Biliary Cystadenoma: A Suggested 'Cystamatic' Approach?

A 45-year-old woman was referred to our clinic in 2014 for evaluations of a recurrent hepatic cyst incidentally discovered by computed tomography (CT) scan approximately 10 years prior to referral. Since its radiographic appearance was consistent with a simple cyst, no intervention was recommended. She developed right upper quadrant and epigastric pain in 2011, prompting a repeat CT scan that demonstrated the diameter of the cyst to have increased to *12 cm. Though it was still thought to be a simple cyst, given her new symptoms and modest growth in cyst size, she underwent a laparoscopic cyst fenestration with biopsy of the cyst wall. Although the final pathological examination revealed a hepatobiliary cystadenoma with ovariantype stroma, no action was taken beyond surveillance. Symptoms recurred after her operation; the abdominal pain intensified after she became pregnant. Magnetic resonance imaging (MRI) repeated in 2013 demonstrated a 14-cm hepatic cystic mass with a thin septation. Complete blood count and comprehensive metabolic panel were normal with the exception of a mildly elevated serum alkaline phosphatase (140 l/mL). Serum cancer antigen 19–9 was slightly elevated (70 l/mL). A repeat MRI at our hospital showed a large cyst in the center of the liver with perihilar mass effect and mild intrahepatic biliary ductal dilation. The cyst was located at the bifurcation of the right and left hepatic pedicles with more profound distortion of the left (Fig. 1). She appeared healthy without jaundice with a benign abdominal examination. Based on the pathology from her initial operation and the relentless cyst growth, an extended left hepatectomy was recommended for definitive resection. The patient elected to wait a year until her child was older prior to undergoing the operation. At surgery in 2015, intraoperative ultrasound was consistent with the previous CT scan in that the cyst had internal debris without clear solid components (Fig. 2). The liver parenchyma was carefully divided in the plane between the cyst wall and the segment 5 and 8 pedicles in efforts to enucleate the cyst and preserve these pedicles to the right lobe of the liver (Fig. 3). The gross specimen contained a 13.5-cm cyst with no mural nodularity (Fig. 4). Pathology demonstrated a mucinous cystic neoplasm with low-grade dysplasia. Her postoperative recovery was uncomplicated.