British Journal of Radiology 74 (2001),270-272 © 2001 The British Institute of Radiology
Haemorrhagic hepatic cyst: a differential diagnosis of cystic tumour
A Hagiwara, MD1,
Y Inoue, MD1,
T Shutoh, MD2,
H Kinoshita, MD2 and
K Wakasa, MD3
1 Departments of Radiology
2 2nd Surgery
3 Pathology, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno, Osaka 545-8585, Japan
Correspondence: A Hagiwara MD, Department of Radiology, Kobe City General Hospital, 4-6 Minatojimanakamachi, Chuo-ku, Kobe 650-0046, Japan.
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Abstract
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A 63-year-old man was found on ultrasound examination to have a hepatic cystic mass with a mural nodule, which was mildly enhanced on contrast enhanced CT and MRI. At surgery, the cystic fluid was haemorrhagic and histological examination of the mural nodule demonstrated an organized haematoma. This case is of interest in that an apparent mural nodule was present in a non-neoplastic cyst. Haemorrhagic hepatic cyst with an organized haematoma should be included in the differential diagnosis of cystic neoplasms.
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Introduction
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Simple liver cysts are common and benign, usually asymptomatic and require no treatment. Although rare, haemorrhage, infection, rupture or torsion may occur in simple cysts and may require treatment. On imaging studies it is sometimes difficult to differentiate simple hepatic cysts from cystic neoplasms, particularly when the cyst wall is irregular in appearance or a portion of the cyst is abnormally enhanced after intravenous contrast medium. We report a case of unusual imaging findings for a haemorrhagic liver cyst with a large mural nodule, which was found to be an organized haematoma.
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Case report
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A 63-year-old man with chronic hepatitis C had been observed for 4 years. Laboratory tests demonstrated mildly abnormal liver function and an ultrasound examination was therefore performed. He had no pertinent past medical history other than chronic hepatitis, and no history of abdominal trauma. Blood counts, coagulation factor levels and tumour marker levels were normal. Ultrasound showed an 8 cm cystic mass in the right lobe of the liver, containing cyst fluid that was isoechogenic to hyperechogenic compared with the liver parenchyma, and a hyperechogenic mural nodule 2 cm in diameter. On unenhanced CT, the cyst wall appeared thin and smooth with small scattered calcifications and a mural nodule. The cyst fluid was hyperdense relative to water (Figure 1
). On MRI, the cyst fluid was homogeneously hyperintense on T1 weighted images (Figures 2 and 3) and heterogeneously hyperintense with multiple linear isointense areas on T2 weighted images (Figure 4). The mural nodule was hypointense on both T1 and T2 weighted images, and focal faint enhancement was noted on contrast enhanced T1 weighted images (Figure 5). A hepatic cystic neoplasm with intracystic haemorrhage or with protein-rich cyst fluid was suspected based on these imaging findings. Cyst aspiration or biopsy of the mural nodule was not performed because of risk of dissemination. At surgery, the cyst margin was well defined and total removal of the lesion was easily performed. The cyst wall was thin and smooth, the mural nodule had a smooth margin, and the cyst fluid was haemorrhagic, dark red, of low viscosity and contained numerous white cholesterin granules (Figure 6). On histological examination, the mural nodule was an organized haematoma, composed of fibrous tissue and capillaries with old and new haematoma. The cyst wall was composed of fibrous tissue without epithelial cells. No neoplastic cells were observed in either the mural nodule or the cyst wall. The lesion was diagnosed as a haemorrhagic liver cyst (Figure 7). No recurrence has been noted during the 3-year period following surgery and the patient has been well.
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Figure 1. Non-contrast CT. A cystic mass is seen in the right lobe of liver. The cyst wall is partially calcified and appears ill defined as a result of partial volume effect on this image. A mural nodule is seen on the ventral aspect of the cystic mass.
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Figure 2. Coronal T1 weighted spoiled gradient echo image (TR/TE/flip angle 79.7/7.1/90). The margin of the cystic lesion is well defined and the cyst wall is thin and smooth. The fluid is homogeneously hyperintense and the mural nodule is hypointense.
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Figure 3. Axial T1 weighted spoiled gradient echo image (TR/TE/flip angle 146.1/4.1/90). The mural nodule is hypointense. As a result of partial volume effect, the margin of the cystic lesion is unclear and the fluid appears heterogeneously hyperintense.
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Figure 4. Axial T2 weighted spin echo image (TR/TE/flip angle 2014/80/65). The fluid is heterogeneously hyperintense with linear isointense areas, and the mural nodule is hypointense.
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Figure 5. Enhanced axial T1 weighted spoiled gradient echo image (TR/TE/flip angle 146.1/4.1/90). Focal enhancement is noted in the mural nodule (arrow).
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Figure 7. Pathological specimen of the mural nodule (x10). The cyst wall is composed of fibrous tissue, and epithelial cells are absent. The outer portion of the wall is the liver parenchyma, while the upper portion of the wall is the mural nodule.
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Discussion
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Haemorrhage into a simple liver cyst is rare. Symptoms of haemorrhagic liver cysts are non-specific and include abdominal pain, discomfort and nausea. In some cases, as in this one, haemorrhagic liver cysts are asymptomatic and an incidental finding. Medical or surgical treatment may be necessary if symptoms develop. In recent years, there has been a trend to avoid surgical treatment of such cysts, because intracystic injection of ethanol or minocyclin achieves better results with fewer complications [1]. However, surgery is often performed because it is difficult to differentiate this type of lesion from cystic neoplasm, as in this case.
In most cases, the causes of intracystic haemorrhage are unclear. Haemangioma and vascular malformation near or in the cyst wall may cause intracystic haemorrhage, as can trauma. In this case, however, no such lesions were found on histological examination and there was no past history of abdominal trauma. Since the mural nodule was composed of various stages of haematoma from erythrocytes to fibrous tissue, it seems likely that haemorrhage repeatedly occurred and organized, so that the mural nodule gradually became enlarged.
Typical findings on ultrasound in haemorrhagic liver cysts are cyst fluid that is hyperechogenic compared with that in simple cysts and, frequently, internal echoes that mimic septations or solid portions [1–4]. On CT and MRI, most cyst walls are thin and smooth, and not enhanced after intravenous contrast medium. However, enhanced thick walls are occasionally seen when inflammation, granulation or fibrosis occurs. Calcification may occur in the cyst wall, but may also be seen in non-haemorrhagic simple cysts. As a result of haemorrhage, cyst fluid is usually hyperdense on CT, hyperintense on T1 weighted MR images and hypointense to hyperintense on T2 weighted images. A fluid–fluid level is sometimes observed [1–4]. An enhanced mural nodule, which was histologically proven to be benign granuloma, has been reported in the Japanese litarature, but it was much smaller than the mural nodule in the present case.
In this case, differentiation from cystic neoplasm was very difficult before surgery because of the focally enhanced large mural nodule present in the cyst. In retrospect, since the mural nodule was weakly enhanced and was of relatively low signal intensity on T2 weighted images, possible diagnoses other than cystic neoplasm should have been considered in this case, such as organized haematoma, granuloma or other masses mainly composed of collagen or fibrous structures. In contrast, most solid components of cystic neoplasms are hyperintense compared with the surrounding liver parenchyma on T2 weighted images.
In conclusion, when a hepatic cystic mass with a mural nodule is observed, haemorrhagic liver cyst with organized haematoma should be included in the differential diagnosis.
Received for publication August 2, 2000.
Revision received October 20, 2000.
Accepted for publication November 2, 2000.
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References
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Vilgrain V, Silbermann O, Benhaniou JP, Nahum H. MR imaging in intracystic hemorrhage of simple hepatic cysts. Abdom Imaging 1993;18:164–7.[Medline]
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Wilcox DM, Weinreb JC, Lesh P. MR imaging of a hemorrhagic hepatic cyst in a patient with polycystic liver disease. J Comput Assist Tomogr 1985;9:183–5.[Medline]
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Yamaguchi M, Kuzume M, Matsumoto T, Matsushima A, Nakano H, Kumada K. Spontaneous rupture of nonparasitic liver cyst complicated by intracystic hemorrhage. J Gastroenterol 1999;34:645–8.[Medline]
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