Korean J Gastroenterol.  2025 Jan;85(1):83-88. 10.4166/kjg.2024.131.

Primary Cholangiocarcinoma of the Liver Presenting as a Complicated Hepatic Cyst: A Diagnostic Challenge

• Ha CW
• Shin SD
• Goh MJ
• Song BG
• Kang W
• Sinn DH
• Gwak GY
• Paik YH
• Choi MS
• Lee JH

• KMID: 2565020
• DOI: http://doi.org/10.4166/kjg.2024.131

Abstract

Primary cholangiocarcinoma is a rare bile duct epithelial neoplasm that can present with atypical clinical manifestations, complicating its diagnosis. A 62-year-old male showed symptoms suggestive of a complicated hepatic cyst that was later identified as intrahepatic cholangiocarcinoma. The patient presented with abdominal discomfort without fever. Imaging revealed a large cystic lesion in the liver. Despite the initial treatment for a presumed abscess, a biopsy confirmed cholangiocarcinoma. This case highlights the diagnostic challenge of distinguishing between benign complicated hepatic cysts and malignancies, particularly when typical markers of infection are absent. Early biopsy and vigilant assessments are crucial in such presentations to avoid a delayed diagnosis and initiate appropriate treatment.

Keyword

Liver cyst; Cholangiocarcinoma, intrahepatic

Figure

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  Fig. 1 Transabdominal US image obtained in a 62-year-old man shows (A) two hypoechoic lesions and (B) mixed-echogenicity lesions without biliary dilatation.

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  Fig. 2 (A) Probable 12 cm abscess in the left liver lobe. (B) Segmental enhancing wall thickening at the hilar bile duct resulting in upstream dilatation of intrahepatic ducts.

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  Fig. 3 (A) Magnetic resonance imaging (MRI) T2-weighted images showing a 12 cm high-signal lesion in the left lobe, which was presumed to be an abscess, with associated bilateral intrahepatic duct dilatation. (B) MRI T1 mDIXON portal phase revealed LI-RADS M, indicating definite or probable malignancy not specific to hepatocellular carcinoma.

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  Fig. 4 Cytology showed a few atypical cells.

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  Fig. 5 Liver biopsy showing moderately differentiated adenocarcinoma with tumor necrosis (H&E stain, ×200).

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  Fig. 6 (A) PET CT scan showing a hypermetabolic mass involving the segment 4 area of the liver. (B) Hypermetabolic lesions in the right internal mammary region. PET CT, positron emission tomography-computed tomography.

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  Fig. 7 Contrast-enhanced biliary CT image taken 22 days after inserting the PTBD (A) The cystic component still has a PCD inserted and appears more collapsed than before. (B) The cholangiocarcinoma in the left liver shows no significant change in the size of the solid portion; it continues to invade around the hilar duct. CT, computed tomography; PTBD, percutaneous transhepatic biliary drainage; PCD, percutaneous catheter drainage.

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