Tumors In The Liver - Diagnostic Problems
Case 7 -
Linda D. Ferrell, M.D.
Wendy L. Frankel, M.D.
32 year old asymptomatic woman with a large palpable
non-tender mass in her RUQ found on physical exam. CT scan showed a mass in the liver. The mass was
cystic and measured 8 cm.
Case 7 - Figure 1 - Multilocular cyst partially denuded with an epithelial lining, low power
Case 7 - Figure 2 - Mucinous epithelium with basally oriented nuclei and an underlying "ovarian type" stroma, medium power
Multilocular cyst partially denuded with a focal
epithelial lining. Mucinous epithelium with basally oriented nuclei and an underlying "ovarian type"
Diagnosis- Biliary Cystadenoma
Hepatobiliary (biliary) cystadenoma (and cystadenocarcinoma)
Clinical features. Hepatobiliary, or biliary, cystadenomas are rare lesions, with
a higher incidence in women and histological counterparts in the pancreas and ovary. These cystic tumors
are typically associated with an ovarian type of stroma when they occur in women, but not in men. The
lesion can also be associated with the development of cystadenocarcinoma, which tends to be a low-grade
adenocarcinoma in the women, but has greater malignant potential in men.
Gross features. Hepatobiliary cystadenomas are almost always multilocular with a
smooth or somewhat trabeculated inner surface to the cyst walls. The cysts contain fluid of variable
appearance, including serous, mucinous, gelatinous, occasionally hemorrhagic, or even purulent. There
is no communication between the cysts and the biliary tree. Large polypoid projections from or dense
masses in the wall of a cyst often indicate zones of malignant transformation.
Microscopic features. The cysts are lined by a single layer of epithelial cells,
usually of a mucinous type. The cells can vary from flattened to cuboidal to columnar shapes, and small
papillary tufts may be present along the surface. The epithelial nuclei are bland and basally located
without mitotic activity. The underlying stroma often has an appearance similar to ovarian stroma (when
the lesion occurs in a woman), but this stroma may not be uniformly present. A more densely, hyalinized
stroma often separates the ovarian-like stroma from the adjacent liver. The cyst walls may also be lined
focally by macrophages, calcification, or scar-like tissue.
Cystadenocarcinomas arising in this lesion often have a
tubulopapillary type of histology. Features such as marked nuclear pleomorphism, loss of polarity,
mitotic figures, and multilayering of the epithelium all could suggest the possibility of transformation
to malignancy, and be designated as in situ cystadenocarcinoma, but invasion of the tumor into the stroma
is the best evidence for the presence of carcinoma.
Clinical features. Simple biliary cysts are generally an incidental finding. When
multiple cysts are present, they often represent a component of polycystic disease and are often
accompanied by von Meyenburg complexes (biliary hamartomas). Simple cysts have no or only slight
Gross features. Simple cysts are usually found in a subcapsular location, but some
can occur deeper in the parenchyma. They typically contain a clear, light-yellow fluid.
Microscopic features. Simple cysts are lined by a cuboidal to low columnar
epithelium with a fibrous wall. The epithelium may be disrupted or may be flattened, and the wall may
be thickened. Evidence for reactive changes such as recent or remote hemorrhage in the cyst wall may be