Should radiology reporting change surgeon's indication for surgery in cases of hepatic cyst?

Abstract

Presenter: Aman Kumar MD | University of North Carolina at Chapel Hill Background: Simple liver cyst is a benign condition with virtually no malignant potential. Patients either present with symptoms or they are discovered incidentally due to increasing utilization of abdominal imaging. Historically management is driven by symptoms of pain; however, with increasing reporting of ‘rule out biliary cystadenoma’, patients and surgeons are even more likely to pursue surgical option. Aim of the study is to correlate radiology reports and histology by conducting a retrospective analysis of patients referred to a tertiary hospital. Methods: We analyzed the clinical, radiologic and histopathologic data for patients operated on with a diagnosis of a cystic lesion in the liver in between January 2018 - December 2020. Results: Twenty patients are included in the study. CT/MRI of 6 (30%) patients were reported as biliary cystadenoma and 13 (65%) were reported as simple hepatic cyst and 1 (5%) had a diagnosis of cystic HCC. 10 (50%) patients had CT scans and 10 (50%) had MRI done for evaluation. All imaging was reported by an attending in radiology and the cases were discussed in a multidisciplinary hepatobiliary meeting. Out of the 6 cases reported as biliary cystadenoma, 5 (83%) were reported on MRI and 1 (16%) on CT scan. 18 out of 20 patients (90%) had intraoperative finding of a simple liver cyst and the patients underwent cyst wall fenestration demonstrative of clear fluid. 1 (5%) had a finding of HCC, so non-anatomical liver resection was performed. Histopathology in 18 of all the operated cases was conclusive of benign hepatic cystic lesion from the cyst wall biopsy. Four of the 20 cases, (20%) were asymptomatic and out of these 4 cases, 3 (75%) were initially reported as cystadenoma which ultimately turned out to be simple liver cyst on final pathology. There was a single patient who was reported as simple hepatic cyst on imaging turned out to be cystadenoma on histopathology. In this series the radiologic diagnosis of cystadenoma lead to unnecessary surgical intervention in 3 out of 4 (75%) of patients who were asymptomatic. Conclusion: Increasingly utilized ‘rule out diagnosis of biliary cystadenoma’ in patients with a simple hepatic cyst creates anxiety for the patient and can lead to unnecessary surgery in asymptomatic patients. Based on this series it may be time to revisit the radiologic reporting on hepatic cysts.