Laparoscopy-assisted extended right hepatectomy for giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma: a case report

Abstract

Background: Hemorrhagic hepatic cysts infrequently involve several iconographic changes requiring a differential diagnosis, primarily with a cystic malignancy. We herein report a case of laparoscopy-assisted extended right hepatectomy for a giant hemorrhagic hepatic cyst with an enhancing mural nodule that was clinically suspected of being biliary cystadenocarcinoma.

Case presentation: A 73-year-old woman was followed up for giant hepatic cyst occupying the right lobe of the liver. During the follow-up, an enhancing mural nodule was newly noted on computed tomography in 2016. Based on additional clinical examinations, biliary cystadenocarcinoma was undeniable, and laparoscopy-assisted extended right hepatectomy was performed for diagnostic and therapeutic purposes. She had no perioperative complications and was discharged on postoperative day 13. A histological examination of the mural nodule showed neovascularization within an organized hematoma.

Conclusion: We herein report a rare case of giant hemorrhagic hepatic cyst mimicking biliary cystadenocarcinoma that was successfully treated with laparoscopy-assisted extended right hepatectomy. Laparoscopic surgery in our case was an effective procedure performed with the utmost care.

Keywords: Hemorrhagic hepatic cyst; Laparoscopy-assisted surgery; Neovascularization; Organized hematoma.

Fig. 1

CT images of mural nodules in giant cyst. a Plain CT showed a dorsal unenhanced mural nodule within the cyst wall (arrow), b which did not change thereafter (arrow). c Enhanced CT showed a ventral mural nodule with weak enhancement in the early phase (arrow) and d with centripetal prolonged enhancement in delayed phase (arrow)

Fig. 2

MRI and FDG-PET images of the ventral mural nodule. a MRI showed that the cyst content was a high-signal and the mural nodule was a low-signal on T1 W1. b MRI showed the cyst content was a high-signal and the mural nodule was partially high-signal on T2WI. c MRI showed that the mural nodule was partially strong high-signal on DWI, d with low ADC value (ADC_min 0.00 mm²/s, ADC_max 0.91 mm²/s, ADC_mean 0.6 × 10⁻³ mm²/s). e FDG-PET showed an abnormal uptake in the mural nodule with SUV-max 2.3

Fig. 3

Surgical procedures. a The cyst content with chocolate color was trans-hepatically aspirated from a 7-cm upper midline incision. b The adhesiotomy between the cyst wall and right diaphragm was laparoscopically performed without rupturing the cyst wall. c Preparation for a hanging maneuver was performed. d Parenchymal division was performed under direct vision through the small laparotomy wound using a hanging maneuver (arrow) and the Pringle’s maneuver (arrowhead). e The specimen was carefully excised from the mini-laparotomy

Fig. 4

Macroscopic and microscopic findings of the resected specimen. a (left-hand): Macroscopically, a dark-red solid protuberance was found in the cyst wall (arrow). a (right-hand): Macroscopically, a thickened portion of the cyst wall where the dorsal mural nodule seemed to have originally existed was detected (arrowhead). b, c Hematoxylin and eosin staining showed that the cyst wall mainly consisted of thick fibrous stroma and the ventral mural nodule consisted of several sizes of blood-filled vascular cavities surrounded by endothelial cells within the organized hematoma (original magnification: b × 40, c × 100). d, e Hematoxylin and eosin staining showed that the thickened portion of the wall consisted of malformed veins of various sizes within the calcified hematoma (original magnification: d × 40, e × 200)

Fig. 5

Immunohistochemical staining. Immunohistochemical staining of ventral mural nodule was a positive for CD31 (original magnification × 40) and b negative for αSMA and c MDM2 (original magnification × 200). d The Ki-67 labeling index was 19.0% (original magnification × 200). e Immunohistochemical staining of the thickened portion of the cyst wall was positive for αSMA (original magnification × 200)