Liver metastasis mimicking a liver cyst of a thymoma in a 38-year-old immunocompromised patient

Abstract

Cystic liver lesions (CLL) are common and, in the majority of cases, benign. However, the range of differential diagnoses of CLL is wide. A combination of medical history, blood test results, and imaging can help find the correct diagnosis. We report the case of a 38-year-old immunocompromised female patient with a history of thymectomy and postoperative radiation 3 years prior due to thymoma. Subsequently, the patient was referred to our department for clarification of a cystic liver lesion. During short-term follow-up, the lesion increased in size, and due to the contrast agent behavior in the ultrasound and MRI examination, the suspicion of a biliary cystadenocarcinoma was considered.

Furthermore, imaging showed several subcentimetric liver lesions of unknown dignity. Finally, pericystectomy and atypical partial liver resection was performed. Histology revealed a cystic metastasis of the malignant B3 thymoma and a cavernous hemangioma. Liver metastases of a thymoma are rare, and this is the first case of a cystic liver metastasis of a thymoma. The presented case illustrates that in the management of CLLs beside imaging techniques, the medical history with previous conditions should be considered, especially in past malignancies.

Zusammenfassung

Zystische Leberläsionen sind häufig und in der Mehrzahl der Fälle gutartig. Das differenzialdiagnostische Spektrum ist jedoch breit. Die Kombination von Anamnese, Blutuntersuchungen und bildgebender Verfahren ist hilfreich, um die richtige Diagnose zu stellen. Wir berichten den Fall einer 38-jährigen immunsupprimierten Patientin mit Zustand nach Thymektomie und postoperativer Bestrahlung vor 3 Jahren aufgrund eines Thymoms. Anschließend wurde die Patientin zur Abklärung einer zystischen Leberläsion in unsere Klinik überwiesen. Im kurzfristigen Intervall nahm die Läsion an Größe zu und es wurde aufgrund des Kontrastmittelverhaltens in der Ultraschall- und MRT-Untersuchung der Verdacht auf ein biliäres Zystadenokarzinom gestellt. Darüber hinaus zeigte die Bildgebung mehrere sehr kleine Leberläsionen unbekannter Dignität. Schließlich wurden eine Perizystektomie und eine atypische Leberteilresektion durchgeführt. Die histologische Untersuchung ergab eine zystische Metastase des malignen B3-Thymoms und ein kavernöses Hämangiom. Lebermetastasen eines Thymoms sind selten. Dies ist der erste Fall einer zystischen Lebermetastase eines Thymoms. Der vorgestellte Fall verdeutlicht, dass beim Management zystischer Leberläsionen neben bildgebenden Verfahren die Anamnese mit Vorerkrankungen, insbesondere bei zurückliegenden Malignomen, berücksichtigt werden sollte.

Schlüsselwörter

Zystische Leberläsion - Zyste - Biliäres Zystadenokarzinom - Thymom - Lebermetastasen

Keywords

cystic liver lesion - cyst - biliary cystadenoma - thymoma - liver metastasis

Publication History

Received: 01 May 2021

Accepted after revision: 26 September 2021

Article published online:
18 November 2021

• References

• 1 Rawla P, Sunkara T, Muralidharan P. et al. An updated review of cystic hepatic lesions. Clin Exp Hepatol 2019; 5: 22-29 DOI: 10.5114/ceh.2019.83153. (PMID: 30915403)
• 2 Soares KC, Arnaoutakis DJ, Kamel I. et al. Cystic neoplasms of the liver: biliary cystadenoma and cystadenocarcinoma. J Am Coll Surg 2014; 218: 119-128 DOI: 10.1016/j.jamcollsurg.2013.08.014. (PMID: 24045144)
• 3 Devaney K, Goodman ZD, Ishak KG. Hepatobiliary cystadenoma and cystadenocarcinoma. A light microscopic and immunohistochemical study of 70 patients. Am J Surg Pathol 1994; 18: 1078-1091 (PMID: 7943529)
• 4 Bakoyiannis A, Delis S, Triantopoulou C. et al. Rare cystic liver lesions: a diagnostic and managing challenge. World J Gastroenterol 2013; 19: 7603-7619 DOI: 10.3748/wjg.v19.i43.7603. (PMID: 24282350)
• 5 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Thymomas and Thymic Carcinomas. In: . 2013: 30
• 6 Ishibashi H, Hirose M, Ohta S. Successful treatment of combined thymic epithelial tumor with hepatic metastasis: a long disease-free survival case. Gen Thorac Cardiovasc Surg 2020; 68: 1551-1554 DOI: 10.1007/s11748-020-01333-2. (PMID: 32162069)
• 7 Passuello N, Pozza G, Blandamura S. et al. Thymoma metastatic to liver and pancreas: case report and review of the literature. J Int Med Res 2017; 45: 868-874 DOI: 10.1177/0300060516680673. (PMID: 28415940)
• 8 Speisky D, de Davila MTG, Vigovich F. et al. Hepatic metastasis of thymoma: case report and immunohistochemical study. Ecancermedicalscience 2016; 10 DOI: 10.3332/ecancer.2016.693. (PMID: 28101136)
• 9 Kim HJ, Park YE, Ki MS. et al. Spontaneous rupture of hepatic metastasis from a thymoma: a case report. World J Gastroenterol 2016; 22: 9860-9864 DOI: 10.3748/wjg.v22.i44.9860. (PMID: 27956811)
• 10 Khandelwal A, Sholl LM, Araki T. et al. Patterns of metastasis and recurrence in thymic epithelial tumours: longitudinal imaging review in correlation with histological subtypes. Clin Radiol 2016; 71: 1010-1017 DOI: 10.1016/j.crad.2016.05.007. (PMID: 27267746)
• 11 Song Z, Yu X, Zhang Y. Chemotherapy and prognosis in advanced thymic carcinoma patients. Clinics (Sao Paulo) 2015; 70: 775-780 DOI: 10.6061/clinics/2015(12)03. (PMID: 26735216)
• 12 Wang Z, Li H, Cao H. et al. Clinicopathological features of type AB thymoma with liver metastases. Int J Clin Exp Pathol 2014; 7: 8700-8705
• 13 Wang LY, Wu MZ, Yen RF. et al. Asymptomatic thymic carcinoma with solitary hepatic metastasis detected by fluorodeoxyglucose positron emission tomography. J Formos Med Assoc 2009; 108: 677-680 DOI: 10.1016/s0929-6646(09)60389-2. (PMID: 19666356)
• 14 Hoshino S, Furukawa M, Aragane K. et al. Successful multimodal treatment in a patient with thymoma accompanied by hepatic metastasis. J Thorac Oncol 2008; 3: 98-100 DOI: 10.1097/JTO.0b013e318160d633. (PMID: 18166848)
• 15 Tamura Y, Kuroiwa T, Doi A. et al. Thymic carcinoma presenting as cranial metastasis with intradural and extracranial extension: case report. Neurosurgery 2004; 54: 209-211 DOI: 10.1227/01.neu.0000097554.14112.55. (PMID: 14683559)
• 16 Moretti R, Nasuelli D, Torre P. et al. Hepatic metastasis of thymoma. Eur J Neurol 2000; 7: 127-128 DOI: 10.1046/j.1468-1331.2000.00023.x. (PMID: 10809930)
• 17 Marasco WJ, Hergreuter CA, Pritchard E. et al. Surgical resection of a solitary liver metastasis in a 46-year-old patient with a malignant thymoma. J Surg Oncol 1991; 46: 139-140 DOI: 10.1002/jso.2930460213.
• 18 Denayer MA, Rao KR, Wirz D. et al. Hepatic metastatic thymoma and myasthenia gravis twenty-two years after the apparent cure of an invasive thymoma. A case report and review of the literature. J Neurol Sci 1986; 76: 23-30 DOI: 10.1016/0022-510x(86)90139-5. (PMID: 3537213)
• 19 Ichino Y, Obuchi M, Suko K. et al. Malignant thymoma with distant metastases: a case report and review of the literature. Jpn J Clin Oncol 1983; 13: 733-739 (PMID: 6685786)
• 20 Yoshida A, Shigematsu T, Mori H. et al. Non-invasive thymoma with widespread blood-borne metastasis. Virchows Arch A Pathol Anat Histol 1981; 390: 121-126 DOI: 10.1007/BF00443902. (PMID: 7281473)
• 21 Dietrich CF, Nolsøe CP, Barr RG. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver – Update 2020 – WFUMB in cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultraschall Med 2020; 41: 562-585 DOI: 10.1055/a-1177-0530. (PMID: 32707595)
• 22 Marrero JA, Ahn J, Rajender Reddy K. et al. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol 2014; 109: 1328-1347 DOI: 10.1038/ajg.2014.213. (PMID: 25135008)
• 23 Mavilia MG, Pakala T, Molina M. et al. Differentiating cystic liver lesions: a review of imaging modalities, diagnosis and management. J Clin Transl Hepatol 2018; 6: 208-216 DOI: 10.14218/JCTH.2017.00069. (PMID: 29951366)
• 24 Auer TA, Fischer T, Garcia SRM. et al. Value of contrast-enhanced ultrasound (CEUS) in focal liver lesions (FLL) with inconclusive findings on cross-sectional imaging. Clin Hemorheol Microcirc 2020; 74: 327-339 DOI: 10.3233/CH-190718. (PMID: 31658052)
• 25 Laghi F, Catalano O, Maresca M. et al. Indeterminate, subcentimetric focal liver lesions in cancer patients: additional role of contrast-enhanced ultrasound. Ultraschall Med 2010; 31: 283-288 DOI: 10.1055/s-0029-1245383. (PMID: 20517816)
• 26 Strobel D, Bernatik T, Blank W. et al. Diagnostic accuracy of CEUS in the differential diagnosis of small (≤ 20  mm) and subcentimetric (≤ 10  mm) focal liver lesions in comparison with histology. Results of the DEGUM multicenter trial. Ultraschall Med 2011; 32: 593-597 DOI: 10.1055/s-0031-1271114. (PMID: 22161556)
• 27 Holalkere N-S, Sahani DV, Blake MA. et al. Characterization of small liver lesions: Added role of MR after MDCT. J Comput Assist Tomogr 2006; 30: 591-596 DOI: 10.1097/00004728-200607000-00007. (PMID: 16845289)
• 28 Patterson SA, Khalil HI, Panicek DM. MRI evaluation of small hepatic lesions in women with breast cancer. AJR Am J Roentgenol 2006; 187: 307-312 DOI: 10.2214/AJR.04.1030. (PMID: 16861531)