Evaluation of hepatic cystic lesions

Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions

Over the past 20 years, contrast-enhanced ultrasound (CEUS) has become established as a procedure that is complementary to B-mode ultrasound and color Doppler sonography.The aim of this review is to provide the fundamental knowledge required for examining the liver with CEUS. Additionally, the characteristic CEUS patterns of frequent focal liver lesions are described.Considering the limitations of ultrasound, CEUS offers an equivalent alternative to other imaging modalities, such as computed tomography and magnetic resonance imaging, for evaluating focal liver lesions. It should be utilized as a primary modality due to its lack of radiation exposure and rapid availability. KEY POINTS::   · CEUS plays an important role particularly in the detection and evaluation of incidentally detected liver lesions.. · Considering the limitations of ultrasound, CEUS offers an equivalent alternative to other imaging modalities, such as CT and MRI, for evaluating focal liver lesions.. CITATION FORMAT: · Safai Zadeh E, Prosch H, Ba-Ssalamah A et al. Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions. Fortschr Röntgenstr 2024; DOI: 10.1055/a-2219-4726.

Giant complex hepatic cyst causing pseudocystitis: A case report

BACKGROUND

Hepatic cysts are common benign liver tumors that are typically asymptomatic. However, larger cysts, particularly giant liver cysts, can potentially induce symptoms. If the diameter of the cyst exceeds 10 cm, it can exert pressure on adjacent organs, leading to manifestations of corresponding symptoms. Here, we report the case of a complex giant hepatic cyst that caused pseudocystitis.

CASE SUMMARY

A 16-year-old girl was admitted to our hospital with frequent and urgent urination. Ultrasonography revealed no obvious uterine adnexal abnormalities but showed a hypoechoic, cystic mass (173 mm × 84 mm × 138 mm) with clear boundaries, and an unclear blood flow signal in the abdominal cavity (extending from the lower edge of the left lobe of liver to the upper edge of the bladder). Abdominal contrast-enhanced computed tomography revealed a giant cystic mass in the abdominal and pelvic cavities, possibly originating from the liver, and a small amount of free fluid in the pelvic cavity, which subsequent magnetic resonance imaging confirmed. The imaging characteristics were consistent with a benign lesion. The patient underwent laparoscopic resection of the giant liver cyst with partial liver resection. Post-surgery her symptoms urinary symptoms were relieved completely and she was discharged on the sixth postoperative day.

CONCLUSION

Our patient presented with symptoms suggestive of pseudocystitis, stressing the need for considering possibilities of other etiologies and differential diagnoses.

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.

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.

Deep Learning Algorithm for Differentiating Patients with a Healthy Liver from Patients with Liver Lesions Based on MR Images

The problems in diagnosing the state of a vital organ such as the liver are complex and remain unresolved. These problems are underscored by frequently published studies on this issue. At the same time, demand for imaging diagnostics, preferably using a method that can detect the disease at the earliest possible stage, is constantly increasing. In this paper, we present liver diseases in the context of diagnosis, diagnostic problems, and possible elimination. We discuss the dataset and methods and present the stages of the pipeline we developed, leading to multiclass segmentation of the liver in multiparametric MR image into lesions and normal tissue. Finally, based on the processing results, each case is classified as either a healthy liver or a liver with lesions. For the training set, the AUC ROC is 0.925 (standard error 0.013 and a p-value less than 0.001), and for the test set, the AUC ROC is 0.852 (standard error 0.039 and a p-value less than 0.001). Further refinements to the proposed pipeline are also discussed. The proposed approach could be used in the detection of focal lesions in the liver and the description of liver tumors. Practical application of the developed multi-class segmentation method represents a key step toward standardizing the medical evaluation of focal lesions in the liver.

Primary hepatic myopericytoma coexisting with multiple cystic hepatic lesions: a case report

BACKGROUND

Hepatic myopericytoma (MPC) is an extremely rare pathological entity in the liver. Conversely, cystic hepatic lesions are a group of heterogeneous lesions encountered commonly in daily practice. Here, we report a unique case of the coexistence of primary hepatic MPC and multiple cystic hepatic lesions along with our perceptions on its diagnosis and treatment.

CASE PRESENTATION

A 56-year-old female patient was found to have a left liver mass during a routine physical examination. Computer tomography (CT) and magnetic resonance imaging (MRI) confirmed the existence of a left hepatic neoplasm along with multiple hepatic cysts but could not exclude the possible malignant nature of the neoplasm. Computer tomography (CT) also identified an enlarged mediastinal lymph node with a maximum diameter of 4.3 cm, which further underwent core needle biopsy under CT guidance. A histopathological examination was performed to rule out malignancy. Afterwards, the patient underwent left hemihepatectomy to resect a solid tumor of 5.5 cm × 5 cm × 4.7 cm with multiple cystic lesions which were histopathologically examined to establish the diagnosis of myopericytoma with hepatic cysts. Postoperatively, the patient recovered from the surgery quickly without significant adverse events and was not found to have a reoccurrence of the primary pathological entity.

CONCLUSIONS

This is the first reported case of a patient with the co-existence of primary hepatic myopericytoma and multiple cystic hepatic lesions undergoing surgical treatment with eventual recovery.

Hepatic Cyst Infection Following Recurrent Biliary Obstruction in Polycystic Liver Disease

An 89-year-old man with polycystic liver disease (PCLD) received uncovered self-expandable metallic stent (SEMS) placement above the papilla for malignant biliary obstruction caused by cholangiocarcinoma. He developed cholangitis ten months later due to SEMS occlusion caused by tumor ingrowth, and 2 plastic biliary stents were placed inside the SEMS across the papilla. Fever and right costal pain appeared two weeks after reintervention. Suspecting hepatic cyst infection based on imaging studies, percutaneous transhepatic cyst drainage was performed. Increased inflammatory cells and the presence of pathogens in the cyst fluid led to a definitive diagnosis of hepatic cyst infection. Following drainage, the hepatic cyst shrank with resolution of the symptoms. SEMS occlusive-related cholangitis or retrograde infection due to duodenal-biliary reflux after reintervention was considered as the cause of the hepatic cyst infection. Careful clinical and imaging evaluation should be performed in patients with PCLD undergone biliary stenting, because cyst infection may occur following stent occlusion or subsequent biliary reintervention.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Case report: Rare isolated cystic hepatic metastasis of a patient with squamous cell lung carcinoma history and the prognosis

Cystic hepatic metastasis of squamous cell carcinoma usually develops from necrosis due to insufficient blood supply, yet metastasis initially resembling simple liver cyst is rare. Here, we present a case of a patient with squamous cell lung carcinoma history who found an isolated cystic mass in the liver. Historical MR studies indicated that the mass did not exist 12 months ago and emerged as a small cystic lesion 7 months ago. Radiological findings and tumor markers level suggested metastasis, while 18F-Fluorodeoxyglucose (18F-FDG) PET/CT showed moderate tracer uptakes in solid parts of the mass. Pathological study after surgery confirmed metastatic squamous cell carcinoma. Chemotherapy plus recombinant human endostatin and sintilimab therapy was employed after surgery; however, the patient developed remote metastasis of osteolytic lesions in the humerus bone and thoracic vertebra. Our case indicates that metastasis should be taken into consideration in emerging cystic hepatic lesion with malignant history.

EASL Clinical Practice Guidelines on the management of cystic liver diseases

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

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.

Comparison of the Efficacy and Safety of Single-Session OK-432 and Multiple-Session 99% Ethanol Sclerotherapy for Symptomatic Simple Hepatic Cysts

Purpose

This retrospective study aimed to compare the efficacy and safety of single-session OK-432 and multiple-session 99% ethanol sclerotherapy for symptomatic simple hepatic cysts.

Methods

We reviewed patients who received aspiration sclerotherapy with OK-432 (group A) or 99% ethanol (group B) for symptomatic simple hepatic cysts at Guangdong Provincial People's Hospital from January 2013 to November 2019.

Results

We included 42 patients in group A and 39 patients in group B. No significant difference was found in the mean volume of hepatic cysts between the two groups. The overall success rates were 92.9% (39 of 42 patients) in group A and 79.5% (31 of 39 patients) in group B (P = 0.08). The treatment success for cyst volumes &lt;200 ml, 200–500 ml, and &gt;500 ml was 100, 93.3, and 88.2% in group A, and 100, 84.6, and 57.1% in group B, respectively. The symptomatic relief rate in group A was higher than that in group B for cysts ≥500 ml (P = 0.049) and cysts &lt;500 ml. For treatment-related complications, the incidence of pain at the injection site in group A was lower than that in group B.

Conclusion

Single-session OK-432 sclerotherapy was safer and more effective than multiple-session 99% ethanol sclerotherapy for treating large cysts, although both treatments had similar effects on small cysts.

Complete resection for a giant recurrent biliary cystadenoma: A surgical case report and review of literature

Background

Biliary cystadenoma is a rare cystic neoplasm of the liver. The clinical signs and symptoms are nonspecific, and treatment strategy is variable.

Case presentation

In this study, we presented a case of a 32-year-old female with multilocular biliary cystadenoma. The patient underwent partial removal of the hepatic cyst two times in two different hospitals for two years and that the histopathological results were biliary cystic adenoma but was successfully treated by radical resection after the second recurrence. The patient underwent a J-shaped laparotomy. The giant cystic mass measuring 20 cm × 15 cm was below the position of the right anterior segment. This lesion pushed the liver parenchyma to both sides and compressed the hepatic hilum, causing dilatation of the intrahepatic bile ducts. The patient underwent complete resection of cystic mass. During the dissection, a 0.5mm-diameter fistula of left hepatic duct with the cyst was found. It was sutured using absorbable polydioxanone (PDS 6.0) and the cystic duct tube (C tube) (6 Fr) was inserted via the cystic duct into the left hepatic duct due to drain the bile fluid.

Discussion

A biliary cystadenoma (BCA) primary origin is occasionally rare. Although imaging modalities such as ultrasound, computed tomography and magnetic resonance imaging could be suggestive, however, the definitive diagnosis is depended on the histological examination. Despite of being a benign tumor, it has a high risk of recurrence after conservative treatment. The potential risk for malignant is also present. Therefore, complete resection of the tumors is the treatment of choice.

Conclusion

We herein present a report of a rare case with had a giant biliary cystadenoma (BCA) primary origin. This report aims to improve the understanding of the diagnosis and management of this uncommon disease.

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A biliary cystadenoma (BCA) primary origin is occasionally rare, the clinical manifestations are variable and non-specific.

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BCA should be suspected when there is a multilocular and thick-walled cystic on liver imaging modalities.

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Histological examination and immunohistochemistry staining are considered as the gold standard.

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Radical surgery (enucleation or liver resection) must be still the most effective and major treatment approach.

Frequency of synchronous malignant liver lesions initially detected by ultrasound in patients with newly diagnosed underlying non-hematologic malignant disease: a retrospective study in 434 patients

INTRODUCTION

This study described the frequency of malignant synchronous focal liver lesions (FLLs) in patients with newly diagnosed non-hematologic malignant disease.

METHODS

From June 2013 to January 2017, 434 patients with synchronous FLLs and newly diagnosed underlying malignant disease were included in the study. The diagnosis of the FLLs was made by histology and/or contrast-enhanced imaging. The final medical report was used for analysis in the study.

RESULTS

Of the 434 liver lesions, 258 (59.4%) were malignant and 176 (40.6%) benign. All malignant lesions were metastases. The benign liver lesions were comprised of 93 cysts (21.4%), 52 hemangiomas (12.0%), 20 focal fatty sparing (4.6%), 4 focal nodular hyperplasia (0.9%), 3 unspecified benign lesions (0.7%), 2 regenerative nodules (0.5%), 1 calcification (0.2%), and 1 adenoma (0.2%). Diseases with the highest percentage frequency of synchronous malignant FLLs were cholangiocarcinoma with 86.7%, neuroendocrine tumor with 72.7%, and pancreatic carcinoma with 72.0%. Gastric carcinoma (33.3%), breast carcinoma (44.4%), and urothelial cell carcinoma (45.5%) were the diseases with the lowest percentage frequency of synchronous malignant FLLs.

CONCLUSION

In total, the frequency of malignant synchronous FLLs in newly diagnosed non-hematologic malignant disease was 59.4%. In particular, cholangiocarcinoma, neuroendocrine tumor, and pancreatic carcinoma were the diseases with the highest rate of synchronous malignant FLLs.

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.

Extensive solitary lymphatic malformation of the liver in a child: a case report and literature review

Intrabdominal lymphatic malformations are rare benign congenital vascular anomalies that account for less than 5% of benign masses in childhood, with an extremely variable clinical presentation. For this reason, although their radiological appearance is usually typical, diagnosis can be challenging and not always immediate. This report describes a unique case of extensive solitary hepatic lymphatic malformation in a 10-year-old boy with both extra- and intraparenchymal development with no associated symptoms. A literature review of reported cases of solitary hepatic lymphatic malformation is also included.

Efficiency of diffusion-weighted MRI for differentiating radiologically similar simple and type I hydatid cysts of the liver

BACKGROUND

Determining the nature of purely cystic hepatic lesions is essential because different kinds have different follow-ups, treatment options, and complications.

PURPOSE

To explore the potential of apparent diffusion coefficient (ADC) values of diffusion-weighted imaging (DWI) for the differentiation of type I hydatid cysts (HC) and simple liver cysts (SLC), which have similar radiological appearances.

MATERIAL AND METHODS

This single-center prospective study was conducted during 2016-2019. Round, homogenous, anechoic liver cysts >1 cm were classified according to at least two years of imaging follow-up, radiological features, serology, as well as puncture aspiration injection reaspiration procedure and pathology results. ADC values of 95 cysts (50 type I HCs and 45 SLCs) were calculated on DWI. The differences in ADC values were analyzed by independent t-test.

RESULTS

Of 51 patients, 28 were female, 23 were male (mean age 32.07 ± 22.95 years; age range 5-82 years). Mean diameter of 45 SLCs was 2.59 ± 1.23 cm (range 1.2-7.6 cm) and ADC_mean value was 3.03 ± 0.47 (range 2.64-5.85) while mean diameter of 50 type I HCs was 7.49 ± 2.95 cm (range 2.8-14 cm) and ADC_mean value was 2.99 ± 0.29 (range 2.36-3.83). There was no statistically significant difference in ADC values between type I HCs and SLCs.

CONCLUSION

Some studies report that ADC values of type I HCs are statistically significantly lower than those of SLCs. Others suggest no significant difference. In our study with a higher number of cases, using ADC parameters similar to those in previous studies, we did not find any statistically significant difference.

The Persistent Approach to Diagnose Infectious Hepatic Cysts in a Patient With Recurrent Fever: A Case Report

Diagnosing infectious hepatic cysts (IHCs) can be challenging. Moreover, patients with IHCs may present with various symptoms. Diagnosis of IHCs can be even more difficult in patients with multiple liver cysts. For appropriate diagnosis, the detection of infectious sections in the liver is essential. However, diagnosing and determining definite treatments for patients with IHCs can be particularly challenging when they have polycystic liver disease. We present a case of a 70-year-old man who visited a rural community hospital with a primary complaint of recurrent fever and pain in the right upper quadrant. Based on his clinical history, physical examination findings, and imaging findings after three admissions, he was diagnosed with IHCs. This case demonstrates the challenges in diagnosing IHCs in patients with multiple hepatic cysts and highlights the necessity of a careful follow-up of clinical histories and findings of definitive imaging tests in the diagnosis of IHCs in patients with recurrent fever. To diagnose IHCs effectively, a comprehensive approach including history taking, physical examination, and diagnostic testing, is essential. IHCs should be considered by physicians when patients present with recurrent fever. To avoid missing IHCs, physicians in outpatient departments should continuously follow up on patients’ IHC-related symptoms such as fever and right upper quadrant pain.

OUP accepted manuscript

Mucinous cystic neoplasms of the liver are uncommon cystic lesions of the liver, most commonly seen in women in the fifth decade of life. We present a case of a 16-year-old girl with an incidentally discovered abdominal mass while undergoing a tonsillectomy. Investigation revealed a multiloculated, septated 17 × 17 × 11 cm cystic lesion arising from the left lobe of the liver, with displacement of the remaining upper abdominal viscera. Serum Ca19.9 was significantly elevated at 2256 U/ml (range 0–37), but other bloods including liver function tests, alphafoetoprotein and carcinoembryonic antigen were within normal limits. We proceeded to open formal left hemi-hepatectomy. Histology was consistent with a diagnosis of mucinous cystic neoplasm with low-grade intra-epithelial neoplasia.

Radiologic Reporting of Simple Hepatic Cyst Versus Biliary Cystadenoma May Lead to Unnecessary Surgery

BACKGROUND AND AIMS

Simple liver cyst (SHC) is a benign condition with no malignant potential. They are typically discovered incidentally due to the increased use of abdominal imaging, but some patients may present with abdominal pain. A radiologist's differential diagnosis in cases of SHC will often include "rule out biliary cystadenoma." Under these circumstances, patients and surgeons are more likely to pursue surgical options even in asymptomatic cases. The aim of this study is to conduct a retrospective analysis of presentation, radiologic reporting, management plan, and histopathology of patients referred to a tertiary hospital in order to determine the correlation between radiology and histology.

METHODS

We retrospectively analyzed the clinical, radiological, and histopathological data of 20 patients operated for a diagnosis of a cystic lesion in the liver.

RESULT

The CT/MRI of 6 (30%) patients was reported as a biliary cystadenoma, 13 (65%) were reported as a simple hepatic cyst and 1 patient (5%) had hepatocellular carcinoma (HCC) with the additional diagnosis of multiple hepatic cysts. The lesion reported as HCC on the scan was separate from the cystic lesions. The modality of imaging for these cysts was evenly split, 50% of patients had a CT scan, and 50% had an MRI performed. All imaging studies were interpreted by an attending radiologist and most of them were discussed in multidisciplinary meetings. Nineteen patients (95%) had an intraoperative diagnosis of a simple liver cyst based on its visual appearance and clear fluid within the cyst. These patients underwent cyst wall fenestration and de-roofing with the cyst wall sent for histopathology. One patient (5%) with HCC underwent a non-anatomical liver resection. Histopathology was conclusive for a benign hepatic cystic lesion from the cyst wall biopsy. All 20 patients in this study underwent surgery, either due to symptoms or due to radiologic diagnosis of BCA. Four of the 20 cases (20%) were asymptomatic and out of these four cases, 3 (75%) were diagnosed as cystadenoma on the preoperative imaging studies. All 19 cases were diagnosed as a simple liver cyst on pathology.

CONCLUSION

In summary, there is a growing trend of "ruling-out the diagnosis of biliary cystadenoma" in patients who present with liver cysts. Patients are appropriately more anxious after this preoperative diagnosis and the treating surgeons have medico-legal concerns regarding conservative management in asymptomatic patients diagnosed as BCA. This single center experience draws attention to the radiology criteria utilized for diagnosing a biliary cystadenoma and suggests that it is time to revisit the imaging interpretation and differential diagnosis.

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.

Management of simple hepatic cyst

Simple hepatic cysts are typically saccular, thin-walled masses with fluid-filled epithelial lined cavities that arise from aberrant bile duct cells during embryonic development. With the development of diagnostic modalities such as ultrasonography, computed tomography and magnetic resonance imaging, simple hepatic cysts are seen with relative frequency in daily clinical examination. US is the most useful and noninvasive tool for the diagnosis of simple hepatic cysts, and can generally differentiate simple hepatic cysts from abscesses, hemangiomas and malignancies. Cysts with irregular walls, septations, calcifications or daughter cysts on US should be evaluated with enhanced CT or MRI to differentiate simple hepatic cysts from cystic neoplasms or hydatid cysts.Growth and compression of hepatic cysts cause abdominal discomfort, pain, distension and dietary symptoms such as nausea, vomiting, a feeling of fullness and early satiety. Complications of simple hepatic cysts include infection, spontaneous hemorrhage, rupture, and external compression of biliary tree or major vessels.Asymptomatic simple hepatic cysts should be observed. Treatment for symptomatic simple hepatic cysts includes percutaneous aspiration, aspiration followed by sclerotherapy, and surgery. The American College of Gastroenterology clinical guidelines recommend laparoscopic fenestration based on its high success rate and low invasiveness. Percutaneous procedures for treatment of simple hepatic cysts are particularly effective for the immediate palliation of patient symptoms; however, they are not generally recommended because of the high rate of recurrence.Management of simple hepatic cysts requires correct differentiation from neoplasms and infections, and the selection of a reliable treatment.

Estrogens in polycystic liver disease: A target for future therapies?

BACKGROUND AND AIMS

Patients suffering from polycystic liver disease (PLD) can develop large liver volumes, leading to physical and psychological complaints, reducing quality of life. There is an unmet need for new therapies in these patients. Estrogen seems to be a promising target for new therapies. In this review, we summarize the available experimental and epidemiological evidence to unravel the role of estrogens and other female hormones in PLD, to answer clinical questions and identify new targets for therapy.

METHODS

We identified all experimental and epidemiologial studies concerning estrogens or other female hormones and PLD, to answer pre-defined clinial questions.

RESULTS

Female sex is the most important risk factor for the presence and severity of disease; estrogen supplementation enhances liver growth and after menopause, liver growth decreases. Experimental studies show the presence of the estrogen receptors alfa and beta on cystic cholangiocytes, and increased in vitro growth after administration of estrogen.

CONCLUSIONS

Based on the available evidence, female PLD patients should be discouraged from taking estrogen-containing contraceptives or hormone replacement therapy. Since liver growth rates decline after menopause, treatment decisions should be based on measured liver growth in postmenopausal women. Finally, blockage of estrogen receptors or estrogen production is a promising target for new therapies.

Predicting liver cyst severity by mutations in patients with autosomal-dominant polycystic kidney disease

BACKGROUND

Most patients with autosomal-dominant polycystic kidney disease (ADPKD) develop liver cysts and polycystic liver disease as they age. To date, no simple clinical indicator has been confirmed to predict polycystic liver disease exacerbation. Furthermore, the effect of the type and location of mutation on disease progression of polycystic liver disease remains unclear. Here, we aimed to establish a simple liver cyst indicator for clinical practice and investigate whether gene mutations determined liver phenotype in patients with autosomal-dominant polycystic kidney disease.

METHODS

In total, 129 patients with ADPKD were enrolled and liver cyst indicators were assessed based on mutation type (truncating mutation: nonsense, frameshift, and splicing mutation; non-truncating mutation: substitution) and mutation position. Liver cyst severity was determined using Gigot and Drenth classifications, based on their number, maximum diameter, and area ratio with the liver.

RESULTS

We observed an overall prevalence of 62.8% for polycystic liver disease. Patients with PKD1 nonsense mutations, a type of PKD1 truncating mutation, exhibited more severe liver disease phenotypes than those without the mutation. We identified maximum diameter as a potential liver cyst indicator. Moreover, a subgroup analysis that included a PKD1 nonsense mutation cohort revealed that genetic mutations located closer to the 5' end of PKD1 were associated with a maximum diameter index value ≥ 6 cm.

CONCLUSION

PKD1 nonsense mutations were associated with liver cyst severity, which along with maximum diameter index as a simple clinical indicator for liver cysts, may improve the treatment of polycystic liver disease associated with ADPKD.

Differentiation and management of hepatobiliary mucinous cystic neoplasms: a single centre experience for 8 years

Background

Hepatobiliary mucinous cystic neoplasms (H-MCNs) are relatively rare cystic neoplasms in the liver. The differential diagnosis of H-MCNs remains big challenging, and the management and prognosis between the hepatic simple cyst (HSC) and H-MCNs are quite different. This study aimed to present our experience in the management of H-MCNs and provide a preoperative H-MCNs risk prediction nomogram to differentiating H-MCNs from liver cystic lesions.

Methods

29 patients diagnosed with H-MCNs and 75 patients diagnosed with HSC between June 2011 and June 2019 at Zhejiang University School of medicine, Sir Run-Run Shaw Hospital were reviewed in this study. We analyzed the demographic and clinicopathological variables.

Results

US, CT, and MRI could accurately diagnose only 3.4%, 46.1%, and 57.1% of H-MCNs, respectively. After univariate analysis and multivariate logistic regression analysis, the variables significantly associated with H-MCNs were enhancement after contrast (p = 0.009), tumour located in the left lobe (p = 0.02) and biliary ductal dilation (p = 0.027). An H-MCNs risk predictive nomogram was constructed, which showed excellent discrimination (areas under the receiver operating characteristic curve were 0.940) and consistent calibration between the predicted probability and actual probability.

Conclusion

Among patients with H-MCNs, the location of the tumour, enhancement in CT scan, and biliary duct dilation are significantly independent risk factors. The appropriate treatment of H-MCNs is radical resection. Using our Nomogram could facilitate screening and identification of patients with liver cystic lesions.

Recurrent giant simple hepatic cyst: an unusual cause of dyspnoea in an elderly man

An 88-year-old man presented to the emergency department with exertional dyspnoea and orthopnoea. Clinical examination revealed mildly raised jugular venous pressure, increased respiratory rate, palpable non-tender hepatomegaly and reduced right basal breath sounds. Ultrasonography showed a large right simple hepatic cyst, multiple small left hepatic and renal cysts. A non-contrast CT scan revealed a large, right hepatic thin-walled cyst of volume 4.2 L, exhibiting few thin septae and tiny nodular mural calcifications. Pressure effects were elevated right haemidiaphragm, right atrial compression and adjacent atelectasis. He had a similar episode 2 years ago, treated by percutaneous needle aspiration. Giant simple hepatic cysts are rare and present when symptomatic due to pain, mass effect on adjacent organs, infection or rupture. These may unusually cause dyspnoea or orthopnoea by compressing cardiac chambers. Simple aspiration has a high recurrence rate. Percutaneous sclerosant injection, laparoscopic deroofing and cystectomy are better treatment modalities.

Overview of spontaneous intraabdominal tumor hemorrhage: etiologies, imaging findings, and management

Hemorrhage is a potential complication of benign and malignant tumors and tumor-like conditions in the abdomen. Patients often have non-specific presentations, although they may present critically ill and hemodynamically unstable. Imaging plays an important role not only in the diagnosis of hemorrhage but also in the detection and characterization of an underlying mass. Ultrasound, computed tomography, and magnetic resonance imaging are utilized in evaluating these patients, with each having particular strengths and limitations. Spontaneous tumor hemorrhage is most commonly seen in hepatic and renal lesions, although it can arise from nearly every abdominal organ. In this article, we will review principles of tumor hemorrhage, illustrate common and uncommon imaging features, and highlight different options for management.

Evaluation of Nine Commercial Serological Tests for the Diagnosis of Human Hepatic Cyst Echinococcosis and the Differential Diagnosis with Other Focal Liver Lesions: A Diagnostic Accuracy Study

The differential diagnosis of hepatic cystic echinococcosis (CE) may be challenging. When imaging is insufficient, serology can be applied, but no consensus diagnostic algorithm exists. We evaluated the performances of nine serological tests commercialized in Europe for the diagnosis of “echinococcosis”. We performed a diagnostic accuracy study using a panel of sera from patients with hepatic CE (n = 45 “liquid” content stages, n = 25 “solid” content stages) and non-CE focal liver lesions (n = 54 with “liquid” content, n = 11 with “solid” content). The diagnosis and staging of CE were based on ultrasound (gold standard). Nine commercial seroassays (5 ELISA, 2 WB, 1 Chemiluminescence Immunoassay [CLIA] and 1 Immunochromatographic test [ICT]) were the index tests. Sensitivity (Se) ranged from 43 to 94% and from 31 to 87%, and specificity (Sp) from 68 to 100% and from 94 to 100%, when borderline results were considered positive or negative, respectively. Three seroassays (2 ELISA, 1 WB) were excluded from further analyses due to poor performances. When tests were combined, Sp was 98–100%. The best results were obtained using the WB-LDBIO alone (Se 83%) or as a third test after two non-WB tests (Se 67–86%). A validated WB or two non-WB tests, read with stringent criteria (borderline = negative and considered positive only if concordant positive), possibly confirmed by the WB, appear sensible approaches.

Systematic review on percutaneous aspiration and sclerotherapy versus surgery in symptomatic simple hepatic cysts

BACKGROUND

Simple hepatic cysts (SHC) may cause pain and bloating and thus impair quality of life. Whereas current guidelines recommend laparoscopic cyst deroofing, percutaneous aspiration and sclerotherapy (PAS) may be used as a less invasive alternative. This review aimed to assess the efficacy of PAS and surgical management in patients with symptomatic SHC.

METHODS

A systematic search in PubMed and Embase was performed according to PRISMA-guidelines. Studies reporting symptoms were included. Methodological quality was assessed by the MINORS-tool. Primary outcomes were symptom relief, symptomatic recurrence and quality of life, for which a meta-analysis of proportions was performed.

RESULTS

In total, 736 patients from 34 studies were included of whom 265 (36%) underwent PAS, 348 (47%) laparoscopic cyst deroofing, and 123 (17%) open surgical management. During weighted mean follow-up of 26.1, 38.2 and 21.3 months, symptoms persisted in 3.5%, 2.1%, 4.2%, for PAS, laparoscopic and open surgical management, respectively. Major complication rates were 0.8%, 1.7%, and 2.4% and cyst recurrence rates were 0.0%, 5.6%, and 7.7%, respectively.

CONCLUSION

Outcomes of PAS for symptomatic SHC appear to be excellent. Studies including a step-up approach which reserves laparoscopic cyst deroofing for symptomatic recurrence after one or two PAS procedures are needed.

Extrahepatic Mucinous Biliary Cystadenoma: A Case Report

Biliary cysts refer to cystic dilatation in the biliary ductal system that may be congenital or acquired. Extrahepatic biliary cysts constitute less than 10% of biliary cysts. Extrahepatic mucinous cystadenoma represents an extremely rare clinical condition with less than 100 cases reported in the English medical literature. Herein, we report the case of a middle-aged woman who presented with a clinical picture of cholestatic jaundice. Laboratory findings revealed elevated bilirubin and alkaline phosphatase. After a thorough investigation, she was found to have a cystic lesion in the common bile duct near the cystic duction site. The patient underwent exploratory laparotomy, which revealed a 2.0 × 2.0 cm cystic lesion in the common bile duct that is exerting an obstructive effect on the biliary ducts. Complete en-block excision of the cystic lesion was performed with Roux-en-Y hepaticojejunostomy reconstruction. Histopathological examination revealed mucinous biliary cystadenoma. Although very rare, biliary cystadenoma should be kept in mind as a differential diagnosis of cholestatic jaundice particularly in patients with no history of biliary stones or cholecystectomy.

Management of benign liver tumors

Benign liver tumors in children are far less frequent than their malignant counterparts. Recently, there have been advances of diagnostic procedures and novel treatments with improved classification as a result. While malignant pediatric liver tumors have been comprehensively addressed by multicenter international tumor trials, benign tumors have more usually relied upon individualised workup and treatment. Due to the rarity and heterogeneity of these different entities, large studies are lacking. In this article the authors highlight the spectrum of benign liver tumors with special focus on specific clinical features, pathology, and treatment.

Rapid enlargement of a hepatic hilar cyst leading to bile duct obstruction after acute exacerbation of chronic hepatitis B

A hepatic cyst is usually asymptomatic but, in some cases, can be associated with various complications. Here we report a rare case with rapid enlargement of a hepatic hilar cyst that induced bile duct obstruction after an acute exacerbation of chronic hepatitis B. The case is a 60-year old female who discontinued entecavir by herself. Hyperbilirubinemia was prolonged along with bile duct obstruction due to an enlarged cyst. After the administration of entecavir and steroid pulse therapy, biliary drainage and punctuation of the cyst were performed. There was no evidence of malignancy in the cyst. The therapies were not effective enough, probably due to the prior liver damage, and she died of acute on chronic liver failure. This case suggests that a hepatic hilar cyst in a patient with acute hepatitis or an acute exacerbation of chronic hepatitis can become enlarged and may affect the clinical course of hepatitis. In such a case, the size of the cyst should be monitored frequently and bile duct obstruction should be treated early if it occurs.

Liver findings in patients with Carney complex, germline PRKAR1A pathogenic variants, and link to cardiac myxomas

This study aimed to evaluate liver involvement in patients with Carney complex (CNC) based on a large cohort and to analyze any germline PRKAR1A genotype-phenotype association of liver disease. The study included 83 patients with CNC, followed between 1995 and 2018 at a tertiary research center. We reviewed liver images, recorded types and number of lesions and analyzed per genotype: all patients were sequenced for the PRKAR1A gene. A total of 29/83 patients (24.0%) had liver radiological findings. Patients with liver lesion had a significantly higher rate of pathogenic variants detected in the PRKAR1A gene (72.4 vs 38.9%, P = 0.005, respectively). Patients with a pathogenic variant detected on germline PRKAR1A analysis had a higher risk for having a liver lesion compared with patients with wild-type (WT) PRKAR1A alleles (21/42 (50.0%) vs 8/41 (19.5%), respectively, P = 0.004). Among patients with liver lesions, those with a nonsense PRKAR1A pathogenic-variant had more liver lesions (7/7) than among those with other pathogenic-variant types (8/22, P = 0.001). In multivariable analysis, detection of liver lesion(s) was associated with an odds ratio of 5.2 for cardiac myxomas (95% CI 1.55-17.49, P = 0.008). In conclusion, patients with CNC, particularly with a PRKAR1A pathogenic variant, have a higher rate of liver lesions. Additionally, liver lesions are associated with a high risk for cardiac myxomas in this population.

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.

Portal hypertension in a patient with biliary hamartomas: A case report

BACKGROUND

Biliary hamartomas (BH) are a rare benign disease caused by malformation of the intrahepatic bile ducts. BH are occasionally diagnosed, but often lack obvious clinical symptoms. They are usually diagnosed by biopsy and imaging tests in clinical practice. Few studies have reported the association of BH with portal hypertension.

CASE SUMMARY

A 40-year-old man was repeatedly admitted to our hospital due to hematochezia. The source of bleeding was considered to be gastroesophageal varices and portal hypertensive gastropathy by endoscopy. He had no history of hepatitis virus infection, alcohol abuse, drug-induced liver injury, or autoimmune liver disease. He underwent magnetic resonance imaging, which showed rounded, irregular, low-signal-T1 and high-signal-T2 lesions diffusely distributed on the liver, that were not communicated with the biliary system on magnetic resonance cholangiopancreatography. According to the imaging examination, the patient was considered to have a diagnosis of BH with portal hypertension.

CONCLUSION

Based on the present case report, BH may be a potential etiology of portal hypertension.

Biliary cystadenoma in an endemic zone of hydatid cyst: A rare surgical surprise

The advancement of radiological investigations has led to the early and incidental detection of hepatic cystic lesions. These are most commonly the simple cysts but can be malignant as well. Despite the recent advances, these lesions still pose a diagnostic as well as therapeutic challenge. The biliary cystadenomas and carcinomas form around 5% of all the malignant cystic lesions of liver. These lesions are hardly diagnosed preoperatively and are usually a histopathological surprise. They warrant a surgical excision. Herewith, the authors are describing a case of cystic hepatic neoplasm initially misdiagnosed as hydatid cyst of liver and discovered to be a vascular cystic lesion intraoperatively. This patient underwent resection of the lesion and was discovered to harbour biliary cystadenoma on histopathological specimen.

An Unusual Cause of Dyspnea and Thoracic Pressure

There is a high prevalence of hepatic cysts in the general population. Simple cysts are most of the times asymptomatic and are usually detected incidentally on ultrasonography, computed tomography, or magnetic resonance imaging. Symptoms may range from abdominal discomfort and pain, early satiety, dyspepsia, nausea, and vomiting to jaundice and portal hypertension due to obstruction of adjacent structures. Complications include spontaneous hemorrhage, infection, thrombosis, and atrophy of surrounding hepatic tissue. We present a unique case of a middle-aged patient with acute onset of dyspnea and thoracic pressure due to compression of the right ventricle by a large hepatic cyst.

Simple hepatic cyst rupture exacerbated by anticoagulation

Simple hepatic cysts are usually asymptomatic but can rarely result in life-threatening complications such as haemoperitoneum secondary to rupture. A 70-year-old woman with known simple hepatic cyst presented with acute chest pain and dyspnoea. The initial diagnosis was pulmonary embolism, and anticoagulation was commenced. However, she subsequently collapsed with haemodynamic instability. CT revealed a large hepatic cyst haematoma with rupture into the peritoneal cavity. The patient underwent emergency laparotomy, haemostasis and partial deroofing of the cyst. Retrospective review of CT scans suggested that the bleed had begun on presentation but was exacerbated by anticoagulation. To our knowledge, this is the first report of haemorrhagic hepatic cyst associated with acute anticoagulation. We discuss several important clinical lessons including cyst rupture as a possible cause of chest pain, the need for careful review of imaging and the choice of anticoagulation in patients with known simple hepatic cyst.

Case report of hepatic pseudocyst: A rare manifestation of liver metastasis from an anal squamous cell carcinoma

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Liver metastasis of anal squamous cell carcinoma with a presented pseudocyst is very rare.

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Some hepatic diseases such as infections, simple biliary cysts, and neoplasms demonstrate a cystic change of the liver.

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Metastasis should be suspected when CT findings in patients with a history of gastrointestinal cancer show cystic changes involving the liver.

Introduction

Liver metastasis of an anal squamous cell carcinoma (SCC) with a pseudocyst is uncommon. There are many diseases which form hepatic cystic lesions and sometimes it is difficult to arrive at an accurate diagnosis.

Presentation of case

A 69-year-old woman visited our hospital with complaints of bloody stool and difficult defecation. A palpable mass in the anal canal was found on digital examination. The laboratory tests revealed anemia and raised levels of SCC antigen. On endoscopy a type 2 tumor was identified in the anal canal and biopsy revealed SCC. The patient was diagnosed with advanced anal SCC (cT2N1aM0, cStage IIIA) as a result of the examination and underwent chemoradiotherapy (CRT); unfortunately the tumor persisted after CRT. A salvage abdominoperineal resection with D2 and left lateral lymph node dissection was conducted. Histopathologically, the tumor was diagnosed as poorly differentiated SCC. She was readmitted for fever 3 weeks after surgery, and the abdominal CT showed multiple low density areas with enhancement at the edge of the liver, suggesting abscess or metastasis. The metastatic SCC was revealed by cytology of liver drainage and liver biopsy.

Discussion

Anal cancers are sometimes encountered however; a pseudo cystic presentation of a liver metastasis is very rare which makes it difficult to distinguish from other diseases.

Conclusion

We present a case of SCC in the anal canal with liver metastasis presenting as a hepatic pseudocyst.

Simple liver cysts and cystoid lesions in hepatic alveolar echinococcosis: a retrospective cohort study with Hounsfield analysis

BACKGROUND

Alveolar echinococcosis (AE) is a rare zoonosis caused by the larval stage of the tapeworm Echinococcus multilocularis. AE lesions affect the liver in more than 98% of cases. AE lesions have various morphological characteristics that are described in the Echinococcus multilocularis Ulm classification for computed tomography (EMUC-CT). One of these characteristics is a cystoid portion. The aim of the study was to compare the density of simple hepatic cysts with cystoid portions of AE lesions classified on the basis of the EMUC-CT.

RESULTS

Hounsfield Unit (HU) measurements of the cystoid portions of all EMUC-CT type I-IV AE lesions (n = 155) gave a mean of 21.8 ± 17.6, which was significantly different from that of 2.9 ± 4.5 for the simple hepatic cysts (p < 0.0001). The difference between each of the individual AE types and simple hepatic cysts was also significant. In addition, the HU values of the cystoid portions in types I, II and IIIa/b and simple cysts were each significantly different from type IV (p < 0.0001). The HU measurements in type IV presented by far the highest mean.

CONCLUSIONS

The significantly higher density measured in the cystoid portions of hepatic AE lesions offers a good means of differentiation from simple hepatic cysts.

Giant hepatic cyst as a cause of gastric outlet obstruction

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

Echinococcus Granulosus in Childhood: A Retrospective Study of 187 Cases and Newer Data

Echinococcus granulosus, first reported by Goeze in 1782, is the causative parasite of cystic echinococcosis (hydatidosis) especially for countries that are endemic areas. Since the 1970s, the incidence of echinococcosis in Greece has been very high. Nevertheless, with the implementation of special prevention measures in the 1980s, a large reduction in the incidence of hydatidosis meant that it reached European levels. Therefore, we analyzed the demographics, multiple organ localizations of the parasite, diagnosis, and conservative and optimal surgical treatment over a total period of 39 years, especially for pulmonary and hepatic echinococcosis in children. The higher incidence of pulmonary echinococcosis compared with other localizations, male predominance, wide range of age, and various cystic sizes were some of the main demographics. Because cystic echinococcosis remains a main public health problem, we advocate a meticulous clinical investigation and treatment methodology to bridge the gap between knowledge and awareness of this important disease.

Biliary Mucinous Cystadenoma: A Review of the Literature

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Morphological and dynamic evaluation of complex cystic focal liver lesions by contrast-enhanced ultrasound: current state of the art

Complex cystic and cystic-like focal liver lesions (FLLs) encompass a spectrum of disorders ranging from non-neoplastic conditions to benign and malignant tumors. In this prospective, the possibility of non-invasive differentiation of these lesions is extremely important, because the clinical implications and therapeutic strategies vary considerably. Because of its advantageous cost/benefit ratio, widespread availability and easy execution, ultrasound (US) is the first-line imaging modality in most countries for the initial liver survey and represents the imaging technique that usually detects a complex liver cyst. However, US showed poor efficacy in the differential diagnosis of complex cystic FLLs. Thus, for years, computed tomography (CT) and magnetic resonance (MR) imaging have been used for further assessment of these lesions. Recently, the development of low mechanical index real-time contrast-enhanced ultrasound (CEUS) technique performed with the second generation of US contrast agents has led to an accurate depiction of macrovasculature and microvasculature. The technique yields information about contrast enhancement of the liver and FLLs almost as CT and MRI do, but in real time and without the use of ionizing radiation. To date, there is only a small amount of evidence about the role of CEUS in the less common setting of complex liver cysts. The aim of this review is to offer an up-to-date overview on the state of the art of CEUS in the study of the most common complex cystic focal liver lesions. To our knowledge, there are no literature comprehensive reviews on this topic.