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June 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(6):756. doi:10.1001/archsurg.2011.124-b

Answer: Cystic Hepatocellular Carcinoma

Pathological examination revealed a hemorrhagic and necrotic hepatocellular carcinoma involving the cyst's wall, which was surrounded by a fibrous capsule (Figure 2). Cirrhosis and 20% of fatty degeneration were also reported. A right lobectomy was performed 2 months later that was associated with a partial diaphragm resection caused by firm adhesions involving the liver. Postoperative course was uneventful. Final pathological examination revealed a 2-cm residual cystic hepatocellular carcinoma (HCC) with hepatic and diaphragmatic margins free of tumor. After 13 months of disease-free survival, the patient is abstinent and continues with a favorable outcome.

Figure 2 
Microscopic photography of cystic hepatocellular carcinoma. The small circle shows the hepatocellular carcinoma, which is the wall of the cyst. The big circle shows the cavity of the cyst.

Microscopic photography of cystic hepatocellular carcinoma. The small circle shows the hepatocellular carcinoma, which is the wall of the cyst. The big circle shows the cavity of the cyst.

In a cirrhotic liver, HCC is the most frequent primary malignant tumor. Although diagnosis of classical forms of HCC has been improved thanks to standardized criteria (imaging studies with contrast enhancement and α-fetoprotein levels),1 the diagnosis of particular forms of HCC remains challenging.

In our patient, the first radiological assessment allowed us to rule out a simple hepatic cyst, which classically displays neither capsule nor peripheral enhancement. The main diagnoses assumed were a hydatic cyst, a liver abscess, and a mucinous cystadenoma or cystadenocarcinoma. Despite negative serological test results and the absence of calcifications within the cystic wall, a hydatic cyst could not be ruled out. The patient's adequate health (without inflammatory distress) did not exclude a diagnosis of liver abscess but made it less likely. The radiological features could also correspond to either a necrotic tumor (such as a primary or metastatic tumor) or a cystic tumor (such as mucinous cystadenoma or cystadenocarcinoma). A fluid analysis of the cyst for carcinoembryonic antigen and cancer antigen 19-9 levels had been proposed to help for this latter diagnosis, but it was not performed for our patient.2

Cystic HCC is a rare entity with very few cases reported in the literature.3-5 Because the most common form of presentation for HCC is a solid tumor, this kind of cystic mass is difficult to differentiate from other benign or malignant cystic lesions, especially abscesses or necrotic tumors.5 These cystic tumors are mostly of metastatic origin, such as those arising from carcinoid tumors, ovarian or pancreatic cystadenocarcinomas, sarcomas, choriocarcinomas, epidermoid carcinomas, melanomas, or small cell lung tumors.3,6

In conclusion, we report the unusual case of a cystic HCC. This very rare form of presentation should be kept in mind when trying to diagnose an atypical hepatic cyst in a cirrhotic patient.

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Article Information

Correspondence: Ahmed Fouad Bouras Jr, MD, Department of Digestive Surgery and Transplantations, Aile Ouest, Hopital Huriez, rue Michel Polnovski, 59037 Lille CEDEX, France (

Accepted for Publication: February 26, 2010.

Author Contributions:Study concept and design: Bouras, Truant, Zerrweck, Boleslawski, Pruvot, and Zerbib. Acquisition of data: Bouras. Drafting of the manuscript: Bouras and Zerrweck. Critical revision of the manuscript for important intellectual content: Truant, Boleslawski, Pruvot, and Zerbib. Study supervision: Truant, Boleslawski, Pruvot, and Zerbib.

Financial Disclosure: None reported.

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