Mucinous Cystic Neoplasm of the Liver or Intraductal Papillary Mucinous Neoplasm of the Bile Duct? A Case Report and a Review of Literature

Robotic hepatectomy and cholecystectomy in the management of intraductal papillary mucinous neoplasm of the biliary tract: A case report and literature review

BACKGROUND

In the Western Hemisphere, Intraductal papillary mucinous neoplasm of the biliary tract (IPMN-B) is a rare lesion with uncertain aetiology. This report outlines a scarcely documented instance of IPMN-B treated using robotic hepatectomy and cholecystectomy supplemented with intraoperative imagery aimed at informing future robotic procedures.

METHODS

A healthy person with acute cholangitis symptoms underwent diagnostic imaging followed by successful robotic hepatectomy and cholecystectomy. Pathological examination confirmed IPMN-B.

RESULTS

The patient was consulted regarding the proposed procedure of robotic left hepatectomy, cholecystectomy, and potential hepaticojejunostomy, to which she provided consent. Subsequent surgical intervention resulted in clear margins for malignancy, and the patient recovered without complications.

CONCLUSIONS

This case emphasises the importance of early diagnosis and intervention in managing IPMN. The use of a robotic approach, specifically through robotic left hepatectomy combined with cholecystectomy, offers minimally invasive surgery that provides exceptional visualisation and precise control.

Mucinous cystic neoplasms of the liver with biliary prolapse

Objectives

To describe the prevalence, clinical and radiological findings of biliary prolapse in pathologically proven mucinous cystic neoplasm of the liver (MCN-L).

Methods

Thirty-four patients, all female with median age 50 years (range, 14–82), with histologically confirmed MCN-L were enrolled. Median tumor size was 9 cm (range, 2–21 cm). Fifty-seven examinations (17 ultrasound, 25 CT, and 15 MR) among 34 MCN-Ls were reviewed. Two radiologists retrospectively assessed images for tumor location, size and other morphological features of the tumor, presence of biliary prolapse and upstream bile duct dilatation. Ultrasound, CT, and MR were assessed separately. Clinical features were evaluated. Clinical and radiological characteristics of MCN-L with and without biliary prolapse were compared.

Results

15% (5/34) of MCN-Ls showed biliary prolapse confirmed at pathology. None of MCN-Ls were associated with invasive carcinoma. Patients with biliary prolapse were significantly younger than those without (median 27 years [22–56] vs. median 51 years [14–82], p = 0.03). MCN-Ls with biliary prolapse were significantly smaller than those without (median 6.4 cm [2.2–7.5] vs. median 9.6 cm [3.1–21], p = 0.01). The upstream bile duct was dilated more frequently in MCN-Ls with biliary prolapse (100% vs. 38%, p = 0.02). Jaundice was significantly more common in MCN-Ls with biliary prolapse (80 vs 3%, p = 0.0005). Other clinical or radiological features were not significantly different between two groups.

Conclusions

Biliary prolapse was found in 15% of MCN-Ls. MCN-Ls with biliary prolapse were significantly smaller and were more commonly associated with upstream bile duct dilation and jaundice than those without biliary prolapse.

Cystic liver lesions: a pictorial review

Hepatic cysts (HC) are sac-like structures mainly filled with liquid and showing a distinct membrane. They are usually found incidentally through imaging. A wide spectrum of imaging patterns may be observed for common and uncommon, neoplastic and non-neoplastic diseases. While simple hepatic cysts occur frequently and do not require any treatment or follow-up, non-typical cysts should be carefully analysed to avoid misdiagnosing a lesion that would require appropriate management. Therefore, adequate knowledge of all the relevant imaging patterns is critical to secure an accurate diagnosis. The aim of this review is to describe the imaging features of the different types of hepatic cysts.

Pure Laparoscopic Left Hepatectomy for Regrowth of Mucinous Cystic Neoplasm of the Liver after Laparoscopic Deroofing

Background

Hepatic cystic lesions are common entities, most of which are simple hepatic cysts (SHCs). Mucinous cystic neoplasm of the liver (MCN-L) is a rare tumor characterized by ovarian-like stroma and accounts for <5% of all hepatic cysts. Distinguishing between SHCs and MCN-L is challenging because of the similarity in their imaging findings. Herein, we report a rare regrowth case of MCN-L after laparoscopic deroofing, treated with pure laparoscopic left hepatectomy. Case Presentation. A 63-year-old woman with a large hepatic cystic lesion and abdominal pain was referred to our hospital for surgical treatment. Computed tomography (CT) showed cystic lesions with septations arising from macrolobulations in the left medial segment. She underwent laparoscopic deroofing based on the diagnosis of SHCs; however, the final histopathological diagnosis was MCN-L. She chose observational follow-up, and MCN-L regrowth was detected on follow-up CT 6 months after the laparoscopic deroofing. We performed pure laparoscopic left hepatectomy for complete resection of the MCN-L. She had an uneventful postoperative course and no recurrence at the 5-year follow-up after the radical resection of the MCN-L.

Conclusion

MCN-L is a rare entity, and accurate diagnosis with imaging modalities is greatly challenging. Laparoscopic hepatectomy for MCN-L should be considered as a strong alternative to secure safety and curability.

Surgical Treatment of Intraductal Papillary Neoplasm of the Bile Duct: A Report of Two Cases and Review of the Literature

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare bile duct tumor characterized by intraductal papillary or villous neoplasms covered by neoplastic epithelium with fine fibrovascular stalks in the dilated bile ducts (1). Its true etiology remains unknown. Herein, we report two cases of IPNB that underwent surgical resection. The first case was a 66-year-old male who complained of upper abdominal pain for three years. We found obstruction of the common bile duct and dilation of the intrahepatic and extrahepatic bile ducts after MRCP. Laparoscopic hepatic segmentectomy (S2, S3, S4), resection of the common bile duct, cholecystectomy, and hepaticojejunostomy were performed. The second case was a 67-year-old male with asymptomatic dilation of the intrahepatic duct. The patient underwent robot-assisted laparoscopic hepatic segmentectomy (S5, S6, S7, S8), resection of the common bile duct, hepaticojejunostomy and cholecystectomy.

Laparoscopic S7 hepatectomy for hepatic mucinous neoplasm: a case report and literature review

Background

Mucinous cystic neoplasm of the Liver is rare tumors with malignant potential that occur in the biliary epithelium. Because of its rare presentation, it is often misdiagnosed before surgery.

Case presentation

A 63-year-old female patient presented with intermittent upper abdominal pain for three months. Laparoscopic hepatectomy of Segment 7 was conducted based on the preoperative diagnosis of space-occupying lesion in the right lobe of the liver. Postoperative pathology showed a low-grade mucinous cystic neoplasm in the right posterior lobe of the liver. The preoperative CA19-9 level was significantly increased while the postoperative CA19-9 returned to the normal range.

Conclusions

The diagnosis of mucinous cystic neoplasm of the liver is closely related to the thickening of the cystic wall or the increase of CA19-9, which has great significance and deserves clinical attention.

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.

Pedunculated mucinous cystic neoplasm of the liver

In 2010, the World Health Organization classified mucin-producing bile duct tumors of the liver into two distinct entities; mucinous cystic neoplasm of the liver (MCN-L) and intraductal papillary mucinous neoplasm of the bile duct. We present the case of a patient with MCN-L having a uniquely pedunculated shape. A 32‐year‐old woman was referred to our institution with a diagnosis of biliary cystic neoplasm. She had undergone left salpingo-oophorectomy for ovarian cancer 15 years ago. Imaging studies showed an 8 cm-sized well defined, multiloculated cystic lesion suggesting a mucinous cystic neoplasm. The cystic mass was pedunculated at the liver capsule and pathologically diagnosed as MCN-L. The mass was resected with partial hepatectomy. The patient recovered uneventfully. She was discharged 7 days postoperatively. The patient has been doing well for 6 months after the operation. The patient will be followed up annually because of the favorable postresection prognosis of MCN-L.

Mucinous Cystic Neoplasm of the Cystic Duct: A Rare Location of a Rare Entity

Mucinous cystic neoplasms (MCNs) are uncommon cystic lesions that arise in the liver and biliary system (MCN-LBS) and the pancreas (MCN-P) and rarely arise from the extrahepatic biliary system. Histologically, these lesions are defined by the presence of variably mucin-producing epithelium with ovarian-like, hypercellular mesenchymal stroma. Herein, we present a case of extrahepatic MCN-LBS in a 51-year-old woman. This lesion arose from the cystic duct and was removed via laparoscopic cholecystectomy. Histologic examination confirmed the diagnosis. To our knowledge, this is the third case report of an MCN-LBS arising from the cystic duct in the English literature. In this article, we review clinical and histologic characteristics of MCNs and present two other reports of MCN-LBS of the cystic duct.

Intraductal Papillary Neoplasm of the Bile Duct: A Rare Case of Intrahepatic Space-Occupying Lesion

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare tumor and is considered one of the precursor lesions for cholangiocarcinoma. Though relatively common in the far east countries, it is uncommon in the Indian population. A 67-year-old gentleman presented with vague upper abdominal pain with no history of fever, jaundice, melena, or hematemesis. An abdominal ultrasound showed a solid cystic lesion in the left lobe of the liver with upstream dilatation of bile ducts. Computed tomography and magnetic resonance imaging showed similar findings. With a differential diagnosis of intrahepatic cholangiocarcinoma, intraductal papillary neoplasm, and biliary cystadenoma, he underwent robotic-assisted left hepatectomy. Histopathology was suggestive of IPNB. Following surgery, he had an uneventful recovery and was advised for follow-up visits every six months. A clinical, radiological, and pathological profile of this rare tumor has been described here with a review of the existing literature.

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

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

Mucinous cystic neoplasm of the liver with biliary communication: case report and surgical therapeutic option

Background

Mucinous cyst neoplasm of the liver (MCN-L) comprise less than 5% of all cystic liver lesions and is characterized by the presence of ovarian stroma and absence of bile duct communication.

Case presentation

Here, we discuss a 45-year-old woman who presented with symptomatic liver mass. Diagnostic workup detected a 4.2 × 3.6 cm septate cyst located in segments I, V, and VIII of the liver in communication with the right hepatic duct. An open right liver resection with total bile duct excision and hilar lymphadenectomy was performed. Pathology revealed a multiloculated cyst with lined mucinous epithelium and ovarian-like stroma, consistent with low-grade MCN-L.

Conclusions

This case shows that unusual location and bile duct communication can be present in MCN-L.

Intraductal Papillary Neoplasm of Bile Duct: Updated Clinicopathological Characteristics and Molecular and Genetic Alterations

Intraductal papillary neoplasm of the bile duct (IPNB), a pre-invasive neoplasm of the bile duct, is being established pathologically as a precursor lesion of invasive cholangiocarcinoma (CCA), and at the time of surgical resection, approximately half of IPNBs show stromal invasion (IPNB associated with invasive carcinoma). IPNB can involve any part of the biliary tree. IPNB shows grossly visible, exophytic growth in a dilated bile duct lumen, with histologically villous/papillary neoplastic epithelia with tubular components covering fine fibrovascular stalks. Interestingly, IPNB can be classified into four subtypes (intestinal, gastric, pancreatobiliary and oncocytic), similar to intraductal papillary mucinous neoplasm of the pancreas (IPMN). IPNBs are classified into low-grade and high-grade based on lining epithelial features. The new subclassification of IPNB into types 1 (low-grade dysplasia and high-grade dysplasia with regular architecture) and 2 (high-grade dysplasia with irregular architecture) proposed by the Japan–Korea pathologist group may be useful in the clinical field. The outcome of post-operative IPNBs is more favorable in type 1 than type 2. Recent genetic studies using next-generation sequencing have demonstrated the existence of several groups of mutations of genes: (i) IPNB showing mutations in KRAS, GNAS and RNF43 belonged to type 1, particularly the intestinal subtype, similar to the mutation patterns of IPMN; (ii) IPNB showing mutations in CTNNB1 and lacking mutations in KRAS, GNAS and RNF43 belonged to the pancreatobiliary subtype but differed from IPMN. IPNB showing mutation of TP53, SMAD4 and PIK3CA might reflect complicated and other features characterizing type 2. The recent recognition of IPNBs may facilitate further clinical and basic studies of CCA with respect to the pre-invasive and early invasive stages.

Mucinous cystic neoplasm of the liver: a case report

A 50-year-old woman was investigated for epigastric pain. Imaging revealed a multilocular cyst with multiple thin septae within segment IV of the liver, measuring up to 140 mm in diameter. There was associated bile duct dilatation. Given the patient’s symptoms, the size of the cyst and malignant potential, a hemi-hepatectomy was performed. Histopathology demonstrated a cyst lined by columnar mucinous epithelium with underlying ovarian-type stroma. Therefore, the diagnosis was mucinous cystic neoplasm of the liver (MCN-L). MCN-L is a rare disease, and the presence of bile duct dilatation is an even rarer finding. This article presents a case report and review of literature of this entity.

Intraductal papillary neoplasm of the bile duct (IPNB): CT and MRI appearance with radiology-pathology correlation

PURPOSE

Intraductal papillary neoplasm of the bile duct (IPNB) is a precursor to invasive carcinoma and is a distinct pathologic diagnosis. The purpose of this study was to evaluate imaging features of IPNB on cross-sectional imaging studies with histopathologic correlation.

MATERIALS AND METHODS

In this IRB approved, HIPAA compliant retrospective observational analysis of 23 pathology proven IPNB tumors 22 imaging studies were reviewed, 14 CT and 8 MRI scans. Features evaluated in consensus by two subspecialty-trained abdominal radiologists included: presence of specific lesion/mass within the bile duct, location within the biliary tree, size, morphology, enhancement characteristics, and bile duct caliber.

RESULTS

Majority of the subjects (16/18, 90%) had definite intraluminal mass, of which 7 (39%) had a polypoid mass with upstream diffuse biliary ductal dilation and 5 (28%) had a plaque-like mass with focal stricture and upstream biliary ductal dilatation. 6/18 (33%) subjects had low grade dysplasia, most commonly intestinal subtype, 7/18 (39%) subjects presented with invasive component, commonly pancreaticobiliary subtype, and 5/18 (28%) presented with high grade dysplasia.

CONCLUSION

IPNB has increased predilection for extrahepatic bile ducts, commonly presenting as either an intraluminal polypoidal mass with associated upstream biliary ductal dilation or a focal plaque like mass with associated ductal stricture at the site of the tumor.

Infrequent intrahepatic cystic neoplasm: dilemmas in diagnosis and management

Biliary mucinous cystic neoplasm (BMCN) is a rare intrahepatic neoplasm comprising approximately 5% of cystic liver lesions. It can cause diagnostic dilemmas with most common differentials being complex hepatic cyst, hydatid cyst and intraductal papillary neoplasm of the bile duct. Affecting middle-aged female population, BMCN presents variedly ranging from vague abdominal symptoms to obstructive jaundice. Preoperative diagnosis is difficult. Preoperative CT scan with intravenous contrast and carbohydrate antigen 19.9 levels may give a clue towards the diagnosis. Intraoperative frozen section or cyst fluid aspiration cytology might help confirm the diagnosis. Fine needle aspirations should not be performed if BMCN is suspected, and intraoperative cyst spillage should be avoided to prevent tumour dissemination. We present here a case with a very atypical presentation of BMCN and review its present literature in brief.

Mucins: the Old, the New and the Promising Factors in Hepatobiliary Carcinogenesis

Mucins are large O-glycoproteins with high carbohydrate content and marked diversity in both the apoprotein and the oligosaccharide moieties. All three mucin types, trans-membrane (e.g., MUC1, MUC4, MUC16), secreted (gel-forming) (e.g., MUC2, MUC5AC, MUC6) and soluble (non-gel-forming) (e.g., MUC7, MUC8, MUC9, MUC20), are critical in maintaining cellular functions, particularly those of epithelial surfaces. Their aberrant expression and/or altered subcellular localization is a factor of tumour growth and apoptosis induced by oxidative stress and several anti-cancer agents. Abnormal expression of mucins was observed in human carcinomas that arise in various gastrointestinal organs. It was widely believed that hepatocellular carcinoma (HCC) does not produce mucins, whereas cholangiocarcinoma (CC) or combined HCC-CC may produce these glycoproteins. However, a growing number of reports shows that mucins can be produced by HCC cells that do not exhibit or are yet to undergo, morphological differentiation to biliary phenotypes. Evaluation of mucin expression levels in precursors and early lesions of CC, as well as other types of primary liver cancer (PLC), conducted in in vitro and in vivo models, allowed to discover the mechanisms of their action, as well as their participation in the most important signalling pathways of liver cystogenesis and carcinogenesis. Analysis of mucin expression in PLC has both basic research and clinical value. Mucins may act as oncogenes and tumour-promoting (e.g., MUC1, MUC13), and/or tumour-suppressing factors (e.g., MUC15). Given their role in promoting PLC progression, both classic (MUC1, MUC2, MUC4, MUC5AC, MUC6) and currently tested mucins (e.g., MUC13, MUC15, MUC16) have been proposed to be important diagnostic and prognostic markers. The purpose of this review was to summarize and update the role of classic and currently tested mucins in pathogenesis of PLC, with explaining the mechanisms of their action in HCC carcinogenesis. It also focuses on determination of the diagnostic and prognostic role of these glycoproteins in PLC, especially focusing on HCC, CC and other hepatic tumours with- and without biliary differentiation.