spread to other areas of the body, and they usually do not pose a serious health risk. In fact, in most cases, benign liver tumors are not diagnosed because patients are asymptomatic. When they are detected, it’s usually because the person has had medical imaging tests, such as an ultrasound (US), computed tomography (CT) scan, or magnetic resonance imaging (MRI), for another condition.

Materials and methods

A search of the literature was made using cancer literature and the PubMed, Scopus, and Web of Science (WOS) database for the following keywords: “hepatic benign tumors”, “hepatic cystic tumors”, “polycystic liver disease”, “liver macroregenerative nodules”, “hepatic mesenchymal hamartoma”, “hepatic angiomyolipoma”, “biliary cystadenoma”, and “nodular regenerative hyperplasia”.

Discussion and conclusion

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in some areas of the world; there is an increasing incidence worldwide. Approximately 750,000 new cases are reported per year. More than 75 % of cases occur in the Asia-Pacific region, largely in association with chronic hepatitis B virus (HBV) infection. The incidence of HCC is increasing in the USA and Europe because of the increased incidence of hepatitis C virus (HCV) infection. Unlike the liver HCC, benign tumors are less frequent. However, they represent a chapter always more interesting of liver disease. In fact, a careful differential diagnosis with the forms of malignant tumor is often required in such a way so as to direct the patient to the correct therapy. In conclusion, many of these tumors present with typical features in various imaging studies. On occasions, biopsies are required, and/or surgical removal is needed. In the majority of cases of benign hepatic tumors, no treatment is indicated. The main indication for treatment is the presence of significant clinical symptoms or suspicion of malignancy or fear of malignant transformation.

Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts

We conducted a systematic review of the literature on the electronic databases Medline, Embase, Ovid and Cochrane to identify studies from 1990 to 2011 regarding the surgical management of non-parasitic liver cysts treated with laparoscopy (LT) and/or laparotomy (OT) to identify short-term and long-term outcomes of the relative treatments. Two reviewers independently extracted data regarding the following parameters: first author, year of publication, type of journal, study design, number of patients operated on, male/female ratio, mean age, mean size of the cysts treated, laparoscopic conversion rate, morbidity, mortality and recurrence in both groups (LT and OT). A qualitative analysis was carried out using the Pearson Chi square test and the Fischer's exact test where necessary. The data analysis was conducted by dividing the sample into three periods in relation to the development of laparoscopic surgery: period 1 (P1), 1990-1995 "pioneering" period of laparoscopy; period 2 (P2), 1996-2000 period of the "development of laparoscopy"; period 3 (P3), 2001-2011 period of "diffusion of laparoscopy." Thirty studies involving 948 patients comparing LT with OT were included in the final pooled analysis. Twenty-two studies were retrospective (73.3 %) and only 8 (26.7 %) were prospective. The number of publications increased during the three periods analysed. The correlation between the type of journal and the year of publication showed an increase (p = 0.048) in journals dedicated to LT during the three periods. In P1, the preferred approach was open surgery (66.3 %) with only 11 cases treated with LT. The conversion rate was 18.1 %. The overall complication rate was 33.3 % with a substantial equivalence between the two approaches (27.2 % for laparoscopic surgery and 36.6 % for laparotomic). The overall recurrence rate was 18.1 % with 36.3 % in the laparoscopic group and 9.2 % in the laparotomic group. In P2, the preferred approach was laparoscopic (56.7 %). The conversion rate was 2.3 %. The overall complication rate was 5.8 % but with some differences between the two approaches (10.3 % for the laparoscopic approach and 0 % for open surgery). The overall recurrence rate was 14.4 % with 17.4 % in the laparoscopic group and 10.4 % in the laparotomic group. In P3, the preferred approach was laparoscopic (69.9 %). The overall recurrence rate was 11.1 %; it was 6.1 % for the laparoscopic approach while it was 11.5 % for laparotomic. In all three periods analysed, the laparoscopic approach showed a statistically significant reduction in operative time (p = 0.009) and hospital stay (p = 0.001) and a significant (p < 0.05) reduction rate in symptomatic recurrences in patients with polycystic liver disease (25 %) as compared with simple liver cysts (7.5 %). The current data in the literature show that the laparoscopic approach may be the treatment of choice in patients with symptomatic non-parasitic cysts of the liver, providing the short-term advantages of minimally invasive surgery. Recurrence rates were acceptable and comparable to those of conventional surgery. Long-term outcomes should be verified by additional randomised controlled trials and long-term follow-ups.

Current diagnosis and management of simple hepatic cysts detected prenatally and postnatally

PURPOSE

The optimal management of simple hepatic cysts (SHCs) remains controversial. A retrospective review was carried out to evaluate the clinical presentation and surgical consideration of children with SHCs and outcome of management at our institution.

METHODS

We performed a retrospective review of all patients diagnosed with SHCs between January 1993 and May 2013. Patient variables included prenatal findings, age, gender, presenting symptoms, signs and diagnostic modality. Operative management and nonoperative follow-up were abstracted.

RESULTS

The 67 patients comprised 42 females and 25 males: 16 had prenatally detected, and 51 had postnatally detected hepatic cysts with a mean follow-up of 3.2 years (10 months-12 years). The average age was 5.9 years (0-17 years). Ten patients (six females and four males) were treated surgically. Fifty-seven asymptomatic patients were observed. Of those 57 patients, 9 (17%) had enlarged cysts, and 1 (2%) had clinical signs. The average enlargement time was 36 months (6-67 months). The cysts occurred in the right lobe in 47 patients, in the left lobe in 17 patients and in both lobes in 3 patients. The median cyst size for the asymptomatic cases was 2.1 cm (1.5-6 cm) and 13.7 cm (8-25 cm) for the surgery group. A statistically significant difference in cyst size was found between these two groups (p < 0.05). Prenatally detected cysts (n = 5) were subjected to surgery postnatally at an average age of 1.5 months (1 week-6 months). The main indication was the compressive effect of the cyst on the surrounding area. There was one case of hepatomegaly found to be causing pressure symptoms, two cases of respiratory distress, one case of hydroureteronephrosis, and one case of jaundice due to compression of the biliary system. Five patients underwent surgery in the postnatally detected group, and the main indication was a complication of the cyst or progressive enlargement. Symptoms included abdominal discomfort and pain in all five patients: one case exhibited a hemorrhage within the cyst, one case displayed a rupture with possible peritonitis, one case had a 25-cm cyst leading to secondary infection, and two cases were admitted with progressive enlargement with clinical symptoms.

CONCLUSION

Conservative management of SHCs is practical. Surgical excision is recommended in patients with larger cysts, causing pressure symptoms, or if the cyst size does not seem to involute with intractable abdominal pain or becomes complicated in the follow-up period.

Intracystic concentrations of tumour markers for the diagnosis of cystic liver lesions

BACKGROUND

Imaging occasionally fails to differentiate hepatic simple cysts from malignant or premalignant mucinous cystic lesions such as biliary cystadenomas. Hepatic simple cysts can be treated conservatively, whereas malignant or premalignant cysts require complete resection. This study assessed the ability of intracystic tumour marker concentrations to differentiate these disease entities.

METHODS

Intracystic fluid was sampled in patients undergoing partial or complete resection of a cystic lesion of the liver. The indication for surgery in hepatic simple cysts was symptoms or suspicion of a biliary cystadenoma. Intracystic concentrations of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9 and tumour-associated glycoprotein (TAG) 72 were measured to assess the diagnostic accuracy of these tumour markers. Cut-off values were defined by receiver operating characteristic (ROC) curves.

RESULTS

The study population comprised 118 patients (94 women) with a median age of 59 years. There were 75 patients with hepatic simple cysts, 27 with mucinous cysts (19 biliary cystadenomas, 4 biliary cystadenocarcinomas, 4 intraductal papillary mucinous neoplasms of the bile duct) and 16 with miscellaneous cysts. Unlike CEA and CA19-9, a TAG-72 concentration of more than 25 units/ml differentiated hepatic simple cysts from mucinous cysts with a sensitivity and a specificity of 0·79 and 0·97 respectively. The area under the ROC curve was 0·98 for mucinous versus hepatic simple cysts.

CONCLUSION

The concentration of TAG-72 in cyst fluid accurately identified hepatic cysts that required complete resection.

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.

Clinicopathological features and prognosis of mucin-producing bile duct tumor and mucinous cystic tumor of the liver: a multi-institutional study by the Japan Biliary Association

BACKGROUND

The aim of this study was to determine the clinicopathological features and surgical outcomes of mucinous cystic neoplasm of the liver (MCN) and mucin-producing intraductal papillary neoplasm of the intrahepatic bile duct (M-IPNB).

METHODS

We performed a multi-institutional, retrospective study of patients with MCN or M-IPNB pathologically defined by the presence or absence of an ovarian-like stroma.

RESULTS

The M-IPNB and MCN were diagnosed in 119 and nine patients, respectively. MCN was observed in female patients, while M-IPNB produced symptoms of cholangitis. M-IPNBs were classed as low or intermediate grade in 53 cases, high grade in 23 and invasive carcinoma in 43. Fifty-one of the M-IPNBs were the pancreatobiliary type (PT), 33 were the intestinal type (IT), 23 were the oncocytic type (OT), and 12 were the gastric type (GT). The 1-, 5- and 10-year survival rates for the 105 patients with M-IPNB were 96%, 84% and 81%, respectively, while the 5-year survival rate for patients with MCN was 100%. OT and GT M-IPNB had better 10-year survival rates than PT and IT M-IPNB.

CONCLUSIONS

Although MCN has different features from M-IPNB, both diseases have a good prognosis after resection. The cellular type of M-IPNB appears to predict outcome.

Prevalence of simple liver cysts and hemangiomas in cirrhotic and non-cirrhotic patients submitted to magnetic resonance imaging

Objective To determine the prevalence of liver cysts and hemangiomas in the general population and in cirrhotic patients. Materials and Methods Retrospective, observational, and cross-sectional study selecting consecutive magnetic resonance imaging studies performed in the period from February to July 2011. A total of 303 patients (187 women and 116 men) with mean age of 53.3 years were included in the present study. Patients with previously known liver lesions were excluded. The images were consensually analyzed by two observers in the search for simple liver cysts and typical liver hemangiomas, according to universally accepted imaging criteria. Lesions prevalence, diameters and location were determined in both cirrhotic and non-cirrhotic individuals. Results The authors observed prevalence of 8.6% for hemangiomas and 14.5% for simple cysts. No statistically significant difference was observed in relation to prevalence of hemangiomas and cysts among cirrhotic and non-cirrhotic patients (p = 0.954; p = 0.472). Conclusion In the present study, the prevalence of cysts and hemangiomas was higher than the prevalence reported by autopsy series. No influence of cirrhosis was observed on the prevalence and appearance of such incidental lesions.

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.

SSAT/AHPBA joint symposium on evaluation and treatment of benign liver lesions

BACKGROUND

Benign liver lesions are common incidental radiologic findings.

METHODS

Experts convened in 2011 at a Society for Surgery of the Alimentary Tract/ Americas Hepato-Pancreato-Biliary Association joint symposium to discuss the evaluation and treatment of benign liver lesions.

RESULTS

Most benign liver lesions can be accurately diagnosed with high-quality imaging, including ultrasonography, multiphase computed tomography, and magnetic resonance imaging, particularly with hepatocyte-specific contrast agents. Percutaneous biopsy is reserved for lesions that cannot be characterized radiographically, and its accuracy is improved with immunophenotypic markers. Hepatic cysts are the most commonly diagnosed benign liver lesions; these must be distinguished from malignant cystic lesions, which are rare. Among the solid benign liver lesions, hemangiomas and focal nodular hyperplasia seldom require treatment. In contrast, hepatocellular adenomas are associated with a risk for complications. A new classification system for hepatocellular adenomas based on genetic and phenotypic features can help guide patient care. In patients who are symptomatic or at risk for complications, multidisciplinary evaluation and treatment based on clinicopathologic, radiographic, and molecular analysis is needed.

CONCLUSIONS

Most benign liver lesions can be accurately diagnosed radiographically and do not require treatment. Treatment is necessary for patients with symptoms or at risk for complications.

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.

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.

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.

Successful surgical management of an extrahepatic biliary cystadenocarcinoma

Extrahepatic bile duct cancer is an uncommon disease, and few cases are curable by surgery. We report a case of extrahepatic biliary cystadenocarcinoma (BCAC) associated with atrophy of the left hepatic lobe. A 54-year old male was admitted with painless obstructive jaundice and a hepatic palpable mass noticed one month before presentation. Liver functions tests were consistent with cholestatic damage and serum carbohydrate antigen 19.9 (CA 19-9) was increased before treatment. Magnetic resonance imaging (MRI) disclosed dilatation of the left hepatic bile duct with irregular wall thickening close to the hepatic confluence, and atrophy of left hepatic lobe. The patient was submitted to en bloc extended left hepatectomy with resection of caudate lobe, hilar lymphadenectomy, and suprapancreatic biliary tree resection. All surgical margins were grossly negative, and postoperative course was uneventful, except for a minor bile leak. The patient was discharged on the 15th postoperative day; he is alive without tumor recurrence one year after primary therapy. Although technically challenging, extended en bloc resection is feasible in adults with extrahepatic BCAC and can improve survival with acceptable and manageable morbidity.

Mucinous cystic neoplasms of the liver: a clinicopathological study and comparison with intraductal papillary neoplasms of the bile duct

Mucinous cystic neoplasm of the liver has been a controversial entity, in particular, regarding differentiation from intraductal papillary neoplasm of the bile duct. In this study, we compared the characteristics of hepatic mucinous cystic neoplasms with ovarian-like stroma (n=29) to those of cyst-forming intraductal papillary neoplasms of the bile duct (n=12). Radiological or macroscopic appearance, histological grade of malignancy, and postoperative clinical course were recorded. Immunohistochemistry for biliary or gastrointestinal markers was performed to characterize cell phenotypes. The patients with hepatic mucinous cystic neoplasm were all female and ranged in age from 21 to 67 years, which was significantly younger than that in the patients with biliary intraductal papillary neoplasm. Eighteen mucinous cystic neoplasms (76%) were located in the left lobe, with 13 (54%) in segment IV. Mucinous cystic neoplasms were significantly larger than intraductal papillary neoplasms (median diameter: 110 vs 50 mm, P=0.008). In contrast to intraductal papillary neoplasms that were all histologically malignant, 26 mucinous cystic neoplasms (90%) were adenomas, 2 (7%) were borderline malignant, and 1 (3%) was a carcinoma in situ. Benign mucinous cystadenomas had the pure biliary immunophenotype, whereas gastrointestinal markers including cytokeratin 20 and mucin core proteins 2, 5AC, and 6 were more frequently expressed in borderline or malignant mucinous cystic neoplasms and biliary intraductal papillary neoplasms. There was no mortality in the patients with mucinous cystic neoplasm, whereas one patient with intraductal papillary neoplasm died of cancer. In conclusion, hepatic mucinous cystic neoplasms and biliary intraductal papillary neoplasms have different clinicopathological characteristics as evidenced by differences in the age and gender of patients, macroscopic appearance, immunophenotypes, and grades of malignancy.