The Role Of Endoscopic Ultrasound With Fine Needle Aspiration In Guiding Treatment For Unusual Hepatic Cysts

Background: Evaluation of hepatic cysts is usually performed by radiological or surgical techniques. Delineation of requirement for laparotomy is often inconclusive. Appropriate surgical management (unroofing of cyst vs. complete excision) may also change if cysts are mucinous adenomas or not. EUS has the potential to improve such decision making. Aim: To evaluate whether the endosonographic appearance and evaluation of cyst fluid aspirate can reliably predict appropriate course of medical or surgical treatment for unusual hepatic cysts. Patients & Methods: A retrospective analysis of patients referred for endosonographic evaluation of liver cysts. Patients were included only if prior evaluations by radiologic means were inconclusive, and when hepatic cyst composition was unknown. All patients underwent EUS by two experienced endosonographers during which hepatic cysts were described and aspirated with 22 or 19 gauge needles. Cyst fluid was evaluated for levels of carbohydrate antigen 19-9 (CA19-9), carcinoembyronic antigen (CEA), cytology and other markers when necessary. FNA of solid cyst components was performed. The endosonographic interpretation was compared to the post surgical pathologic diagnosis when available. EUS guided appropriate surgical or medical management was assessed for each patient. Results: Nine patients were included in the analysis. Descriptions of the patient's clinical presentation, endosonographic and surgical diagnosis are tabulated. Endosonography appropriately guided therapy for 8 of 9 patients. Conclusion: Endoscopic ultrasound with hepatic cyst fluid aspirate and tissue FNA can effectively guide management of complex liver cysts when radiological evaluation is inconclusive. Elevated hepatic cyst CA19-9 is not specific for hepatic mucinous cystadenomas. Further study is warranted. Tabled 1Results: Clinical characteristics EUS diagnosis Tumor markers (aspirate) Surgical findings EUS guides appropriate management? Pancreatic cystadenocarcinoma with liver cyst Metastatic mucinous adenocarcinoma CA19-9: 23,000 CEA: 12,300 None YES Pancreatic cystadenocarcinoma with liver cysts Metastatic mucinous adenocarcinoma CA19-9 and CEA: normal None YES Pancreas cyst and irregular liver cysts Septated liver cyst, microcystic adenoma of pancreas CA19-9: 3.2 million CEA: <50 Mucinous cystadenoma YES Large liver cyst Multiseptate cystic mass CA19-9:> 5 million CEA: 24 Mucinous cystadenoma YES Abdominal pain with large lobulated hepatic cyst Multiseptate cyst with hyperechoic debris CA19-9: 3.5 million CEA: 78 Mucinous cystadenoma YES Abdominal pain with large hepatic cyst Large anechoic simple cyst with hemorrhage CA19-9: 841 CEA: 855 Old blood None YES Fever with hilar mass Simple cyst with polymicrobial infection CA19-9: 2.9 million CEA: 2140 Simple cyst with hemorrhage and inflammation YES Idiopathic pancreatitis and hilar cystic mass Multiseptate hilar cyst with debris and pus CA19-9: 1 million CEA: 150 WBC: 1 million None YES Hepatic cyst (50% filled with hyperechoic debris) Benign ductal epithelium with macrophages Old blood (markers not available) Benign chronic inflammation with organized hematoma NO Open table in a new tab