Effective treatment of biliary cystadenoma

Abstract

Objective: Evaluate experience over 15 years with treatment of this lesion.

Summary background data: Biliary cystadenoma, a benign hepatic tumor arising from Von Meyenberg complexes, usually present as septated intrahepatic cystic lesions.

Methods: Data were collected concurrently and retrospectively on patients identified from hospital medical records reviewed for pertinent International Classification of Diseases, Ninth Revision, Clinical Modification and CPT codes, pathology logs, and from operative case logs. Pathology specimens were rereviewed to confirm the diagnosis of biliary cystadenoma or biliary cystadenocarcinoma by 2 GI pathologists.

Results: From October 1989 to April 2004 at our institution, 19 (18F:1M) patients had pathologically confirmed biliary cystadenomas, including one with a biliary cystadenocarcinoma. The mean age was 48 +/- 15 years at initial evaluation. Complaints included abdominal pain in 74%, abdominal distension in 26%, and nausea/vomiting in 11%. Only 1 patient presented with an incidental finding. Symptoms had been present for 3 +/- 5 years, with 1 to 4 different surgeons and many other physicians involved in the diagnosis or treatment prior to definitive ablation. Eight patients had undergone 20 previous treatments, including multiple percutaneous aspirations in 4 and 11 operative procedures. CT or US was diagnostic in 95%, with internal septations present in the hepatic cysts. Definitive operative intervention consisted of hepatic resection in 12 patients, enucleation in 6 patients, and fenestration and complete fulguration in 1 patient. There were no perioperative deaths. No recurrences were observed after definitive therapy, with follow-up of 4 +/- 4 years.

Conclusions: Biliary cystadenoma must be recognized and treated differently than most hepatic cysts. There remains a need for education about the imaging findings for biliary cystadenoma to reduce the demonstrated delay in appropriate treatment. Traditional treatment of simple cysts such as aspiration, drainage, and marsupialization results in near universal recurrence and occasional malignant degeneration. This experience demonstrates effective options include total ablation by standard hepatic resection and cyst enucleation.

FIGURE 1. Gross photograph of a typical formalin-fixed resection specimen of a biliary cystadenoma, showing a trabecular, multilocular cystic lesion with a thickened wall, and no papillary excrescences, polypoid areas, or significant solid components.

FIGURE 2. Biliary cystadenoma (40× magnification, hematoxylin and eosin stain). Lumen, upper third of frame. The mucosal surface is a simple, orderly, biliary-type columnar epithelium with basally oriented uniform and round nuclei. The mesenchymal stroma is typical of biliary cystadenomas, showing a benign spindle-cell population (“ovarian-like” stroma).

FIGURE 3. Biliary cystadenocarcinoma (40× magnification, hematoxylin and eosin stain). Increased nuclear pleomorphism and chromatin irregularity with increased epithelial cell stratification and tubulopapillary growth as compared with the biliary cystadenoma.

FIGURE 4. Representative CT scan image from a patient with a large biliary cystadenoma of the left lobe of the liver. Several septations are present. The interior illustrates a homogeneous appearance without studding of the internal lining sometimes seen with cystadenocarcinomas.