Flea Bytes: Hepatic Cysts

More common in women, 1.5:1 female to male ratio. 5% of people have cysts on autopsy and 5% of these are neoplastic. The majority of liver cysts (90%) are asymptomatic. Found incidentally on US or CT. Neoplastic cysts are mostly solitary. US imaging is most helpful and CT scan are used in specific cases. US helps determine content of the cysts. Certain cysts are responsive to estrogen.

Location in the liver does not help differentiate neoplastic from non-neoplastic.

Non-neoplastic cysts: wall is smooth, no septa, and no debris. Presence of these suggests the possibility of biliary cystadenoma or cystadenocarcinoma.

Liver tests are normal. In cases of congenital polycystic liver disease alkaline phosphatase maybe elevated.

Surgical removal and histologic sectioning is the only way to determine if neoplastic or not.

First must rule out Echinococcus – endemic worldwide and associated with rural areas with sheep. Test with ELIZA which is 90% sensitive. If surgery is not an option can consider aspiration. Mucin in cystic fluid is concerning for malignancy, but absence does not rule out malignancy. Also can check CEA and CA 19-9 in the aspirate, but inadequate NPV.

Monitor cysts that are 1-2cm, but if they grow to 2-5 consider, and definitely > 5 cm must consider surgery.

If all of the cyst tissue is removed, recurrence is unlikely, however if any part of the cyst wall is left behind recurrence can be up to 50%.
References:

Advances in Hepatology: Current Developments in the Treatment of Hepatitis and Hepatobiliary Disease: Managment of Heaptic Cysts – Jorge L Herrera
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886389/

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