PMC3804805_01
Computed tomography scan (A) and magnetic resonance imaging (B, C) demonstrating an extremely large, cystic mass in the right hepatic lobe. T1-weighted images (B) and T2-weighted images (C). 18F-fluorodeoxyglucose positron emission tomography scan with an area of FDG avidity (arrow) in the cyst wall (D).
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The patient, a 59-year old man, was admitted with a complaint of abdominal fullness and early satiety and a 30x25 cm cystic mass in the right hepatic lobe, demonstrated on computed tomography (CT) (Figure 1A). On magnetic resonance imaging (MRI), the signal pattern of the cystic contents had low signal intensity on T1-weighted images (Figure 1B) and high intensity on T2-weighted images (Figure 1C). AFP and PIVKA-II were all normal. An 18F-fluorodeoxyglucose positron emission tomography scan (FDG-PET) demonstrated an FDG avid area in the cyst wall (Figure 1D).
Intraoperative findings. The cyst occupied the epigastrium (A). A small excrescence (arrow) was observed in the cystic wall in the area of FDG avidity (B). Histopathological findings of the cyst removed during the first surgery. The wall was composed of fibrotic tissue (C). Papillary tissue was evident in the frozen section, and cellular abnormalities were observed (D).
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Laparotomy exposed the cyst which was covering the epigastrium (Figure 2A). The cyst was opened and a small excrescence was present in the area corresponding to the hypermetabolic area on FDG-PET (Figure 2B). Pathological examination showed most of the cyst wall was composed of a fibrotic tissue (Figure 2C). However, in the permanent sections using frozen tissue for intraoperative diagnosis, papillary proliferation of atypical cells with enlarged nuclei was observed (Figure 2D).
The residual cyst was removed along with the right hepatic lobe (A). Atypical papillary epithelium (B). The atypical epithelium was contiguous with the normal bile duct epithelium (C).
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A partial hepatectomy encompassing the cyst and hepatic right middle lobe was performed (Figure 3A). Pathological examination demonstrated papillary atypical epithelium lining portions of the cyst wall (Figure 3B) which was contiguous with the normal bile duct epithelium (Figure 3C), indicating that the cyst originated in the biliary tree.