Various kinds of cystic lesions in the Liver: Case-based analysis

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1 Various kinds of cystic lesions in the Liver: Case-based analysis Poster No.: R-0018 Congress: RANZCR-AOCR 2012 Type: Educational Exhibit Authors: J.-H. Yoon, S.-H. Kim, Y.-J. Lim, J.-H. Ryu, H.-D. Kim Keywords: Liver, Abdomen, Ultrasound, CT, MR, Biopsy, Contrast agentintravenous, Education, Cysts, Pathology, Education and training DOI: /ranzcraocr2012/R-0018 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 55

2 Learning Objectives 1. To differentiate various focal cystic lesions form developmental, inflammatory, neoplastic lesion in the liver and perihepatic location. 2. To introduce critical clinical features, key radiologic findings of various cystic mass correlated with pathologic findings. Background In practice, we daily meet various cystic mass in the liver or perihepatic location from simple cyst to cystic neoplasm. The therapeutic strategy and clinical courses are very different between each disease that presents as cystic mass in the liver. So it is important to differentiate with noninvasive diagnostic methods. In this exhibit, each disease entity is introduced with radiologic findings and correlated pathologic findings. I hope you to enjoy the self-test form of this case-based analysis. Imaging Findings OR Procedure Details The contents of cystic liver lesions are developmental fibrocystic liver disease (biliary hamartoma, peribiliary cyst, autosomal dominant polycystic liver disease, Caroli disease, Choledocal cyst, ciliated hepatic foregut cyst), inflammatory and infectious cystic disease (pyogenic liver abscess, Hydatid cyst, hepatic Tuberculosis, eosinophilic infiltration, inflammatory pseudotumor), and Neoplastic cystic lesions (cystic metastasis, biliary cystadenoma, biliary cystadenocarcinoma, cystic HCC, IPMT, neuroendocrine neoplasm, epithelioid hemangioendothelioma, perihepatic lymphangioma, Mullerian cyst, and peritoneal inclusion cyst. Page 2 of 55

3 These patients were underwent US, contrast-enhanced US, CT or MRI (MRCP). All images were reviewed the shape, morphology, presence of septum and enhancing solid portion, and correlated with pathologic characteristics. Images for this section: Fig. 1: F/31,Incidentally performed contrast enhanced CT scan shows saccular dilatation of the biliary tree with enhancement of eccentrical vascular structures. Page 3 of 55

4 Fig. 2: F/31,Contrast enhanced CT scan shows saccular dilatation of the biliary tree with enhancement of central portal vein radicals, suggesting intraluminal portal vein "central dot sign" Percutaneous transhepatic cholangiogram shows multiple saccular dilatations of the intrahepatic bile ducts (arrows), mostly at the periphery of the liver, and fusiform dilatation of the common bile duct. Page 4 of 55

5 Fig. 3: F/45, Incidentally performed abdominal CT scan shows multiple small sized cystic lesions in both lobe, mainly periportal areas, suggesting peribiliary cysts Page 5 of 55

6 Fig. 4: 47/F, Incidentally detected Calori disease combined with peribiliary cysts Page 6 of 55

7 Fig. 5: 64/M, biopsy confirmed. Incidental findings. CT on arterial and portal phase show numerous small cystic lesions scattered throughout the liver. No enhancement is seen. Page 7 of 55

8 Fig. 6: US is confirmative tool! US findings of Biliary Hamartomas 1)Small well circumscribed lesions, less than 1.5cm scattered throughout liver 2)Hypo-, hyperechoic foci with reverberation artifacts!! 3)Sometimes, mimicking chronic hepatitis or liver cirrhosis Page 8 of 55

9 Fig. 37: F/75 jaundice, no fever Low echoic mass in liver No vascularity on CDI Page 9 of 55

10 Fig. 38: About 3.5cm lobulating contoured low echoic lesion in S-7/8. - DDx. 1) abscess. 2) infected cyst. 3) bilairy cystadenoma 4) several hepatic cysts in both hepatic lobe. Diagnosis) Liver abscess -Alpha hemolytic streptococcus Page 10 of 55

11 Fig. 39: F/61, F/U after breast cancer Well marginated cystic mass with irregular morphology Periph rim enhancement Radiologic DDx) Metastasis, Fungal abscess Page 11 of 55

12 Fig. 40: Diagnosis: Eosinophilic Infiltration Page 12 of 55

13 Fig. 36: Primovist enhanced Dynamic MRI, this mass leion shows centripetal enhancement pattern with nonenhancing central portion. Dx: Epithelioid Hemangioendothelioma, high grade, positive for CD34, Factor VIII, Vimentin Page 13 of 55

14 Fig. 35: T2-T1-in-out On MRI, intermediate SI on T2WI, low SI on T1WI. No definite signal drop on in and out of phase T1WI. Page 14 of 55

15 Fig. 34: M/22, Incidental mass on liver low echoic mass with suspected cystic foci on US. Iso-or subtle hypoechoic mass and on CT, a low density mass in medial aspect of S-5/6 with suspicious nodular enhancement on delayed phase. D/Dx) hemangioma or other mass lesion. Page 15 of 55

16 Fig. 33: Imaging Finding of Primary or secondary hepatic NET. Page 16 of 55

17 Fig. 32: Dx: Neuroendocrine neoplasm G2 (well-differ endocrine carcinoma) Page 17 of 55

18 Fig. 31: T2 high SI and T1 low SI main lesion with T2 very high SI internal foci without enhancement Arterial peripheral enhancement and definite contrast washout on delayed phase. Diffusion restriction on DWI. Page 18 of 55

19 Fig. 41: M/41, Rt. Chest pain Multifocal cystic mass with rim enhancement, subcapsular location DDx) Liver abscess (pyogenic, eosinophilic), metastasis Page 19 of 55

20 Fig. 42: D/Dx) 1. Tbc pleurisy 2. Parasitic infection 3. eosinophilic lung disease Dx) Hypereosinophilic syndrome Page 20 of 55

21 Fig. 52: Recent article for Inflammatory Pseudotumor Page 21 of 55

22 Fig. 51: Recent article for Inflammatory Pseudotumor Page 22 of 55

23 Fig. 50: 38/M, incidentally detected liver mass during URI treatment US of liver demonstrates well defined heterogeneous low echoic solid mass with central anechoic portion (arrow). Color Doppler US shows linear septal like vascularity. Arterial phased CT show four layered enhancing pattern, central low, intermediate high, peripheral low, and far lateral hyperemic change (arrows). Delayed phased CT shows two layered enhancing pattern due to thick peripheral enhancement. Dx: inflammatory pseudotumor Page 23 of 55

24 Fig. 49: US shows poorly defined subtle low echoic mass lesion in Rt. lobe, liver (arrows). Histopathlogy confirmed mass composed of fibrocollagenous stroma, immature fibroblasts, myofibroblasts, plasma cells, histiocytes, and eosinophils, so compatible with Inflammatory pseudotumor. Page 24 of 55

25 Fig. 48: 58/M fever, chilling for 15 days CT scan show multilayered enhancing solid mass showing delayed peripheral enhancement more than normal parenchyma (arrow) Page 25 of 55

26 Fig. 47: Another Tbc. Case 38/F, general ache for 1 wk. Page 26 of 55

27 Fig. 46: Review of Hepatic Tuberculosis Page 27 of 55

28 Fig. 45: M/75, Incidental mass Dx. Partial hepatectomy : granulomatous inflammation with extensive central necrosis, c/w Tbc. granuloma Page 28 of 55

29 Fig. 44: M/75, Incidental mass Underlying chronic liver disease Cystic mass with septation, peripheral rim enhancement DDx) Peripheral CCC, Biliary cystadenoma Page 29 of 55

30 Fig. 43: Idiopathic Hypereosinophilic syndrome Page 30 of 55

31 Fig. 30: On CT, hypovascular mass containing tiny several cystic portion. Page 31 of 55

32 Fig. 29: M/71 known prostatic cancer Mixed echoic masses in liver with several intratumoral cystic foci on US. Page 32 of 55

33 Fig. 15: M/40, RUQ discomfort, fever/chill, lived in Iraq last 4 yrs. & favor to eat the baked dog, sheep & snake. Page 33 of 55

34 Fig. 14: Dx Consistent with choledochal cyst Fusiform dilatation of CHD and cystic duct Choledochal cyst with GB cancer and pancreatic cancer(synchronous cancer) Page 34 of 55

35 Fig. 13: F/55, incidentally detected pancreatic cystic mass Necrotic solid pancreatic mass Abnormal GB wall thickening Fusiform dilated CHD (arrow) High uptake on PET CT Page 35 of 55

36 Fig. 12: F/15, incidentally detected mass Fusiform dilatation of mid CBD & cystic duct Dx) Consistent with choledochal cyst involving cystic duct (varient) Page 36 of 55

37 Fig. 11: 6 months F/U CT --Slightly thickened wall of the cyst, No significant change of size --DDx) congenital hepatic cyst biliary cystadenoma --Dx:ciliated foregut cyst Page 37 of 55

38 Fig. 10: M/60 1. Underlying chronic liver disease with CAPD status. 2. probable pyogenic liver abscess in the left lobe lateral segment showing soap-bubble like appearanced low density lesion with peripheral thin rim like enhancement. Septated low density probable cystic mass lesion in the S-4 (3.5x2cm). --DDx) congenital hepatic cyst such as hepatic foregut ciliary cyst Page 38 of 55

39 Fig. 9: ADPCKLD with peribiliary cysts. T2WI Coronal MRI shows innumerable renal and hepatic cysts. The cysts are thin walled with regular margins. Peribiliary cysts are combined state. Photograph of the hepatectomy specimen shows numerous cysts that completely replace the hepatic parenchyma. Page 39 of 55

40 Fig. 7: Case 4. What's your diagnosis? 42/M, Multiple variable sized hepatic cysts in both lobe some cysts contain peripheral calcifications. Page 40 of 55

41 Fig. 8: Characteristics of Hepatic ADPCLD Page 41 of 55

42 Fig. 16: Well demarcated large low attenuated cyst in Rt. lobe Numerous membranelike structure in the cyst. Multiseptated cyst with surrounded daughter cysts in Lt. lobe of liver, containing ring like calcification. Confirmed with Hydatid cyst. Page 42 of 55

43 Fig. 17: F/47, RUQ pain Cystic mass with inner papillary solid component with good enhancement on CE-US and CT. DDx Liver abscess, hydatid cyst Page 43 of 55

44 Fig. 18: Histology Cuboidal or culumnar epithelium with papillary projection, confirmed with Biliary cysadenocarcinoma. DDx point Multiloculated/septated cystic mass Inner papillary solid component with good enhancement Page 44 of 55

45 Fig. 28: Pathophysiology of cystic liver metastasis. Page 45 of 55

46 Fig. 27: M/45 Multiple low attenuating cystic masses in liver Similar cystic lesion in pancreas. USG guided needle aspiration confirmed metastatic adenocarcinoma of liver, clinically from pancreas cancer. Page 46 of 55

47 Fig. 26: Histology confirmed totally necrotic nodule with cell ghost of HCC. Page 47 of 55

48 Fig. 24: M/51, incidentally detected mass Low attenuating mass on CT, subtle peripheral enhancement and iso echoic mass on USG with spotty peripheral vascularity. Page 48 of 55

49 Fig. 23: F/59, RUQ pain CT and USG show extrahepatic, thin walled cyst containing solid protruding nodules in the cyst Radiologic DDx) Cystic lymphangioma Cystic teratoma Mesothelial cyst Dx) Pathologic confirmed with Cystic lymphangioma CD31, CD34, FVIII, Col IV(+) Page 49 of 55

50 Fig. 22: F/57, known breast cancer CT and USG. MRI show intrahepatic,thin walled, tubular, multiseptated cyst, mimicking IHBD dilatation Dx) Pathologic confirmed with IPMT, high grade dysplasia. Page 50 of 55

51 Fig. 21: Op finding shows 10x5x5cm sized cystic mass attached to diaphragm, liver capsule and omentum, normal both ovaries. Histology reveals cuboidal to columnar epithelial cell lining with cilia resemble fallopian tube epithelium, confirmed with Mullerian cyst. Page 51 of 55

52 Fig. 20: F/59, RUQ pain On CT and USG, extrahepatic cystic mass with thin walled, multiseptations. High attenuating debris in the cyst. Radiologic DDx) 1.Cystic lymphangioma 2.Cystic teratoma 3.Mesothelial cyst Page 52 of 55

53 Fig. 19: F/39 Lobulating cystic mass with solid component, intrahepatic bile duct dilatation on US and CT. On cystography, lobulating contoured cystic mass communicated with IHBD, confirmed with Biliary cystadenoma. Page 53 of 55

54 Fig. 25: Dynamic MRI manifested complete ring enhancement. Page 54 of 55

55 Conclusion We tried to show all kinds of cystic lesions which can occur in the liver and perihepatic location with pathologic correlation. We hope that this help you differentiate cystic lesions that are faced frequently in daily practice. Personal Information Jung-Hee Yoon M.D., Ph.D. Associate Professor Department of Radiology Haeundae Paik Hospital, Inje University, College of Medicine 1435 Jwa-dong, Haeundae-gu, Busan, , Korea References 1. Brancatelli G, Federle MP, Vilgrain V, Vullierme MP, et al. Fibropolycystic liver disease: CT and MR imaging findings. Radiographics. 2005;25: Mortele KJ, Ros PR. Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiographics 2001;21: Page 55 of 55