What is the significance of a 3.5 x 2.2 x 2.4 cm mildly lobulated hepatic (liver) cyst in a 55-year-old male with fatty liver (steatosis) infiltration?

Significance of a 3.5 x 2.2 x 2.4 cm Mildly Lobulated Hepatic Cyst with Fatty Liver

A 3.5 x 2.2 x 2.4 cm mildly lobulated hepatic cyst in a 55-year-old male with fatty liver is most likely a benign finding (ONCO-RADS category 2) that requires no specific intervention unless symptomatic. 1

Classification and Risk Assessment

• Simple hepatic cysts are common findings, occurring in up to 15-18% of the population, and are typically benign with no clinical significance 2
• According to the Oncologically Relevant Findings Reporting and Data System (ONCO-RADS), hepatic cysts are classified as Category 2 (benign finding highly likely) 1
• The presence of fatty liver (steatosis) is a separate finding also classified as Category 2 (benign finding highly likely) and is not directly related to the cyst 1
• The size of this cyst (3.5 x 2.2 x 2.4 cm) is within the range typically considered benign and not requiring intervention 1, 3

Evaluation of Concerning Features

• The mildly lobulated appearance warrants assessment for worrisome features that could suggest a mucinous cystic neoplasm (MCN) rather than a simple cyst 1
• Worrisome features would include:
  • Major: Thick septations, nodularity 1
  • Minor: Upstream biliary dilatation, thin septations, internal hemorrhage, perfusional change, fewer than 3 coexistent hepatic cysts 1
• Based on the description provided, the cyst appears to have mild lobulation but no other concerning features that would suggest malignancy 1, 4

Clinical Implications

• Asymptomatic simple hepatic cysts do not require treatment, regardless of size 3
• Symptoms, if they develop, typically occur when cysts become large (particularly >8 cm) and may include:
  • Abdominal discomfort or pain
  • Nausea, vomiting, early satiety
  • Feeling of fullness or abdominal distension 5, 3
• Potential complications of hepatic cysts include:
  • Hemorrhage into the cyst (presenting as sudden, severe abdominal pain)
  • Infection (presenting with fever, right upper quadrant pain, and elevated inflammatory markers)
  • Rupture (rare but can cause acute abdominal pain)
  • Compression of surrounding structures 5, 6

Management Recommendations

• For asymptomatic cysts like this one, observation is appropriate with no specific intervention needed 3
• If symptoms develop, management options include:
  • Aspiration sclerotherapy for symptomatic relief (72-100% improvement rate, though high recurrence rate) 5, 3
  • Laparoscopic fenestration for persistent symptoms (higher success rate, lower recurrence) 5, 6
  • Open surgical deroofing for recurrent symptomatic cysts after failed laparoscopic treatment 6

Follow-up Considerations

• No specific follow-up is required for asymptomatic simple hepatic cysts 3
• The fatty liver finding should be addressed separately with appropriate lifestyle modifications and metabolic risk factor management 1
• If the cyst develops any concerning features on future imaging (increasing size, development of mural nodules, thick irregular septations), further evaluation with MRI would be warranted 1, 4

Differential Diagnosis

• Simple hepatic cyst (most likely) 2, 3
• Mucinous cystic neoplasm (less likely given the absence of worrisome features) 1, 4
• Complicated cyst (hemorrhagic or infected) - would typically present with symptoms 5
• Cystic metastasis (rare and typically seen in patients with known primary malignancy) 4