Biliary cystadenoma is a cystic (either unilocular or multilocular) intrahepatic lesion that is considered to be a rare entity in clinical practice [1] [2] [3]. The tumor originates in the bile ducts, with the right lobe identified as the principal location in more than half of all cases [1] [4]. However, extrahepatic location (the cystic, common hepatic, and bile ducts) has been documented in a small number of patients [1] [5]. The exact pathogenesis model remains unknown; for some reason, biliary cystadenomas are mainly encountered in middle-aged women [2] [3] [4] [6]. The potential for malignant transformation of biliary cystadenoma is low [7], but a delay in diagnosis (signs and symptoms can be present up to several years) is perhaps one of the main factors for a poorer prognosis, implying that early recognition is essential [3]. The clinical presentation starts with symptoms such as abdominal pain that is often chronic in nature and a palpable mass in the right upper quadrant that persists for weeks, months, or even years [2] [3] [5] [6]. Anorexia, nausea, vomiting, and either weight gain or weight loss are other important symptoms [3] [6]. At some point, biliary tract obstruction leads to jaundice [1] [5] [6].

• Chest Discomfort

  CLINICAL DATA : Presented with upper abdominal discomfort and right chest discomfort for 3/12. Normal LFT. [wsoonli15.wordpress.com]

• Soft Tissue Mass

  CT in two of the three cystadenocarcinomas showed thick and coarse mural and septal calcifications as well as large solid soft-tissue masses in one. CT showed mural soft-tissue nodules in the single case of a unilocular cystadenocarcinoma. [ncbi.nlm.nih.gov]

• Abdominal Fullness

  The most common clinical symptoms were abdominal discomfort (i.e., abdominal pain), reported in seven cases (50 %), and fullness after eating, reported in two cases (14.3 %). Jaundice was a less common symptom reported in one case (7.1 %). [ncbi.nlm.nih.gov]

  His abdominal fullness worsened and, in January 2000, massive ascites developed. [nature.com]

• Abdominal Tenderness

  Physical exam was significant for abdominal tenderness and a palpable right upper quadrant mass extending into the left upper quadrant. [academic.oup.com]

• Epigastric Mass

  A 27-year-old woman was admitted to our hospital with a firm epigastric mass. At laparotomy, a large cystic mass was resected from the left hepatic lobe, and diagnosed as biliary cystadenoma. [ncbi.nlm.nih.gov]

• Recurrent Jaundice

  : A case of biliary cystadenocarcinoma with recurrent jaundice. Diagnostic evaluation of computed tomography. Cancer 55:2722–2724, 1985 Google Scholar 13. Devine P, Ucci AA: Biliary cystadenocarcinoma arising in a congenital cyst. [springerlink.com]

  A case of biliary cystadenocarcinoma with recurrent jaundice. Diagnostic evaluation of computed tomography. Cancer. 1985 Jun 1. 55(11):2722-4. [Medline]. Karahan OI, Kahriman G, Soyuer I, Ok E. [emedicine.medscape.com]

• Biliary Colic

  Laparoscopic cholecystectomy had been previously afforded for treatment of presumed biliary colic, but was unsuccessful in alleviation of pain. [academic.oup.com]

• Hyperpigmentation

  Case presentation A 62-year-old woman with a remote history of breast cancer and hypothyroidism presented to her primary care physician with 1 week history of dysuria and hyperpigmentation of her urine. [casereports.bmj.com]

• Suggestibility

  The preoperative diagnosis of biliary cystadenoma and cystadenocarcinoma was suggested due to the radiological detection of vascularity in the septa and the invasion of the thoracoabdominal wall. The surgeon was informed in both of the cases. [ncbi.nlm.nih.gov]

• Dysuria

  Case presentation A 62-year-old woman with a remote history of breast cancer and hypothyroidism presented to her primary care physician with 1 week history of dysuria and hyperpigmentation of her urine. [casereports.bmj.com]

The differential diagnosis of biliary cystadenoma is very broad, as hydatid cysts, liver abscesses, other malignant or benign tumors (including its malignant form - biliary cystadenocarcinoma), as well as hemorrhagic cysts, may have a similar clinical and radiologic presentation [7]. For this reason, a meticulous workup should start with a carefully obtained patient history that will assess the course and progression of symptoms, as well as their duration. The physical examination can be a crucial component if a mass is detected during abdominal inspection and palpation. As soon as sufficient evidence suggests a hepatic lesion, imaging studies need to be employed. Abdominal ultrasonography is a useful first-line procedure that is able to reveal typical findings of a biliary cystadenoma - a unilocular or multilocular cyst [1]. More advanced studies, however, are necessary in order to strengthen the diagnosis. Computed tomography (CT) shows a cystic lesion sharply delineated by a thick capsule made of fibrous tissue with internal septation (calcifications may also be present) [1] [2] [3] [5] [6], but the introduction of magnetic resonance imaging (MRI, particularly gadolinium-enhanced), and especially magnetic resonance cholangiopancreatography (MRCP) has greatly improved the overall diagnosis rate of many lesions, including biliary cystadenoma [1] [7] [8]. These two procedures are the gold standard and should be used whenever possible, showing a homogeneously low intensity on T1-weighted images and very high signal intensity on T2-weighted images [5] [8].

• Right Pleural Effusion

  Possible findings include coarse curvilinear calcifications in the right upper abdominal quadrant and elevation of the right hemidiaphragm, if hepatomegaly or right pleural effusion is present. [emedicine.medscape.com]

• Multilocular Cyst

  Radiological examination, which included radionuclide liver scan, abdominal ultrasonography, computed tomography, and hepatic angiography, demonstrated a large, globular, multilocular cyst arising from the left lobe of the liver. [ncbi.nlm.nih.gov]

  Abdominal ultrasonography is a useful first-line procedure that is able to reveal typical findings of a biliary cystadenoma - a unilocular or multilocular cyst. More advanced studies, however, are necessary in order to strengthen the diagnosis. [symptoma.com]

  Ultrasound At US, a biliary cystadenoma appears as a unilocular or multilocular cyst with enhanced through transmission. [radiopaedia.org]

There remains a need for education about the imaging findings for biliary cystadenoma to reduce the demonstrated delay in appropriate treatment. [ncbi.nlm.nih.gov]

A case of benign biliary cystadenoma with mesenchymal stroma is presented along with a review of the relative literature addressing the clinical presentation, histology, histogenesis, differential diagnosis, imaging features, treatment and prognosis of [ncbi.nlm.nih.gov]

The exact etiology of these tumors is unknown, but several theories have been proposed. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, and resection. [ncbi.nlm.nih.gov]

TERMINOLOGY Definitions Cystic biliary neoplasm arising within liver May arise in extrahepatic biliary tree, including gallbladder ETIOLOGY/PATHOGENESIS Unknown May arise from gallbladder precursor elements or peribiliary glands Most cystadenocarcinomas [basicmedicalkey.com]

Etiology The etiology of hepatic cystadenomas is unknown. The resemblance of embryonic structures, such as the gallbladder and the biliary tree, originating from the foregut suggests that these lesions arise from ectopic remnants. [emedicine.medscape.com]

Etiology In most cases, adenomas develop for unclear reasons in an otherwise healthy liver. [orpha.net]

The true etiology of IHBCA remains idiopathic since first reported by Keen in 1892 ( 2 ). Abnormal embryonic development resulting in ectopic foregut or gonadal epithelium sequestered in the liver has been proposed ( 3, 4 ). [academic.oup.com]

Unknown May arise from gallbladder precursor elements or peribiliary glands Most cystadenocarcinomas arise from preexisting biliary cystadenoma Some may represent cystic variant of cholangiocarcinoma Occasionally may arise in biliary cysts CLINICAL ISSUES Epidemiology [basicmedicalkey.com]

Summary Epidemiology Annual incidence is estimated at one case per million. Clinical description Mean age at diagnosis is 34 years (ranging from 15 to 64 years). HA rarely occurs in children. [orpha.net]

Archives of Photogrammetry, Remote Sensing and Spatial …, 2015 1 2015 A new post vulvectomy reconstructive technique FM Camacho, J Navarro, JC Moreno, MA Muñoz Journal of the European Academy of Dermatology and Venereology 8 (2), 137-139, 1997 1 1997 Epidemiology [scholar.google.es]

Epidemiology United States data The prevalence of hepatic cystadenomas is low, with fewer than 200 cases reported in the literature. These tumors account for a very small number of all hepatic tumors. [emedicine.medscape.com]

Tumors and tumor-like lesions of the liver and biliary tract: aetiology, epidemiology and pathology.In: MacSween RNM, Burt AD, Portmann BC, Ishak KG, Scheuen PJ, Anthony PP, editors. Pathology of the liver. 4th ed. [nature.com]

Pathophysiology Hepatic cystadenomas appear as multilocular (rarely unilocular) cystic lesions that are surrounded by a smooth and thick fibrous capsule. [emedicine.medscape.com]

Anatomy and pathophysiology of gastro-esophageal junction (GEJ) in gastro-esophageal prolapse (GEP). [unibo.it]

Radical resection is the best treatment for IHBCA and can effectively prevent recurrence. [ncbi.nlm.nih.gov]

Hence, a high degree of suspicion and a multidisciplinary approach are needed to plan the surgical procedure and prevent inadequate treatment. The surgical strategy would be to radically excise the lesion. [jmedicalcasereports.biomedcentral.com]

1. Levy AD, Murakata LA, Abbott RM, Rohrmann CA Jr. From the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Institute of Pathology. Radiographics. 2002;22(2):387-413.
2. Horton KM, Bluemke DA, Hruban RH, Soyer P, Fishman EK. CT and MR imaging of benign hepatic and biliary tumors. Radiographics. 1999;19(2):431-451.
3. Thomas KT, Welch D, Trueblood A, et al. Effective Treatment of Biliary Cystadenoma. Ann Surg. 2005;241(5):769-775.
4. Mortelé KJ, Ros PR. Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiographics. 2001;21(4):895-910.
5. Murphy BJ, Casillas J, Ros PR, et al. The CT appearance of cystic masses of the liver. Radiographics 1989; 9:307-322.
6. Ariff A, Hassan H, John G. Biliary Cystadenoma - Computed Tomography Findings. Malays J Med Sci. 2002;9(1):49-51.
7. Billington PD, Prescott RJ, Lapsia S. Diagnosis of a biliary cystadenoma demonstrating communication with the biliary system by MRI using a hepatocyte-specific contrast agent. Br J Radiol. 2012;85(1010):e035-e036.
8. Lewin M, Mourra N, Honigman I et-al. Assessment of MRI and MRCP in diagnosis of biliary cystadenoma and cystadenocarcinoma. Eur Radiol. 2006;16 (2): 407-413.