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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤ Conclusion
 ¤  References
 ¤  Article Figures

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 Table of Contents     
UNUSUAL CASE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 83-85
 

Mesothelial cyst of the round ligament of the liver


1 Department of Digestive Surgery, Regina Elena Cancer Institute, Rome, Italy
2 Department of Pathology, Regina Elena Cancer Institute, Rome, Italy

Date of Submission30-Jan-2015
Date of Acceptance23-Mar-2015
Date of Web Publication17-Dec-2015

Correspondence Address:
Fabio Carboni
Department of Surgery, Regina Elena Cancer Institute, via Elio Chianesi 53, 00144 Rome
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.158954

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 ¤ Abstract 

A 34-year-old man was admitted in our department with a 3 months history of epigastric pain, abdominal distension and tenderness. Helical computed tomography scan and magnetic resonance imaging showed a 10 cm low-density fluid-filled polilobate cystic lesion with internal septations and calcifications located between the left lobe of the liver, shorter gastric curvature, pancreas and mesocolon. Laparoscopic exploration was performed. Macroscopically the lesion was a unilocular serous cyst with a thick fibrous wall. Histopathology revealed a thin fibrous wall with a single layer of flattened to cuboidal mesothelial cell lining lacking any cellular atypia. The patient is currently alive without evidence of recurrence at 6 months. Cysts of mesothelial origin are rare lesions seen more frequently in young and middle-aged women, mostly benign and located in the mesenteries or omentum. Diagnosis is usually based on clinical examination and radiographic imaging. Immunohistochemistry is used to differentiate histologic type, with simple mesothelial cysts being positive for cytokeratins and calretinin and negative for CD31. The laparoscopic approach appears safe, feasible and less-invasive without compromising surgical principles and today should be considered the gold standard in most cases.


Keywords: Cystic lesion, epigastric pain, laparoscopic surgery


How to cite this article:
Carboni F, Valle M, Camperchioli I, Levi Sandri GB, Sentinelli S, Garofalo A. Mesothelial cyst of the round ligament of the liver. J Min Access Surg 2016;12:83-5

How to cite this URL:
Carboni F, Valle M, Camperchioli I, Levi Sandri GB, Sentinelli S, Garofalo A. Mesothelial cyst of the round ligament of the liver. J Min Access Surg [serial online] 2016 [cited 2019 Dec 13];12:83-5. Available from: http://www.journalofmas.com/text.asp?2016/12/1/83/158954



 ¤ Introduction Top


Mesenteric intra-abdominal cystic lesions have been recently classified on the basis of histopathological features. [1],[2],[3] Their distinction is important because the incidence, presentation, and biological behavior differ. Cysts of mesothelial origin are rare lesions seen more frequently in young and middle-aged women, mostly benign and located in the mesenteries or omentum. What makes our particular case interesting is that it arose within the round ligament of the liver in a male patient. Owing to the low incidence, etiology remains unclear although true simple mesothelial cysts are mainly congenital. Cyst size ranges from few centimeters to 40 cm. [2],[3],[4],[5]


 ¤ Case Report Top


A 34-year-old man was admitted in our department complaining for the last 3 months of epigastric pain, abdominal distension and tenderness. Past medical history was unremarkable. Physical examination revealed mild abdominal distension with a sense of fullness in the epigastric region. Blood tests were negative, and serum tumor markers (carcinoembryonic antigen, carbohydrate antigen [CA] 19-9, CA 72-4, α-fetoprotein) levels were within the normal range. Serum immune hemagglutination for echinococcus was negative as well. Helical computed tomography (CT) scan [Figure 1]a and magnetic resonance imaging (MRI) [Figure 1]b showed a 10 cm low-density fluid-filled polilobate cystic lesion with internal septations and calcifications located between the left lobe of the liver, shorter gastric curvature, pancreas and mesocolon. A presumed diagnosis of cystic lymphangioma was made, and laparoscopic exploration was planned. The cyst appeared located within the round ligament extending from the dorsal free margin of the falciform ligament to the anterior abdominal wall [Figure 2]. It was completely aspirated, dissected form the surrounding structures with ultracision harmonic scalpel and then removed with endobag. Macroscopically the lesion was a unilocular serous cyst with a thick fibrous wall. Cytologic examination of the cystic fluid was negative for malignancies. Histopathology revealed a thin fibrous wall with a single layer of flattened to cuboidal mesothelial cell lining lacking any cellular atypia [Figure 3]. Immunohistochemical staining was positive for cytokeratins. Post-operative course was uneventful, and the patient was discharged 2 days after the operation. The patient is currently alive without evidence of recurrence at 6 months.
Figure 1: Magnetic resonance imaging (a) and computed tomography scan (b) showed a low-density fluid-filled polilobate cystic lesion with internal septations and calcifications located between the liver, stomach and pancreas

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Figure 2: Intraoperative view of the cyst before aspiration

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Figure 3: Histopathologic examination showing a thin fibrous cyst wall lined by a single layer of flattened to cuboidal mesothelial cell

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 ¤ Discussion Top


Most of the cysts of mesothelial origin are asymptomatic and represent incidental findings during the course of investigations for other reasons. However, the growth may produce non-specific symptoms depending on size and location. Diagnosis is usually based on clinical examination and radiographic imaging, including CT scan or MRI but precise site, and origin cannot always be determined. Moreover, precise pre-operative differential diagnosis with other intra-abdominal cystic lesions remains challenging. Immunohistochemistry is used to differentiate histologic type, with simple mesothelial cysts being positive for cytokeratins and calretinin and negative for CD31. [1],[2],[3] If symptoms or complications occur, complete surgical excision with clear margins in order to avoid the risk of recurrence is recommended, and prognosis is excellent. [2],[3],[4],[5] Different entities of the cystic lesions within the round ligament of the liver were described. Perivascular epithelioid cell tumor and fibroma with size over 5 cm were recently described. [6],[7] The laparoscopic approach has been reported only in sparse cases of true simple mesothelial cyst, with different locations comparing to ours. [8],[9],[10]


 ¤ Conclusion Top


To the best of our knowledge, this is the first case reported treated with a laparoscopic approach. Laparoscopy appears safe, feasible and less invasive without compromising surgical principles and today should be considered the gold standard in most cases. In the presence of a voluminous mass, complete aspiration before excision may allow to achieve adequate space for dissection.

 
 ¤ References Top

1.
de Perrot M, Bründler M, Tötsch M, Mentha G, Morel P. Mesenteric cysts. Toward less confusion? Dig Surg 2000;17:323-8.  Back to cited text no. 1
    
2.
Wang J, Fisher C, Thway K. Combined mesothelial cyst and lymphangioma of the small bowel: A distinct hybrid intra-abdominal cyst. Int J Surg Pathol 2014;22:547-51.  Back to cited text no. 2
    
3.
Ousadden A, Elbouhaddouti H, Ibnmajdoub KH, Harmouch T, Mazaz K, Aittaleb K. A giant peritoneal simple mesothelial cyst: A case report. J Med Case Rep 2011;5:361.  Back to cited text no. 3
    
4.
Lagoudianakis EE, Michalopoulos N, Markogiannakis H, Papadima A, Filis K, Kekis P, et al. A symptomatic cyst of the ligamentum teres of the liver: A case report. World J Gastroenterol 2008;14:3266-8.  Back to cited text no. 4
    
5.
Tan JJ, Tan KK, Chew SP. Mesenteric cysts: An institution experience over 14 years and review of literature. World J Surg 2009;33:1961-5.  Back to cited text no. 5
    
6.
von Strauss und Torney M, Brunner P, von Holzen U, Hohmann J, Kettelhack C. A large fibroma of the round ligament of the liver. Surgery 2014;155:1095-6.  Back to cited text no. 6
    
7.
Coker D, Kench J, Ansari N, Zhou R, Sandroussi C. Education and imaging: Hepatobiliary and pancreatic: Clear cell myomelanotic tumor of ligamentum teres. J Gastroenterol Hepatol 2013;28:381.  Back to cited text no. 7
    
8.
Deshpande AA, Dalvi AN. Laparoscopic excision of a giant mesothelial omental cyst. J Minim Access Surg 2012;8:57-8.  Back to cited text no. 8
    
9.
Lucandri G, Felicioni F, Monsellato I, Alfano G, Pernazza G, Pende V, et al. Robotic splenectomy for mesothelial cyst: A case report. Surg Laparosc Endosc Percutan Tech 2011;21:e93-6.  Back to cited text no. 9
    
10.
Theodoridis TD, Zepiridis L, Athanatos D, Tzevelekis F, Kellartzis D, Bontis JN. Laparoscopic management of mesenteric cyst: A case report. Cases J 2009;2:132.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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