A 35-year-old male presenting with a 7-month abdominal pain of the right upper quadrant visited our department. He was diagnosed with asymptomatic gallstones 3 years ago. He had no history of abdominal surgery or other medical history, and he has been healthy otherwise.
Due to the right upper quadrant pain, the patient had undergone hepatic puncture drainage at a local hospital 6 months before he visited our hospital. Computed tomography (CT) showed a well-defined, giant, heterogeneous mass (199 × 155 mm) in the right trisegment (Couinaud IV, V, VI, VII, VIII). Around 4,000 ml fluid containing blood was drained out from the mass over a period of 3 days. Erythrocytes and fibrin were present in the fluid, but malignant cells were not. Cytology and clinical examinations at the local hospital led to an initial diagnosis of subacute hematoma. However, the abdominal pain of the right upper quadrant was not resolved after drainage.
The patient was then sent to our hospital with a chief complaint of right upper quadrant abdominal pain. On examination, there were no significant abnormalities except for a palpable liver in the right upper quadrant.
Hematology and biochemistry results showed normal white blood cell count of 2.69 × 109/L (reference range 4.0–10.0 × 109/L), low hemoglobin of 102.0 g/L (reference range 120–160 g/L), and abnormal blood platelets count of 58u109/L (reference range 100–300 × 109/L). Hepatitis B surface antibody (HBsAb), Hepatitis B e antibody (HBeAb), and Hepatitis B core antibody (HBcAb) were all positive. Examination of liver function, kidney function, electrolytes, alpha-fetoprotein(s-FP), carcinoembryonic antigen (CEA), and carbohydrate antigen19-9(CA19-9) was all normal.
The thoracic cavity and lungs were normal on the chest film. Ultrasound scan revealed a giant non-echoic mixed cystic mass (138 × 179 mm) in the right hepatic lobe. Magnetic resonance imaging (MRI) confirmed a giant cystic hepatic lesion (Fig. ). Percutaneous biopsy was not performed considering the risk of bleeding and the possibility of malignant seeding in case that the lesion was neoplastic. Preoperative diagnosis could not be made solely based on imaging. The differential diagnoses included cystadenoma, cystadenocarcinoma, and hepatic cyst with bleeding.
Coronal cover of T-2 weight MRI showing a giant cystic mass involving segment IV, V, VI, VII, VIII of the liver
The patient later discharged himself from hospital due to the financial reasons. However, he returned 2 months later for another enhanced CT scan, which showed no significant changes in the size and character of the lesion; the laboratories studies also showed no noticeable changes. CT scan discovered a huge mass causing a great pain in the right upper quadrant. The laboratory and image findings were not sufficient to differentiate the benign or malignant nature of the mass, but it had a well-defined border with the liver tissues, so we decided that the tumor should be completely removed without further laparoscopic assessment/surgery.
During surgery, a giant, cystic, and smooth mass was found at the right trisegment of the liver (Couinaud IV, V, VI, VII, VIII). The falciform ligament and the left lateral lobe were extruded. Right trisegment resection of the liver combined with a cholecystectomy was therefore performed. There were no intra- or extra-hepatic duct dilatations, and the postoperative course was uneventful.
Histology of the resected specimen revealed a huge cystic mass about 250 × 230 mm in size. The mass was cystic and multilocular. Macroscopically, it was yellow-white in color, with a gel-like consistency, and formed into a massive blood clot (Fig. ). The specimen consisted of multiple thin-walled cysts, filled with clear serous fluid containing red blood cells. On microscopic examination, the specimen consisted of multiple cystic spaces lined by a layer of cells, morphologically consistent with mature differentiated endothelium (Fig. ). Based on these histological findings, a diagnosis of lymphangioma originating from the liver was rendered.
The resected tumor and gallbladder (see arrow). The gallbladder contained gallstones
Microscopically the lesion consisting of multiple cystic spaces lined by a layer of cells, morphologically consistent with mature differentiation endothelium. (H&E, ×200)
The recovery was uneventful and the patient has been followed up for 17 months. He was symptom-free postoperatively, with no evidence of recurrence on subsequent abdominal imaging.