Intrahepatic biliary cystadenoma: Role of cyst fluid analysis and surgical management in the laparoscopic era

Recent interest in cyst fluid analysis (CFA) for carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA), and the introduction of laparoscopic surgery (LS) in the management of hepatic cysts have resulted in sporadic reports of elevated CA 19-9 and CEA levels in intrahepatic biliary cystadenoma (IBC) CFA, and the application of LS in the management of simple cysts. However, the role of CA 19-9 and CEA in the diagnosis of IBC and the role of LS in the management of IBC have not been previously defined. We studied 34 patients with IBC at a single institution (8 years). The first 12 patients with IBC were managed with open surgical intervention. We subsequently developed a diagnostic and treatment algorithm for IBC that included, in the last 22 patients, prospective analysis of CFA for CA 19-9 and CEA, and LS for management All patients with IBC who underwent CFA had elevated CA 19-9 (range, 2247-1,757,510; N < 33 U/mL) and mildly elevated CEA (range, 3.3-212,; N < 3 ng/ml). In all 22 patients the cyst lining consisted of biliary epithelium ± mesenchymal stroma (MS). In 1/22 patients (highest CA 19-9 level), the cyst epithelium did not contain either MS or intestinal metaplasia. In contrast, control patients (simple cysts, n = 8) had normal CFA. In the previous 12 patients managed with laparotomy, 6/12 patients had biliary epithelium alone; the other 6 also contained MS with 1 patient exhibiting intestinal metaplasia and cystadenocarcinoma. We have proposed a management algorithm for IBC that incorporates CFA and laproscopic surgical management that allows for selective minimally invasive cyst wall sampling for patients with IBC.