Double Trouble: A Rare Case of Concurrent Biliary Adenofibroma and Hepatobiliary Mucinous Cystic Neoplasm

Biliary Adenofibroma and the Threat of Malignant Transformation

Biliary adenofibroma (BAF) is a rare hepatic tumor with a high risk for malignant transformation. Since BAF shares many characteristics with other hepatic lesions, diagnosis usually requires meticulous evaluation. The literature review revealed 29 reported patients of BAF, with malignant transformation occurring in 45% of patients. High Ki-67 (>40%) and mutated/overexpressed p53 staining were associated with malignancy, but some patients also had malignant features with low Ki-67 (≤10%) and wild-type p53. We report an elderly female patient who was initially diagnosed with benign liver hemangioma based on an abdominal ultrasound. The mass enlarged by 4 cm raising concerns about potential complications, including hemorrhage, which led to hepatic segmental resection. Histopathological examination revealed predominantly BAF features with focal areas that showed malignant cholangiocarcinoma characteristics.

Imaging features of biliary adenofibroma of the liver with malignant transformation: a case report with literature review

Background

Biliary adenofibroma (BAF) is a rare primary hepatic tumor with the potential risk of malignant transformation. Given the extreme rarity of the disease, the imaging features of BAF are unclear. We presented a case of malignant BAF and conducted a systematic literature review. We highlighted the key imaging features in the diagnosis and aggressiveness assessment of BAF, as well as the role of various imaging modalities in evaluating BAF.

Case presentation

We reported a 64-year-old woman with a 5-months history of pain in the right upper quadrant abdomen. US of the liver showed a hypoechoic subcapsular nodule. CT scan revealed a subcapsular solid-cystic mass in segment V of the liver. The mass showed a marked enhancement in the arterial phase followed by wash-out in the venous phase. The patient underwent partial resection of liver’s right lobe. The mass was diagnosed as BAF with malignant transformation by postoperative pathology.

Conclusions

CT and MRI are helpful in recognizing and characterizing BAF. The imaging features of BAF include a solitary, large solid-cystic mass with a well-defined margin, lobulated shape, and internal septa; subcapsular location; no intrahepatic bile duct communication; the presence of von Meyenberg complexes in background liver. The enhancement patterns may have the potential to assess the aggressiveness of BAF, and that marked enhancement in the arterial phase followed by wash-out in the venous phase is suggestive of malignant BAF.

Imaging presentation of biliary adenofibroma: A case report

BACKGROUND

Biliary adenofibroma (BF) is a rare benign epithelial tumor with the possibility of malignant transformation. Its main pathological feature is a well-defined cystic or honeycomb mass. BF has no specific clinical manifestations or laboratory and imaging findings; thus, it is easily misdiagnosed before surgery. This report describes a case in which biliary cystadenoma was misdiagnosed preoperatively and BF was diagnosed postoperatively. The imaging features, particularly the magnetic resonance imaging (MRI) features, were analyzed and summarized.

CASE SUMMARY

A 68-year-old Chinese man was admitted to our hospital with a 2-mo history of abdominal discomfort. Following admission to our hospital, laboratory examinations showed normal tumor marker concentrations and liver function. Hepatocellular carcinoma was considered after contrast-enhanced ultrasound examination. MRI suggested the possibility of cystadenoma of the bile duct. However, postoperative pathological examination confirmed the diagnosis of BF. No local recurrence was found 1 mo after surgery.

CONCLUSION

Our objective is to highlight the imaging diagnostic value of BF, especially on an MRI enhanced scan with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid.

Robotic enucleation of a biliary adenofibroma

A 69-year-old man was referred to the hepatobiliary surgeons for mild enlargement of an asymptomatic cystic liver lesion found on routine screening in 2017 that measured 3.7×3.6×4.3 cm. Work-up with MRI revealed a complex multilocular cyst that had enlarged to 6.6×5.5×4.6 cm. Other work-up was unremarkable. He had a Eastern Cooperative Oncology Group score of 1; therefore, a surgical excision was planned due to the possibility for malignancy. A robotic approach with enucleation of the lesion was undertaken, with plans for return for a wider resection if pathological examination revealed malignancy. The lesion was noted to be a biliary adenofibroma, an exceptionally rare lesion that is thought to be benign, but requires excision due to potential malignant degeneration. The patient was discharged home the following day and has had minimal pain in his postoperative course.

Magnetic Resonance Imaging Findings of Biliary Adenofibroma

Biliary adenofibroma is a rare tumor with a bile duct origin characterized by a complex tubulocystic non-mucin secreting biliary epithelium with abundant fibrous stroma. The MRI features of biliary adenofibroma are not well established. The authors encountered two patients with biliary adenofibroma and reviewed the literature focusing on the MRI findings. A well-circumscribed multicystic tumor with septal enhancement and no intrahepatic bile duct communication may be the characteristic MRI findings of biliary adenofibroma.

A case of biliary adenofibroma of the liver with malignant transformation: a morphomolecular case report and review of the literature

Background

Biliary adenofibroma is an exceptionally rare benign liver tumor with the potential for malignant transformation. In literature, only 21 cases have been described.

Clinical presentation

In a healthy 63-year-old woman, a partly solid, partly cystic mass in the left lobe of the liver during a routine ultrasound examination was found. The computed tomography (CT) scan of the abdomen showed a 6.3 × 5.0-cm multilobulated cystic, partly hypervascularized mass in the liver segment IVa, with extension into segments II and IVb. There was no evidence of lymph node or distant metastases. Extirpation of the tumor was indicated by the multidisciplinary tumorboard. Microscopic examination showed a biphasic composed tumor with tubules embedded in fibrous stroma. In addition, there were also areas with pseudopapillary projections, as well as parts with focal cribriform-like growth pattern, which have been indicated as a possible sign of malignant transformation. Additionally, we found two different polymorphisms in the encoded TP53 und KIT in both distinct morphology tumor areas by molecular analysis, which ensured a tumor in malignant transformation. The patient has been alive for 24 months after R0 resection without tumor recurrence. Further investigation of more cases of this rare entity is necessary to proof molecular genesis.

Conclusions

We report a rare case of a biliary adenofibroma with transition to an intrahepatic cholangiocellular carcinoma and present a brief literature review.