Biliary Cystadenocarcinoma

Case History: A 52-year-old female patient complaining from right hypochondrial pain and abdominal swelling for three months, nausea and vomiting.

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Figure A: Large multilocular cyst involving most of the right hepatic lobe with enhanced through transmission. The content of the cysts having low-level echoes and mural nodules with papillary projections project into the cyst lumen.

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Figure B: Large multilocular cyst involving most of the right hepatic lobe with enhanced through transmission. The content of the cysts having low-level echoes and mural nodules with papillary projections project into the cyst lumen.

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Figure C

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Figure E

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Figure I

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Figure J

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Figure K

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Figure L

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Figure M

Triphasic CT axial images (arterial phase C-G), (portal phase H-K), (delayed phase L-M) showing large partially defined right hepatic cystic lesion, with heterogeneous enhanced soft tissue papillary projections and mural nodules in the arterial phase followed by wash out of contrast at both venous and delayed phases. Displaced surrounding abdominal structures by the large mass.

Diagnosis: Biliary cystadenocarcinoma

Discussion: A biliary cystadenocarcinoma is a rare cystic hepatic neoplasm. It can be thought of as a malignant counterpart of a biliary cystadenoma. The clinical symptoms are non-specific and are not distinctive from benign cystic liver lesions unless invasive growth of the tumor occurs or distant metastases are present.

The vast majority of these neoplasms are intrahepatic (97 percent) where a small proportion is extrahepatic (3 percent). Some biliary cystadenomas may rarely develop into a cystadenocarcinoma.

The appearance of the cyst fluid on CT is variable depending on its composition. It can range from that of water (HU = 0) to quite hyperattenuating if the cyst has been complicated by recent hemorrhage. Calcifications of septa or cyst wall may be seen. Additionally the septa may enhance following administration of contrast.

The MR signal intensity of biliary cystadenoma is variable on both T1- and T2-weighted images, depending on the content of the cyst fluid.

References:
1. Levy AD, Murakata LA, Abbott RM et-al. From the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Institute of Pathology. Radiographics. 22 (2): 387-413.
2. Lewin M, Mourra N, Honigman I et-al. Assessment of MRI and MRCP in diagnosis of biliary cystadenoma and cystadenocarcinoma. Eur Radiol. 2006;16 (2): 407-13.
3. Horton KM, Bluemke DA, Hruban RH et-al. CT and MR imaging of benign hepatic and biliary tumors. Radiographics. 19 (2): 431-51.

Doaa Ibrahim, MD in radio-diagnosis, Zagazig University Hospitals and TechnoScan Centers in Egypt