Image of the Month—Diagnosis

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.

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

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.