Hepatic Cystadenoma Imaging and Diagnosis

Creator: Dr. Narmatha. A
Published: 2023-05-19T13:08:20

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Hepatic cystadenoma is a rare cystic benign neoplasm of the liver. Read this article to know more about hepatic cystadenoma imaging and diagnosis.

Written by

Dr. Narmatha. A

Medically reviewed by

Dr. Varun Chaudhry

May 19, 2023

June 26, 2023

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Contents

What Is the Pathophysiology of the Biliary Cystadenoma?
What Are the Symptoms of Biliary Cystadenoma?
What Are the Imaging Techniques Used in the Diagnosis of Hepatic Cystadenoma?
What Are the Clinical Investigations Used in the Diagnosis of Biliary Cystadenoma?
What Are the Differential Diagnosis of Biliary Cystadenoma?
What Are the Complications of Biliary Cystadenoma?
What Are the Treatment Options for Biliary Cystadenoma and Cystadenocarcinoma?

Introduction:

Biliary or hepatic cystadenoma (BCA) is a benign, premalignant neoplasm that often originates in the intrahepatic bile ducts, lined by secreting cuboidal or columnar epithelium. About 10 to 20 percent of biliary cystadenoma may arise from the gallbladder and extrahepatic bile ducts, constituting about five percent of all hepatic cystic lesions. The malignant form of biliary cystadenoma is biliary cystadenocarcinoma (BCAC) which arises from the premalignant lesion. The etiology of BCA is not exactly known, and it was suggested that it might arise from ectopic embryonic tissue or the embryonic rest of the primitive foregut.

What Is the Pathophysiology of the Biliary Cystadenoma?

Biliary cystadenoma appears as globular in shape, and its size ranges from 0.59 to 13.78 inches The external surface of the mass is smooth and contains multilocular cysts filled with mucinous fluid that are separated by thick walls. BCA appears as a single or multilocular cystic lesion in which the locules are lined by columnar epithelium with inflammation, hemorrhage, and severe dysplasia. Sometimes the dysplastic epithelium inside the bile duct causes obstruction of the biliary duct.

What Are the Symptoms of Biliary Cystadenoma?

Most patients with biliary cystadenoma remain asymptomatic. However, some of the patients experience the following symptoms:

Abdominal pain.
Abdominal distension.
Nausea (urge to vomit).
Vomiting.
Compression of the duodenum, stomach, biliary tree, and hepatic veins.
In extrahepatic BCT, obstructive jaundice and cholangitis (swelling of the bile duct) may be seen.

What Are the Imaging Techniques Used in the Diagnosis of Hepatic Cystadenoma?

1. Computed Tomography (CT):

In CT, hepatic cystadenomas appear hypodense, and multilocular mass measures as large as 11.81 inches. The wall of the mass is well defined and appears enhanced with the administration of a contrast agent.
Cystadenomas have thin septal calcifications and demonstrate fluid attenuation such as blood, bile, and mucin.
The calcifications inside the mass appear thick and coarse. Sometimes there is a papillary projection into the lumen.
Biliary dilatation is rarely seen in extrahepatic cystadenoma or cystadenocarcinoma.
A CT scan can detect the presence of air inside the hepatic mass.

2. Magnetic Resonance Imaging (MRI):

The fluid containing cystadenomas appears as low signal intensity homogeneous mass on T1-weighted images and high-intensity homogeneous mass on T2-weighted images. Based on the protein content of the fluid, the signal intensity may vary in T1 and T2 weighted images. Therefore, it is difficult to distinguish biliary cystadenomas from cystadenocarcinoma in MRI.
The low-intensity signal inside the high-intensity cyst in T2 weighted images indicates septations.
The combination of diffusion-weighted MRI with conventional MRI helps in the quantitative and qualitative assessment of hepatic lesions, including cysts and malignancy.
MRI can distinguish abscesses from benign biliary cystadenomas with the presence of pericystic edema.
The presence of air inside the hepatic abscess indicates air forming organism, and it appears as a signal void in MRI.

3. Ultrasonography:

With the administration of ultrasound contrast materials, most of the lesion appears in a honeycomb pattern with cystic wall and septa. During the arterial phase, the honeycomb septa appear hyper-enhanced, most commonly in biliary cystadenomas. During portal venous and late phase, the honeycomb septa appear hypo enhanced in biliary cystadenocarcinoma.
The biliary projections and mural nodules may project into the cystic lumen. The wall or septal classification appears as an acoustic shadow in ultrasonography.
The cystic contents such as mucin, blood, or protein appear anechoic to hypoechoic.

What Are the Clinical Investigations Used in the Diagnosis of Biliary Cystadenoma?

Elevated serum CA 19-9 and carcinoembryonic antigen (CEA) level.
Elevated cystic fluid CA 19-9 and CEA levels help distinguish biliary cystadenoma and cystadenocarcinoma from various cystic lesions.
Percutaneous fine-needle aspiration of cystic fluid is used to estimate the bilirubin level. Increased bilirubin level in cystic fluid indicates the communication of biliary cystadenoma with the biliary tract.
It is difficult to differentiate biliary cystadenoma from cystadenocarcinoma preoperatively. Therefore, FNA (fine needle aspiration) and needle biopsy are not indicated before the surgery as they pose the risk of tumor dissemination. Hence FNA can be performed under the guidance of EUS (endoscopic ultrasound).

What Are the Differential Diagnosis of Biliary Cystadenoma?

Hydatid cyst - A cyst occurs by a parasitic infection most commonly seen in the liver and lungs.
Hematomas - Abnormal collection of blood outside the blood vessels.
Liver abscess - A pus-filled mass in the liver.
Post-traumatic cyst - A rare consequence of severe soft tissue trauma.
Polycystic liver disease - A medical condition characterized by multiple cysts inside the liver which cause abdominal distension.
Choledochal cyst - A congenital anomaly of the tube that communicates the liver and gall bladder.

What Are the Complications of Biliary Cystadenoma?

Bleeding.
Obstructive jaundice - A type of jaundice that occurs from narrowing or obstruction of the bile duct, which prevents drainage of bile from the blood into the intestine.
Infection.
Rupture.
Malignant transformation.
Ascites - A disease characterized by an abnormal fluid collection inside the abdominal cavity.
Inferior vena cava obstruction - An abnormal compression or obstruction of the inferior vena cava results in decreased venous return to the heart.
Gastric outlet obstruction - A condition in which obstruction of the stomach or intestine results in vomiting after food (postprandial), abdominal pain, and weight loss.

What Are the Treatment Options for Biliary Cystadenoma and Cystadenocarcinoma?

Due to the lack of reliability in imaging and differentiating biliary cystadenoma from cyst adenocarcinoma, the suspected biliary cystadenoma needs to be surgically removed along with the negative margin.
If the biliary cystadenoma is large and confined to a few segments, it can be treated with hepatectomy. However, some procedures such as fenestration, aspiration, sclerotherapy, internal drainage, and partial resection are limited as they risk a high recurrence rate ranging from 90 to 100 percent.
Cyst enucleation can be performed when the resection is difficult or associated with morbidity.

Conclusion:

Biliary cystadenoma affects about 90 percent of females aged 45 years more than males, while biliary cystadenocarcinoma affects both men and women equally. MRCP (magnetic resonance cholangiopancreatography) helps visualize cystic communication with the biliary tree and to identify the internal septations. The prognosis of biliary cystadenoma is good if the complete excision of the lesion is performed. Even the prognosis of cystadenocarcinoma is good as they are less aggressive, slow-growing, and less commonly metastasis than other malignancies. Even though the patient is asymptomatic and suspected of having biliary cystadenoma, surgery is required.

Frequently Asked Questions

1. Should Hepatic Cysts Be a Cause for Concern?

Hepatic cysts, typically filled with fluid, are frequently found in the liver, often without causing any issues, as they are generally benign. However, when these cysts are numerous or grow considerably, they can raise concerns. Should these cysts lead to discomfort, pain, or a sensation of fullness in the right abdominal region, it is important to notice. Cysts exhibiting irregular shapes and containing solid components may require further evaluation, possibly involving a biopsy. Moreover, any alterations in the appearance of these cysts over time should be regarded as a potential cause for concern.

2. Is Treatment Necessary for Hepatic Cysts?

The approach to treating cysts varies based on several factors. When dealing with small, painless, and stable cysts that do not cause discomfort, they typically do not necessitate any specific treatment. However, surgical removal or drainage becomes a necessary course of action when confronted with large, symptomatic cysts. Treatment options like sclerotherapy or surgical intervention are called for in the case of complex cysts or any indications of growth or changes.

3. What Leads to the Development of Hepatic Cysts?

The exact cause of liver cysts remains elusive, yet various contributing factors play a role. These include congenital factors, which can either be present from birth or arise from genetic abnormalities. Polycystic liver disease is an example of a genetic disorder characterized by cyst formation in the liver. Aberrations in the bile ducts can also lead to cyst development. Acquired liver cysts may result from liver disease or trauma. Inflammatory conditions, such as abscesses, can likewise contribute to the formation of cysts.

4. What Is the Critical Size for a Hepatic Cyst?

Hepatic cysts are fluid-filled sacs, typically characterized by their benign nature. Cysts that measure less than 1.96 inches in size generally remain asymptomatic, causing no discomfort. However, when these cysts exceed 2 inches, they can lead to complications such as internal bleeding, pain, jaundice, and digestive disorders. It is worth noting that cysts gradually increasing in size over the years can eventually become a source of discomfort, often necessitating surgical resection.

5. What Are the Methods for Treating Hepatic Cysts?

The treatment approach for hepatic cysts is contingent upon their specific characteristics. Small, asymptomatic cysts are typically monitored without any active intervention. On the other hand, larger cysts often necessitate different treatment options, like aspiration (a procedure in which a needle drains the cyst's fluid content.) and sclerotherapy (injecting a chemical agent or alcohol into the cyst after drainage). In the case of sizable cysts, surgical removal becomes the recommended course of action, and this can often be accomplished using a laparoscope for a minimally invasive approach.

6. Do Hepatic Cysts Have the Potential to Grow?

Indeed, hepatic cysts are not static; they can grow, although the growth rate may differ from one individual to another. While some cysts remain small, others may gradually increase in size. These cysts can exhibit a slow growth pattern, ranging from 0.039 to 1.96 inches per year. Symptoms and discomfort manifest when these cysts rupture or exert pressure on adjacent structures.

7. Are There Dietary Choices That Can Help Reduce Liver Cysts?

As a standalone approach, dietary choices are not the foremost or most effective method for reducing liver cysts. The management of liver cysts primarily hinges on their size and characteristics. Nevertheless, it is important to note that maintaining a healthy diet can significantly benefit overall liver health. A well-balanced diet that restricts sodium intake moderates alcohol consumption, promotes proper hydration, and minimizes the consumption of processed foods, all contribute to the liver's well-being.

8. Is a Hepatic Cyst Synonymous With a Tumor?

It is crucial to clarify that hepatic cysts are not synonymous with tumors. A cyst is a fluid-filled sac that typically remains benign and does not exhibit uncontrolled growth. These cysts are often asymptomatic and are usually discovered incidentally during imaging tests. In contrast, liver tumors represent abnormal growths that can be either non-cancerous or cancerous, and they can present a range of symptoms. The management of liver tumors typically involves surgical removal or radiotherapy, depending on the specific characteristics of the tumor.

9. Are There Natural Ways to Reduce the Size of Liver Cysts?

The options for naturally enhancing liver health may be limited, but there are certainly effective methods to consider. These include adhering to a well-balanced diet encompassing whole grains, lean proteins, and healthy fats. Ensuring proper hydration, incorporating antioxidant-rich foods, limiting alcohol intake, engaging in regular physical activity, and effectively managing stress all promote liver well-being.

10. Explain What a Simple Hepatic Cyst Is?

A fluid-filled sac, reassuringly non-cancerous, characterizes a simple hepatic cyst and maintains controlled growth. Encased within a delicate membrane, it lacks solid components, resulting in an asymptomatic condition. On imaging studies, these cysts typically present as distinct, fluid-filled structures with well-defined boundaries. Importantly, they seldom demand any specific treatment but necessitate regular monitoring to ensure stability and rule out unforeseen developments.

11. What Are the Typical Sensations Associated With Liver Cyst Pain?

Common symptoms linked to liver cysts often encompass a feeling of fullness in the right abdominal region stemming from the pressure exerted on neighboring areas. Additionally, individuals may experience persistent, intermittent, or dull pain in the right abdomen. Discomfort or a dull ache can also arise when changing body positions. Abdominal tenderness at the site of the cyst can be another manifestation of these symptoms.

12. How and Why Does a Liver Cyst Result in Pain?

Pain and discomfort can manifest when pressure is exerted on the adjacent structures. As cysts enlarge, they may apply pressure on their own capsule, leading to pain. Moreover, irritation and inflammation of neighboring structures can also be a source of discomfort. Compression of blood vessels due to cyst expansion can contribute to pain. However, in more severe cases, such as infection, hemorrhage, or cyst rupture, the resulting discomfort can be intense, necessitating immediate and urgent management.

13. Is It Common to Have Hepatic Cysts?

Hepatic cysts are incredibly prevalent, and many individuals harbor small, asymptomatic liver cysts, often detected incidentally during imaging studies. Notably, approximately 5 to 10 percent of people worldwide have these liver cysts. Nevertheless, the likelihood of developing these cysts can increase as individuals age. Regular monitoring becomes imperative to ensure stability and rule out potential growth or changes over time.

14. What Are the Indicators of a Cancerous Hepatic Cyst?

Detecting a cancerous hepatic cyst involves paying attention to several key indicators. These include a noticeable alteration in the cyst's size, solid components within the cyst, thick walls or septations, and irregularly shaped cysts. The emergence of symptoms such as pain, discomfort, or jaundice is also a potential red flag. Moreover, increased blood flow within the cyst, observable in MRI or CT scans, can be another concerning sign. Biopsies can provide the necessary insights to diagnose the cyst as cancerous definitively.

Sources

Dr. Varun Chaudhry

Radiodiagnosis

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