Serum and cystic fluid CA 19-9 determinations as a diagnostic help in liver cysts of uncertain nature

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.

Mucin-producing hepatic cystic neoplasms: an uncommon but challenging disease often misdiagnosed and mismanaged

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant.Methods: Nine MHCN were encountered in our centre for over 32 years. Patients' clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification).Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1-132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free.Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable.

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

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

Clinicopathological features and post-resection outcomes of biliary cystadenoma and cystadenocarcinoma of the liver

Backgrounds/Aims

Biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC) account for 5%-10% of liver cystic diseases. In this study, we analysed the clinical presentation and surgical management of patients with BCA and BCAC.

Methods

We retrospectively analysed the medical records of 23 BCA and 7 BCAC cases diagnosed between January 2007 and December 2013.

Results

There was a statistically significant difference in age (p=0.044) and sex (p=0.048) between BCA and BCAC groups. In the BCA group, 17 patients showed no symptoms (74%), 5 had abdominal pain (22%) and 1 showed abdominal distension (4%). In the BCAC group, two patients were without any symptoms (29%), three had abdominal pain (43%), one showed abdominal distension (14%) and one had fever and chills (14%). The cystic lesion size was widely variable; thus, there was no statistical difference (p=0.84). Complete resection was performed in all patients with BCA and BCAC. No tumour recurrence developed in patients with BCA. In patients with BCAC, 1-, 3- and 5-year disease-free survival rates were 100%, 85.7% and 57.1%, respectively, and 1-, 3- and 5-year overall patient survival rates were 100%, 100% and 75.0%, respectively.

Conclusions

It is difficult to distinguish between BCA and BCAC via clinical manifestations and diagnostic imaging findings. Surgical resection is the treatment of choice for BCA and BCAC, and patient prognosis after complete resection was very favourable.

Hepatic Intracystic Organizing Hematoma Mimicking Biliary Cystadenocarcinoma in a Patient with Polycystic Liver Disease

Hepatic intracystic hemorrhage is a rare complication of polycystic liver diseases, such as autosomal dominant polycystic kidney disease (ADPKD). A hepatic cyst with mural nodules and septation may suggest the presence of a cystic malignancy, such as biliary cystadenocarcinoma. We herein report a case of hepatic intracystic hematoma with a mural nodule mimicking biliary cystadenocarcinoma in a patient with ADPKD. Hepatic intracystic hemorrhage with a mural nodule is a very rare occurrence. A fat-saturated T1-weighted magnetic resonance image may be useful for making an accurate diagnosis of intracystic hematoma.

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.

Preoperative differential diagnosis between intrahepatic biliary cystadenoma and cystadenocarcinoma: A single-center experience

AIM: To investigate preoperative differential diagnoses made between intrahepatic biliary cystadenoma and intrahepatic biliary cystadenocarcinoma.

METHODS: A retrospective analysis of patient data was performed, which included 21 cases of intrahepatic biliary cystadenoma and 25 cases of intrahepatic biliary cystadenocarcinoma diagnosed between April 2003 and April 2013 at the General Hospital of PLA. Potential patients were excluded whose diagnoses were not confirmed pathologically. Basic information (including patient age and gender), clinical manifestation, duration of symptoms, serum assay results (including tumor markers and the results of liver function tests), radiological features and pathological results were collected. All patients were followed up.

RESULTS: Preoperative levels of cancer antigen 125 (12.51 ± 9.31 vs 23.20 ± 21.86, P < 0.05) and carbohydrate antigen 19-9 (22.56 ± 26.30 vs 72.55 ± 115.99, P < 0.05) were higher in the cystadenocarcinoma subgroup than in the cystadenoma subgroup. There were no statistically significant differences in age or gender between the two groups, or in pre- or post-operative levels of alanine aminotransferase, aspartate aminotransferase, total bilirubin (TBIL), and direct bilirubin (DBIL) between the two groups. However, eight of the 21 patients with cystadenoma and six of the 25 patients with cystadenocarcinoma had elevated levels of TBIL and DBIL. There were three cases in the cystadenoma subgroup and six cases in the cystadenocarcinoma subgroup with postoperative complications.

CONCLUSION: Preoperative differential diagnosis relies on the integration of information, including clinical symptoms, laboratory findings and imaging results.

An intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst: a case report

An intraductal papillary neoplasm of the bile duct is a biliary, epithelium-lined, cystic lesion that exhibits papillary proliferation and rarely causes large hemorrhagic cystic lesions. Here, we report a case of an intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst in a middle-aged man with large hemorrhagic hepatic cysts who experienced abdominal pain and repeated episodes of intracystic bleeding. Following portal vein embolization, extended right hepatic lobectomy was performed, and intraoperative cholangiography revealed communication between the intracystic space and the hepatic duct. Although histological studies revealed that the large hemorrhagic lesion was not lined with epithelium, the surrounding multilocular lesions contained biliary-derived epithelial cells that presented as papillary growths without ovarian-like stroma. A diagnosis of oncocytic-type intraductal papillary neoplasm of the bile duct was made, and we hypothesized that intracystic bleeding with denudation of the lining epithelial cells might occur as the cystically dilated bile duct increased in size. Differential diagnosis between a hemorrhagic cyst and a cyst-forming intraductal papillary neoplasm of the bile duct with bleeding is difficult. However, an intraductal papillary neoplasm of the bile duct could manifest as multilocular hemorrhagic lesions; therefore, complete resection should be performed for a better prognosis.

Hemorrhagic hepatic cyst: report of a case and review of the literature with emphasis on clinical approach and management

OBJECTIVE

Hemorrhage within a hepatic cyst (hemorrhagic hepatic cyst, HHC) is a complication of liver cysts that is difficult to differentiate from other neoplastic entities on imaging. Even when accurately diagnosed, there has been a lack of consensus on the optimal treatment strategy. After presenting our experience with a patient treated via laparoscopy, we aimed to conduct a review of the literature on HHCs.

METHODS

A computerized search in Medline, PubMed, Google Scholar, and The Cochrane Collaboration was carried out for journal articles or abstracts published from 1950 to 2011.

RESULTS

A total of 24 patients with HHCs were identified from 1983 to 2011. The cohort had an even gender distribution with a mean age of 62.7 years. Most patients presented with abdominal pain (80 %), while three (14 %) patients were asymptomatic at the time of presentation. CT imaging and ultrasound were unable to accurately diagnose HHC, whereas hyperintensity on MRI was a reliable diagnostic tool. Three (13 %) patients were managed conservatively with observation. Seven (30 %) patients had percutaneous transhepatic drainage. Among these, two patients experienced recurrence that required repeat treatment. Two (9 %) patients underwent open unroofing of their HHC and one (4 %) laparoscopically, without recurrences. Seven (30 %) patients underwent hepatic resection, whereas six (26 %) patients had a cyst enucleation for their HHCs. All patients had uneventful recoveries, with a mean follow-up of 25 months.

CONCLUSIONS

MRI is a reliable diagnostic tool in the setting of an HHC. Laparoscopic unroofing of HHCs may represent a less morbid and safe treatment modality with low recurrence rates. Given the low level of clinical evidence available so far, these results should be interpreted with caution.

[Benign non-parasitic hepatic cystic tumours]

Hepatic cystic tumours are a heterogeneous group of diseases with different aetiology and incidence, and with similar clinical signs and symptoms. They are classified as congenital, traumatic, parasitic, or neoplastic cysts. The congenital cystic tumours are the most prevalent, and include the simple cyst and polycystic hepatic disease. Other less common lesions are, hepatic cystadenoma, ciliated embryonic cyst, and a miscellaneous group. We have carried out a review of all benign non-parasitic hepatic cystic tumours, placing special emphasis on therapeutic strategies.

Biologic and clinical features of benign solid and cystic lesions of the liver

The widespread use of imaging analyses, either routinely or to evaluate symptomatic patients, has increased the detection of liver lesions (tumors and cysts) in otherwise healthy individuals. Although some of these incidentally discovered masses are malignant, most are benign and must be included in the differential diagnosis. The management of benign hepatic tumors ranges from conservative to aggressive, depending on the nature of the lesions. New imaging modalities, increased experience of radiologists, improved definition of radiologic characteristics, and a better understanding of the clinical features of these lesions have increased the accuracy of diagnoses and reduced the need for invasive diagnostic tests. These advances have led to constant adjustments in management approaches to benign hepatic lesions. We review the biologic and clinical features of some common hepatic lesions, to guide diagnosis and management strategies.

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.

Hemorrhagic hepatic cysts mimicking biliary cystadenoma

The hemorrhagic simple hepatic cyst is extremely rare and can sometimes be confused with biliary cystadenoma or cystadenocarcinoma. Here we present two cases of huge hemorrhagic simple hepatic cysts. Case 1 was a 43-year-old man with a cystic lesion measuring 13 cm × 12 cm in the right hepatic lobe. Ultrasound and computed tomography showed several mural nodules on the irregularly thickened wall and high-density straps inside the cyst. Case 2 was a 60-year-old woman with a huge cyst measuring 15 cm × 14 cm in the central liver. Ultrasound and magnetic resonance imaging showed the cystic wall was unevenly thickened and there were some flame-like prominences on the wall. The iconographic representations of the two cases mimicked biliary cystadenoma. Cystectomy and left hepatectomy were performed for the two patients, respectively. Both patients recovered quickly after their operations and showed no recurrence.

A simple hepatic cyst with elevated serum and cyst fluid CA19-9 levels: a case report

Introduction

Simple hepatic cysts rarely cause symptoms, however, occasionally they become symptomatic due to mass effect, rupture, hemorrhage, and infection. We report a patient with a large hepatic cyst with elevated serum and cyst fluid CA19-9 levels. We studied serum and cyst fluid CA19-9 levels in this patient, before and after the intracystic instillation of minocycline hydrochloride.

Case presentation

A 76-year-old Japanese woman was diagnosed as having an infected hepatic cyst, by physical examination and enhanced abdominal computed tomography. Serum (170 U/ml; reference: < 37 U/ml) and hepatic cyst fluid (371 U/ml) CA19-9 levels were elevated. After the intracystic instillation of minocycline hydrochloride, necrotic cells in the cyst were drained, and it totally collapsed after 1 week. Cyst fluid CA19-9 levels increased remarkably after the intracystic instillation of minocycline hydrochloride, while serum CA19-9 levels decreased significantly.

Conclusion

Our study is the first report to reveal the influence of intracystic instillation of minocycline hydrochloride on serum and cyst fluid CA19-9 levels in a patient with a simple hepatic cyst.

Cystic tumors of the liver: a practical approach

Biliary cyst tumors (cystadenoma and cystadeno-carcinoma) are an indication for liver resection. They account for only 5% of all solitary cystic lesions of the liver, but differential diagnosis with multiloculated or complicated biliary cysts, atypical hemangiomas, hamartomas and lymphangiomas may be difficult. The most frequent challenge is to differentiate biliary cyst tumors from hemorrhagic cysts. Computerized tomography (CT) and magnetic resonance imaging (MRI) are often not diagnostic and in these cases fine needle aspiration (FNA) is used to confirm the presence of atypical biliary cells. FNA, however, lacks adequate sensitivity and specificity and should always be used in conjunction with imaging. Pre-operative differentiation of cystadenoma from cystadenocarcinoma is impossible and surgery must be performed if a biliary cyst tumor is suspected. When multiple cystic lesions are observed throughout the liver parenchyma, it is important to exclude liver metastasis, of which colonic cancer is the most common primary site. Multiple biliary hamartomas (von Meyenburg complex) can appear as a mixture of solid and cystic lesions and can be confused with cystic metastasis. Strong and uniform T2 hyperintensity on MRI is usually diagnostic, but occasionally a percutaneous biopsy may be required.

Cystadenocarcinoma of the gallbladder

Biliary cystadenocarcinomas are a very rare set of neoplasms that occur in the liver, the extrahepatic bile duct system, and occasionally in the gallbladder. We report on a 75-year-old man with a cystadenocarcinoma of the gallbladder who presented with mild abdominal discomfort and a palpable mass in the right upper abdomen. The diagnostic workup included ultrasound, magnetic resonance tomography, and fine needle core biopsy and revealed a multicystic tumor 16 cm in diameter. The patient underwent multivisceral resection of the tumor with a resection of the right colon, a partial resection of the stomach and the liver, and a lymph node dissection. The resected specimen weighed 2500 g and the final histopatholical diagnosis was a primary, moderately differentiated cystadenocarcinoma of the gallbladder with two lymph node metastases and invasion of the right colon. The patient remains without evidence of recurrence 12 months after surgery. The clinical presentation, diagnosis, therapeutic options, and classification of hepatobiliary cystadenocarcinomas are discussed.

Successful aspiration and ethanol sclerosis of a large, symptomatic, simple liver cyst: Case presentation and review of the literature

Simple liver cysts are congenital with a prevalence of 2.5%-4.25%. Imaging, whether by US, CT or MRI, is accurate in distinguishing simple cysts from other etiologies, including parasitic, neoplastic, duct-related, and traumatic cysts. Symptomatic simple liver cysts are rare, and the true frequency of symptoms is not known. Symptomatic simple liver cysts are predominantly large (> 4 cm), right-sided, and more common in women and older patients. The vast majority of simple hepatic cysts require no treatment or follow-up, though large cysts (> 4 cm) may be followed initially with serial imaging to ensure stability. Attribution of symptoms to a large simple cyst should be undertaken with caution, after alternative diagnoses have been excluded. Aspiration may be performed to test whether symptoms are due to the cyst; however, cyst recurrence should be expected. Limited experience with both laparoscopic deroofing and aspiration, followed by instillation of a sclerosing agent has demonstrated promising results for the treatment of symptomatic cysts. Here, we describe a patient with a large, symptomatic, simple liver cyst who experienced complete resolution of symptoms following cyst drainage and alcohol ablation, and we present a comprehensive review of the literature.

Spontaneous rupture of non-parasitic hepatic cyst

Intrahepatic cysts are generally classified as congenital, traumatic, infectious or neoplastic. Non-parasitic hepatic cysts (NPHCs) include simple cysts and adult polycystic liver disease in which the liver is diffusely occupied by cysts. NPHCs usually reach a large size before causing symptoms, unless a complication such as rupture, bleeding, infection, obstructive jaundice or neoplastic transformation occurs. We report the case of a 67-year-old man with spontaneous rupture of simple liver cyst. The clinical pictures and the unusual ultrasound features of this rare condition are discussed.

Adenocarcinoma and infection in a solitary hepatic cyst: A case report

Solitary non-parasitic liver cysts are being increasingly diagnosed due to the increased use of abdominal sonography. The majority of solitary liver cysts are asymptomatic; however, there are some complications which include infection, perforation, spontaneous hemorrhage, obstructive jaundice and neoplastic degeneration. In some cases a cystic liver lesion may mimic a tumor and is difficult to differentiate with standard imaging studies or fine needle aspiration cytology. Here in, we report a case of adenocarcinoma arising in a solitary hepatic cyst complicated with Klebsiella pneumoniae infection. High levels of CEA in the cyst fluid levels suggested malignancy, which was confirmed by pathology of the resected specimen.

Supra-elevated CA 19-9 in a benign hepatic cyst adenoma

BACKGROUND

Elevated CA 19-9 may be found in both cystadenomas and cystadenocarcinomas of the liver.

CASE OUTLINE

A 59-year-old woman presented with right upper quadrant abdominal pain, malaise and weight loss. Physical examination and laboratory evaluation revealed a mass in the right upper quadrant and a CA 19-9 level of 68 661 U/ml. CT scan demonstrated a cystic liver mass. She underwent a right hepatectomy, and her CA 19-9 returned to normal. Pathologic analysis revealed no malignancy.

DISCUSSION

In hepatic cystic neoplasms, an elevated CA 19-9 should not be used to establish the diagnosis of malignancy nor should it preclude resection.

Laparoscopic management of benign liver diseases: where are we?

The role of laparoscopic surgery in the management of benign cystic and solid liver tumours appears to differ according to each tumour type. As regards congenital liver cysts, laparoscopic treatment is now the gold standard for treating selected, huge, accessible, highly symptomatic or complicated cysts. In contrast, the laparoscopic approach is not useful for patients suffering from adult polycystic liver disease (PLD), except for type I PLD with large multiple hepatic cysts. For benign hepatocellular tumours, the surgical management has recently benefited from a better knowledge of the natural history of each type of tumour and from the improvement of imaging techniques in assuring a precise diagnosis of tumour nature. Thus the general tendency has led to a progressive restriction and tailoring of indications for resection in benign liver tumours, selecting only patients with huge, specifically symptomatic or compressive benign tumours or patients suffering from liver cell adenoma. Despite the enthusiastic use of the laparoscopic approach, selective indications for resection of benign liver tumours should indeed remain unchanged. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. Deep, centrally located lesions or tumours in contact with major vascular or biliary trunks are not ideal candidates for laparoscopic liver resections. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resections and is accompanied by the usual postoperative benefits of laparoscopic surgery. When applied in selected patients and tumours, laparoscopic management of benign liver diseases appears to be a promising technique for hepatobiliary surgeons.

Fine needle aspiration cytology of hepatobiliary cystadenoma with mesenchymal stroma

BACKGROUND

Hepatobiliary cystadenomas (HBCs) with mesenchymal stroma (MS) are rare cystic neoplasms occurring exclusively in women. Hepatobiliary cystadenoma consists of a mucin-producing cyst lining epithelium underlined by a dense MS cell layer. In the current study, the authors review the fine needle aspiration cytology of HBC with MS and identify characteristic cytologic features that suggest such an uncommon neoplasm on aspirates.

METHODS

A search of the histopathology files at the University of Texas Medical Branch at Galveston for the interval of January 1992 through December 2000 yielded four cases of HBC having both cytologic and histologic specimens. The cytologic features of the aspirates were reviewed and correlated with the clinical history, radiologic findings, and the histopathology of the excised specimens.

RESULTS

All four patients were middle-aged women (mean age, 48.5 years) who presented with epigastric pain radiating to the back, due to large cystic lesions in the right liver lobe (three patients) or the left liver lobe (one patient). Aspiration cytology revealed chronic inflammatory exudate in all cases, along with occasional aggregates of bland, cuboidal-columnar epithelial cells (in three cases), which rarely arranged in papillary clusters. No significant atypia, evidence of malignancy, or MS cells were identified on the aspirates. HBC with MS was confirmed histologically on the excised specimens in all cases.

CONCLUSIONS

By ensuring adequate sampling and correlating with consistent clinical and radiologic findings, a diagnosis of HBC or cystic hepatobiliary neoplasm can be suggested on the basis of aspiration cytology.

The surgical management of congenital liver cysts

BACKGROUND

Most series that report the results of surgical treatment for congenital liver cysts focus more on the technical aspects of the operation than on the late outcome of these patients. In this paper, we emphasize the importance of appropriate patient selection and adequate surgical technique for successful long-term outcome.

METHODS

Twenty-four consecutive patients with congenital liver cysts were selected for surgical treatment. According to our own classification, 13 patients had simple liver cysts, nine had multicystic liver disease, and two had type I polycystic liver disease. All of these patients were treated by the fenestration technique. An open approach was used for five patients (group 1) treated between 1984 and 1990. In 19 patients (group 2) treated since 1991, a laparoscopic approach was used. The incidence of complicated liver cysts was 40% in group 1 and 68% in group 2.

RESULTS

There were no treatment-related deaths in this series. The mean postoperative hospital stay was significantly shorter for patients who underwent successful laparoscopic fenestration (p < 0.05). In the open group (group 1), there were no postoperative complications, and all patients were alive and free of symptoms during a mean follow-up of 130 months, without any sign of cyst recurrence. In the laparoscopic group (group 2), four patients were converted to open surgery. One of these patients had an inaccessible posterior cyst; another had bile within the cystic cavity. A further two cases had complicated liver cysts with an uncertain diagnosis between congenital and neoplastic cysts. Four patients (21%) developed peri- or postoperative complications. During a mean follow-up time of 38.5 months, none of the patients with simple liver cysts incurred late symptoms or signs of cyst recurrence. In the six patients with multicystic liver disease, one developed disease-related cyst progression (17%) and required reoperation. One of the two patients with type I polycystic liver disease (50%) developed asymptomatic disease-related cyst progression.

CONCLUSIONS

When patients are carefully selected and a proper surgical technique is employed, excellent long-term results with a low morbidity rate can be achieved in patients with congenital liver cysts. Patients with multicystic liver disease or type I polycystic liver disease are more prone to late cyst recurrence. A tailored approach is thus indicated for patients with congenital liver cystic disease. However, the laparoscopic approach appears to be the gold standard for the treatment of highly symptomatic or complicated simple liver cysts.

Cystadenoma of the liver without mesenchymal stroma in a female following hormonal therapy for acne

BACKGROUND

Liver cystadenomas are relatively rare tumours that can be difficult to diagnose; treatment entails complete surgical extirpation either by either anatomical resection or enucleation.

CASE OUTLINE

A 19-year-old woman presented with acute onset of abdominal pain and was found to have a multilocular giant liver cyst.The cyst was percutaneously drained; CEA and CA 19-9 tumour markers were elevated in this cyst fluid: CEA 96 microg/L, CAI9-9 37 550 kU/L. The cyst was completely enucleated and has not recurred. Pathological examination confirmed a cystadenoma without mesenchymal stroma, and tumour oestrogen and progesterone receptors were negative.

DISCUSSION

This is the fourth report of a liver cystadenoma without mesenchymal stroma in a female and the first to document elevated cyst fluid tumour markers. This case also illustrates the possible relationship between hormonal therapy and tumour growth.

Ciliated hepatic foregut cyst mimicking neoplasm

We describe a ciliated hepatic foregut cyst that was clinically considered neoplastic because it was large, bilocular, and associated with a high serological level of carbohydrate antigen 19-9 (CA 19-9). Histologically, the wall of the cyst showed characteristic pseudopapillae lined by ciliated stratified columnar epithelium with interspersed goblet cells and underlying smooth muscle. The epithelium was strongly immunoreactive for CA 19-9. We therefore conclude that large size, multilocularity, and elevated CA 19-9 do not exclude ciliated hepatic foregut cysts from diagnostic consideration.