Hepatic Cystadenoma


Article Author:
Clayton Brittingham


Article Editor:
Faiz Tuma


Editors In Chief:
Hela KCHIR
Joseph Lee
Savio John


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/30/2019 11:38:40 PM

Introduction

Hepatic cystic lesions were once thought to be relatively uncommon; however, they are being diagnosed more frequently with the continued advancement and improved access of patients to cross-sectional imaging. Estimates are that cystic liver disease affects 5 to 10% of the world population.[1][2] The differential for liver disease is broad and includes infectious, inflammatory, malignant, developmental, and traumatic etiologies. Mucinous cystic neoplasm is a unique subset within the hepatic cyst differential and includes the subgroup of mucinous cystic neoplasm, also referred to as biliary cystadenomas (BCA) and cystadenocarcinomas (BCAC). BCAs and BCACs combined comprise less than 5% of all cystic liver diseases.[1] They can present with relatively nonspecific abdominal symptoms and are usually an incidental finding on imaging. Radiologic features of this neoplasm are often suggestive but tend to overlap the findings in other cystic lesions leading to a differential. BCAs are considered to be premalignant. Although only a few reports have demonstrated malignant evolution current consensus on the best treatment is complete surgical resection. 

Etiology

The exact cause of BCAs remains undetermined. One current theory suggests that BCAs may arise from endodermal precursors to the local biliary epithelium. Contrary to this, there is the theory that these neoplasms are secondary to implantation explaining the ovarian like subepithelial stroma, expression of estrogen and progesterone receptors, predilection to be located in segment IV of the liver.[3] 

Epidemiology

BCACs and BCAs are rare and comprise a small percentage of worldwide cystic liver disease.  The incidence of intrahepatic BCAs is reported to be between the ranges of 1 in 20000 and 1 in 100000. [4] BCAs are seen predominantly in middle-aged women with ages ranging between 40 to 50 years old. Approximately 85% of reported of them arise from the intrahepatic biliary system.[5] They are slow-growing lesions and have been reported to reach sizes up to 30 cm.[6] 

Histopathology

On gross pathology, BCAs are multiseptated, and mucin filled lesions surrounded by a dense fibrous capsule that may on occasion includes calcifications. Microscopically, BCAs have three characteristic layers including a mucin-producing, biliary type epithelial layer; a subepithelial layer of cellular stroma; a dense surrounding layering of collagenous connective.[3] There are two separate subsets of cystadenomas based upon the presence of subepithelial ovarian-like mesenchymal stroma. BCAs with mesenchymal stroma occurs exclusively in women and carry a decreased malignant potential to its counterpart without this layer. Furthermore, BCAs contain no proliferating malignant epithelium, unlike BCACs.[2]

History and Physical

The clinical evaluation of patients with BCAs is exceptionally variable and often nonspecific. Many patients are asymptomatic. They only become aware of this lesion incidentally. Of those that do experience symptoms, the typical presentation includes abdominal pain, distension, nausea, and vomiting.[7]  Rarely, BCAs may present from symptoms secondary to obstructive jaundice, cholangitis, intracystic hemorrhage, or cyst rupture. Currently, no physical exam signs have been reported to correlate with malignant potential.[8] 

Evaluation

The diagnosis of BCAs has its basis a combination of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and clinicopathologic information. These lesions are typically intrahepatic, solitary, slow-growing, multiloculated cystic tumors filled with a clear mucinous fluid. BCAs have a female predominance and are often present within hepatic segment IV.

Sonographically, they appear as a well defined, anechoic lesion surrounded by an echogenic capsule and containing multiple intrinsic septations. At CT, BCAs are a fluid attenuating cystic mass with a soft tissue attenuating rim, internal septa, and possibly capsular calcifications and mural nodularity.[9] At MRI, signal characteristics are typical for fluid containing cystic lesion, including low T1 and high T2 signal. There may be some variability in both T2 and T1 signal depending on the protein content, presence of hemorrhage, or solid components. BCAs do not communicate with the biliary system. These lesions demonstrate mild capsular and septal enhancement on postcontrast imaging at CT and MRI. The existence of internal debris, bile duct dilation, and enhancing mural nodularity is concerning for BCACs.

Laboratory values are typically normal in patients, although in a minority of case reports elevated liver enzymes can be seen, specifically bilirubin levels.[2] Elevated serum carbohydrate antigen 19-9 and carcinoembryonic antigens can also present, and may reflect malignant transformation, though this is neither sensitive nor specific.[10] Fine-needle aspiration of cyst fluid is no longer the recommendation due to the risk of dissemination of cells and the development of peritoneal carcinomatosis.[11] 

Treatment / Management

BCA is considered a premalignant lesion. Although imaging findings may be suggestive, they often are overlapping and nonspecific. No published guidelines on appropriate therapy of BCAs currently exist due to the limited number of reported cases. Percutaneous ablation and unroofing techniques of BCAs are ineffective and have been shown to have recurrence rates up to 80%.[2] Complete surgical resection is the management of choice given the risk of malignant transformation and recurrence.[12] Enucleation of BCAs is appropriate management only in those cases where complete surgical resection is not possible.[2]

Differential Diagnosis

The definitive diagnosis of BCA from BCAC is challenging before surgical resection. Nevertheless, considering the management of these lesions is identical, the role imaging is, therefore, to exclude other benign cystic lesions without malignant potential. Simple hepatic cysts are the most common hepatic cystic lesion. Reliable differentiation of a BCAs from simple cysts is possible due to the lack of internal septations and papillary projections. Differentiating hemorrhagic cysts can often prove to be challenging given their intricate appearance of US. However, given the decrease in spatial resolution on CT, these lesions tend to appear homogenous without internal complexity, unlike BCAs. Furthermore, the clot in hemorrhagic cysts typically appears T1 bright on MR imaging. 

Additional diagnostic considerations include pyogenic hepatic abscesses, hydatid disease, mesenchymal hamartomas, and undifferentiated embryonal sarcoma.  Unlike BCAs, pyogenic hepatic abscess and hydatid disease typically presents in patients with fever and lacks the female predominance. Furthermore, associated imaging findings, including perilesional edema, segmental perfusion difference, and internal gas, are more suggestive of an infectious etiology. Mesenchymal hamartomas and embryonal sarcoma too lack the characteristic female predominance and are typically seen in children and young adults.[2] 

Prognosis

Prognostic data following resection is limited in patients with BCAs due to its rarity. Of those reported, favorable outcomes occur in those with total resection resulting in only 5 to 10% rate of recurrence.[4]

Complications

Reported complications from BCAs include obstructive jaundice, cholangitis, intraperitoneal cyst rupture, intracystic hemorrhage, all of which may cause initial patient presentation. The most feared complication of BCAs is a malignant transformation into BCAC, which has been reported to be as high as 20% of cases.[2]

Deterrence and Patient Education

Patients should receive education, informing them that BCAs are a rare entity without any identifiable risk factors. They should receive information regarding the documented risk of recurrence and malignant transformation in the absence of complete resection.

Enhancing Healthcare Team Outcomes

Enhancing patient care and outcomes begin with clinicians awareness of BCAs and the risks associated. The application of clinicopathologic history and multiphasic imaging is paramount to distinguish this entity from other benign hepatic cysts due to their differing clinical management.  Upon making the diagnosis, clinicians need to follow the patient with serial imaging to ensure that malignant transformation does not occur. Even after surgical excision, there is a risk of recurrence of BCA; hence, patients require monitoring. Interprofessional communication between the radiologists, referring providers, and surgeons are necessary to minimize diagnostic workup, patient anxiety, and optimize outcomes; this is where oncology-trained nursing staff can be of great assistance to the oncologists and other physicians involved in the case. They can provide post-surgical education wound care, and help the patient monitor for malignant transformation if they opt not to pursue surgery, or recurrence if they do, and report to the physician staff should any of these become a concern. This sort of interprofessional collaboration is crucial to the successful management of BCAs. [Level V]

Because of only anecdotal reports, the outcomes of these lesions remains a mystery.


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Hepatic Cystadenoma - Questions

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A 50-year-old female presents with chronic right upper quadrant pain. Vitals and lab work is completed and within normal limits. An MRI is completed and demonstrates a 20 cm multiloculated left hepatic lobe cyst with thin capsular enhancement. What histologic layer of the presumed diagnosis is associated with the worst prognosis?



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A 48-year-old female presents for abdominal distension. Vitals and lab work completed is within normal limits. An abdominal CT is completed and demonstrates a 17 cm multiseptated cyst in the liver. Which imaging findings would one expect to see with a biliary cystadenoma (BCA)?



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A 52-year-old female without significant past medical history presents with chronic bouts of nausea. Labwork and vitals are within normal limits. An abdominal CT is then completed and demonstrates a 12 cm multiloculated cyst with multiple thin septa and subtle capsular enhancement in segment IV of the liver. What are the known causes of the most likely diagnosis?



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A 54-year-old female presents with generalized abdominal pain. Labwork completed is within normal limits. Ultrasound and MRI of the abdomen are then completed and demonstrate findings consistent with a biliary cystadenoma (BCA). What is the best management to mitigate the most feared complication of this diagnosis?



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A 65-year-old female presents to the clinic with chronic right upper quadrant pain. The pain has been present for the past 2 weeks, and it has been associated with occasional nausea and vomiting. Vital signs are within normal limits. Her past medical history is unremarkable. An MRI of the abdomen demonstrates a non-enhancing cystic lesion in segment IV of the liver. What is the most dangerous complication associated with the sampling in this patient with the presumed diagnosis?



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Hepatic Cystadenoma - References

References

Del Poggio P,Buonocore M, Cystic tumors of the liver: a practical approach. World journal of gastroenterology. 2008 Jun 21;     [PubMed]
Soares KC,Arnaoutakis DJ,Kamel I,Anders R,Adams RB,Bauer TW,Pawlik TM, Cystic neoplasms of the liver: biliary cystadenoma and cystadenocarcinoma. Journal of the American College of Surgeons. 2014 Jan;     [PubMed]
Zen Y,Pedica F,Patcha VR,Capelli P,Zamboni G,Casaril A,Quaglia A,Nakanuma Y,Heaton N,Portmann B, Mucinous cystic neoplasms of the liver: a clinicopathological study and comparison with intraductal papillary neoplasms of the bile duct. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2011 Aug;     [PubMed]
Manouras A,Markogiannakis H,Lagoudianakis E,Katergiannakis V, Biliary cystadenoma with mesenchymal stroma: report of a case and review of the literature. World journal of gastroenterology. 2006 Oct 7;     [PubMed]
Martel G,Alsharif J,Aubin JM,Marginean C,Mimeault R,Fairfull-Smith RJ,Mohammad WM,Balaa FK, The management of hepatobiliary cystadenomas: lessons learned. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2013 Aug     [PubMed]
Qian LJ,Zhu J,Zhuang ZG,Xia Q,Liu Q,Xu JR, Spectrum of multilocular cystic hepatic lesions: CT and MR imaging findings with pathologic correlation. Radiographics : a review publication of the Radiological Society of North America, Inc. 2013 Sep-Oct     [PubMed]
Erdogan D,Busch OR,Rauws EA,van Delden OM,Gouma DJ,van-Gulik TM, Obstructive jaundice due to hepatobiliary cystadenoma or cystadenocarcinoma. World journal of gastroenterology. 2006 Sep 21     [PubMed]
Xu M,Shi X,Wan T,Wang H,He L,Chen M,Liang Y,Dong J, [Comparison of clinicopathological characteristics and prognosis of intrahepatic biliary cystic tumor between male and female patients]. Zhonghua yi xue za zhi. 2015 Oct 13     [PubMed]
Mortelé KJ,Ros PR, Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiographics : a review publication of the Radiological Society of North America, Inc. 2001 Jul-Aug     [PubMed]
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