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LETTER TO EDITOR  
Year : 2021  |  Volume : 64  |  Issue : 4  |  Page : 861-863
Mucinous cystic neoplasm of liver in a hepatitis B positive patient


Department of Laboratory Medicine, Chinmaya Mission Hospital, Bangalore, Karnataka, India

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Date of Submission25-Aug-2020
Date of Decision02-Oct-2020
Date of Acceptance01-Mar-2021
Date of Web Publication20-Oct-2021
 

How to cite this article:
Rafiqi L, Keskar S. Mucinous cystic neoplasm of liver in a hepatitis B positive patient. Indian J Pathol Microbiol 2021;64:861-3

How to cite this URL:
Rafiqi L, Keskar S. Mucinous cystic neoplasm of liver in a hepatitis B positive patient. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Nov 28];64:861-3. Available from: https://www.ijpmonline.org/text.asp?2021/64/4/861/328512




Dear Editor,

Mucinous cystic neoplasms (MCNs) are rare tumors occupying a small percentage of less than 5% of all the cystic lesions of the liver.[1] Clinical presentation is varied and differential diagnosis from other cystic lesions is challenging. These tumors are often misdiagnosed as hydatid cysts or simple cysts of the liver.[2] We report a case of MCN of the liver in a hepatitis B positive patient.

A 38-year-old diabetic female presented with a history of on and off jaundice of one-and-a-half-year duration. She was evaluated at multiple centers and was found to be hepatitis B positive with an elevation of liver enzymes. Ultrasound scans [Figure 1]g done outside revealed a 6 × 4 cm cyst in segment IV of the liver with features of hydatid cyst, rupture/extension into the common bile duct causing biliary obstruction along with altered liver texture. The patient was put on anthelmintic medication elsewhere and subsequently referred to our hospital for surgical management as there was no improvement with the medication. The patient underwent removal of the cyst along with cholecystectomy and liver biopsy.
Figure 1: (a) Cyst wall with cyst macrophages (H and E ×100). (b) Cyst lined by columnar epithelium and underlying ovarian-like stroma (H and E ×200). (c) Lining cells show intracellular mucin (H and E ×400). (d) Ovarian type stroma shows immunoreactivity for progesterone receptor (×200). (e) Liver biopsy with features of chronic hepatitis and bridging fibrosis (H and E ×100). (f) Cirrhotic changes in the liver are highlighted by Masson's trichrome stain (×100). (g) Ultrasound scan image shows the cyst communicating with intrahepatic bile duct

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We received fragmented cystic and hemorrhagic tissue, the largest fragment measuring 3.0 × 2.5 cm. The cut surface was cystic and revealed thick mucoid material, the tissue was entirely processed. Microscopy revealed a multiloculated cyst lined by columnar epithelium, mucin containing cells, and areas of mild atypia of the lining [Figure 1]a, [Figure 1]b, [Figure 1]c. Underlying cellular ovarian-like stroma was positive for progesterone receptor [Figure 1]d. Focal stromal inflammation was seen. There was no high-grade dysplasia or invasive malignancy; hence, the diagnosis of low-grade MCN of the liver was made. Liver biopsy revealed chronic hepatitis and cirrhotic changes [Figure 1]e and [Figure 1]f.

MCNs are slow-growing rare cystic lesions of the liver. They mostly present in the fifth decade of life and occur more commonly in females.[1] The tumor is thought to result from the development of ectopic rests of primitive foregut sequestered within the liver or it is due to the obstruction of the congenitally aberrant bile duct.[3] These lesions have been reported as “biliary cystadenoma.” In 2010, the WHO categorized the biliary cystadenoma into MCNs with low-, intermediate-, or high-grade intraepithelial neoplasia.[1]

Clinical manifestations of the tumor are not specific and can be variable. When the lesion compresses the extrahepatic bile duct, obstructive jaundice may be the presenting feature.[4]

The primary location is in the left liver lobe, mostly in segment IV. Communication with the bile duct is not usually associated with MCNs of liver but may rarely occur, as reported in a few cases.[5] With a large diameter, erosion of the expanding cyst wall into the biliary ducts has been proposed as the cause for communication.[6] Hence, communication with the bile duct though typically associated with intraductal papillary mucinous neoplasm, may rarely be seen in cases of MCNs.[5]

On histology, the cystic spaces are typically lined by cuboidal to columnar mucin secreting epithelium with underlying ovarian-type stroma.[2] Malignant transformation may occur; hence, extensive sampling of the lesion is mandatory. The treatment of choice is complete resection.[1]

MCN of the liver should be considered in the differential diagnosis of cystic liver lesions despite bile duct communication since this may rarely occur, as in this case. The patient had co-existent Hepatitis B Virus (HBV)-associated cirrhosis, which does not have any documented pathological association with MCNs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors appreciate the efforts put in by histotechnicians Mr. Narayanaswamy and Ms. Uma Maheshwari.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Simo KA, Mckillop IH, Ahrens WA, Martinie JB, Iannitti DA, Sindram D. Invasive biliary mucinous cystic neoplasm: A review. HPB (Oxford) 2012;14:725-40.  Back to cited text no. 1
    
2.
Ahmad Z, Uddin N, Memon W, Abdul-Ghafar J, Ahmed A. Intrahepatic biliary cystadenoma mimicking hydatid cyst of liver: A clinicopathologic study of six cases. J Med Case Rep 2017;11:317.  Back to cited text no. 2
    
3.
Florman SS, Slakey DP. Giant biliary cystadenoma: Case report and literature review. Am Surg 2001;67:727-32.  Back to cited text no. 3
    
4.
Preetha M, Chung AY, Lim-Tan SK, Lim DT, Thng CH. Intrahepatic biliary cystadenoma presenting with obstructive jaundice. Asian J Surg 2004;27:243-5.  Back to cited text no. 4
    
5.
Kunovsky L, Kala Z, Svaton R, Moravcik P, Mazanec J, Husty J, et al. Mucinous cystic neoplasm of the liver or intraductal papillary mucinous neoplasm of the bile duct? A case report and a review of literature. Ann Hepatol 2018;17:519-24.  Back to cited text no. 5
    
6.
Nakayama Y, Kato Y, Okubo S, Takahashi D, Okada R, Nishida Y, et al. A case of mucinous cystic neoplasm of the liver: A case report. Surg Case Rep 2015;1:9.  Back to cited text no. 6
    

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Correspondence Address:
Lubna Rafiqi
E72, Diamond District Apartments, Kodihalli, Bangalore -560008, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_1023_20

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