{"paper_id":"95500196-c049-4f92-a945-af8499be3445","body_text":"An unexpected liver lesion?\nT. De Somer1, M. D’Hondt2, K. Carels3, E. Monsaert1, V . Bouderez1, E. Vanderstraeten1, H. Alaerts4, C. Van Steenkiste1,5\n(1) Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Buitenring Sint-Denijs 30, 9000 Gent, Belgium ; (2) Department of Abdominal Surgery, \nAZ Groeninge Hospital, President Kennedylaan 4, 8500 Kortrijk, Belgium ; (3) Department of Radiology, Maria Middelares Hospital, Buitenring Sint-Denijs 30, 9000 Gent, \nBelgium ; (4) Department of Histopathology, AZ Groeninge Hospital, President Kennedylaan 4, 8500 Kortrijk, Belgium ; (5) University Hospital Antwerp, Wilrijkstraat \n10, 2650 Edegem, Belgium.\nCase\nA 50-year-old woman presented with pain in her \nright upper abdomen. In her medical history we note \na Caesarean section and a laparotomy with bilateral \novariectomy because of benign cysts. The liver enzymes \nwere mildly elevated: aspartate transaminase 40 U/l \n(reference < 32 U/l), alanine transaminase 53 U/l \n(reference < 31 U/l), gamma-glutamyl transferase 97 U/l \n(reference 5 – 36). Computed tomography (CT) revealed \na large lesion in the right liver lobe with a cyst within \ncyst appearance and with important compression of the \nsurrounding tissue (figure 1, panel A). The total diameter \nmeasured 29 cm by 17 cm by 22 cm. A perioperative \nimage is shown in figure 1 panel B.\nWhat is your diagnosis?\n 1. Hemorrhagic biliary cyst\n 2. Mucinous cystadenoma\n 3. Endometrial cyst\n 4. Echinococcal cyst\nDiscussion\nA small, contrast enhancing proliferation was seen \nanteromedially in the peripheral cyst (figure 1, panel A). \nMagnetic resonance imaging (MRI) showed a watery \ncontent in the internal cyst (high signal on T2 and low on \nT1) and a hyperintense T1 signal in the peripheral cyst, \nsuggestive for hemorrhagic content.\nDuring laparoscopic exploration both cysts were \nincised with evacuation of 3 liters of serosanguineous \nand 3 liters of serous fluid. Subsequently, the whole cystic \nlesion was resected (figure 2, panel A). Histopathological \nexamination revealed the diagnosis of an endometrial \ncyst (figure 2, panel B).\nEndometriosis is defined as the presence of endometrial \ntissue outside the uterus (1,2). Hepatic endometrial cysts \nappear to be rare with only case reports available in the \nliterature. Preoperative diagnosis is challenging, since \nno clinical or radiological findings are characteristic \n(2,3). As a consequence, surgery is the next step for \nboth diagnostic confirmation and treatment (1,3). Since \nperioperative frozen sections can confirm the diagnosis, \nradical hepatectomy sometimes can be avoided and \npericystectomy can be performed (2,3). Unlike the other \npossible diagnoses this endometrial cyst was not actually \na liver lesion, but a lesion against the liver.\nConflicts of interest\nNone declared.\nKeywords : Abdominal pain, endometrial cyst, hepatic \nendometriosis.\nCorrespondence to : Thomas De Somer, Buitenring Sint-Denijs 30, 9000 Gent, \nBelgium. Fax : 09/246.71.09.\nEmail : thomasdesomer@gmail.com\nSubmission date : 04/05/2020\nAcceptance date : 30/06/2020\nActa Gastro-Enterologica Belgica, Vol. 84, April-June 2021\nCLINICAL IMAGE— DOI 10.51821/84.2.385 385\nFigure 1. — panel A: contrast enhanced axial computed \ntomography image: spontaneous isodense aspect of the \nperipheral cyst and hypodense aspect of the internal cyst, arrow: \nsmall contrast enhancing proliferation; panel B: perioperative \nimage after incision of the peripheral cyst.\nFigure 2. — panel A: image of the resected lesion; panel B: \nhistopathological image (magnification x 100) with intraluminal \nblood and macrophages, endometrial type epithelium and \nendometrial stroma in the wall of the cyst.\n\n386 T. De Somer et al.\nActa Gastro-Enterologica Belgica, Vol. 84, April-June 2021\noutcomes of hepatic endometriosis: A systematic review. Ann. Hepatol., 2020, \n19(1) : 17-23.\n3. ANDRES M.P., ARCOVERDE F.V .L., SOUZA C.C.C., FERNANDES L.F.C., \nABRAO M.S., KHO R.M. Extrapelvic endometriosis: A systematic review. J. \nMinim. Invasive Gynecol., 2020, 27(2) : 373-89.\nReferences\n1. ZONDERV AN K.T., BECKER C.M., MISSMER S.A. Endometriosis. N. \nEngl. J. Med., 2020, 382(13) : 1244-56.\n2. PRODROMIDOU A., MACHAIRAS N., PASPALA A., HASEMAKI N., \nSOTIROPOULOS G.C. Diagnosis, surgical treatment and postoperative","source_license":"CC0","license_restricted":false}