What is the diagnostic workup for a septated hepatic cyst?

From the Guidelines

The diagnostic workup for a septated hepatic cyst should begin with an ultrasound, followed by further evaluation using additional imaging such as MRI or CT, as recommended by the EASL clinical practice guidelines 1. The workup for a septate hepatic cyst requires careful evaluation as these cysts may represent cystadenomas or cystadenocarcinomas rather than simple cysts.

• Key elements in the description of hepatic cysts include the number of lesions and architecture, with complex features such as atypical cyst wall or content requiring further evaluation 1.
• Imaging modalities such as ultrasound and MRI are essential in characterizing cystic liver lesions, with ultrasound exploring content and wall thickness, and MRI identifying hemorrhagic or proteinaceous contents and wall enhancement 1.
• The presence of thick septations, nodularity, or enhancement on imaging may warrant further evaluation with endoscopic ultrasound-guided fine needle aspiration to obtain cytology, as these features are associated with mucinous cystic neoplasms (MCNs) of the liver 1.
• Asymptomatic septate cysts with benign features on imaging may be monitored with serial imaging every 6-12 months, while symptomatic patients may require surgical intervention, such as laparoscopic or open cyst fenestration, partial hepatectomy, or complete resection, depending on the cyst's size, location, and suspicion for malignancy.
• MRI is recommended to characterize hepatic cysts with worrisome features, and surgical resection is the gold standard for suspected MCNs of the liver, with complete resection aimed for 1.

From the Research

Diagnostic Workup for Septated Hepatic Cyst

The diagnostic workup for a septated hepatic cyst involves several imaging modalities to differentiate it from other cystic lesions and to assess its potential for malignancy.

• Imaging studies such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) are used to characterize the cyst and identify features such as septae, mural consistency, calcifications, and quality of cystic fluid 2, 3, 4, 5.
• US is typically the first-line imaging modality, while more advanced imaging such as CT or MRI can help narrow down the specific lesion and assess its potential for malignancy 2, 3, 4, 5.
• Contrast-enhanced ultrasound is a newer modality that offers non-invasive evaluation in real-time and can be used to further characterize the cyst 3.
• The presence of septations, irregular walls, or other complex features may indicate a higher risk of malignancy, and surgical resection may be considered if the diagnosis is uncertain or if the cyst is large and symptomatic 4.

Key Features to Identify

• Septae: thin walls or partitions within the cyst
• Mural consistency: the texture and appearance of the cyst wall
• Calcifications: deposits of calcium within the cyst wall or septae
• Quality of cystic fluid: the appearance and characteristics of the fluid within the cyst
• Size and location of the cyst: larger cysts or those located in certain areas of the liver may be more likely to cause symptoms or be malignant

Treatment Options

• Asymptomatic septated hepatic cysts may not require treatment, but regular follow-up imaging may be recommended to monitor for changes or growth 2, 6.
• Symptomatic cysts or those with suspicious features may require treatment, which can include fenestration, aspiration sclerotherapy, or surgical resection 2, 3, 5, 6.