A Giant 25cm Hepatobiliary Mucinous Cystic Neoplasm Mimicking Hydatid Disease- A Diagnostic Pitfall with Radiological Water-Lily Sign: A Case Report with Literature Review
Keywords:
Abstract
Background
Hepatobiliary mucinous cystic neoplasm is a rare type of liver tumor that primarily occurs in middle-aged women. Their radiological appearance can mimic that of parasitic liver disease, which can be a major challenge. We describe a rare case of giant hepatobiliary mucinous cystic neoplasm, which presented imaging features similar to a hepatic hydatid cyst.
Case presentation
A 55-year-old woman had a complaint of progressive abdominal distention with dull right upper quadrant pain for six months. The computed tomography with contrast enhancement revealed a huge multilocated cystic mass, approximately 176 × 164 × 250 mm, located in the right hepatic lobe. The classical radiological appearances of hydatid disease were seen, such as the ‘water-lily sign' and daughter cyst-like structures. The first diagnosis was a hepatic hydatid cyst. Laparotomy showed there was a large cyst compressing the surrounding intraabdominal organs. Intraoperatively, approximately 3 liters of thick mucinous fluid were aspirated, followed by almost complete resection of the cyst wall. The initial histopathological examination performed at the Department of Pathology, Allama Iqbal Medical College, confirmed the diagnosis of a simple seromucinous cyst with endometriosis due to ovarian torsion, which is a benign gynecological process. Further detailed histopathologic evaluation at Shaukat Khanum Memorial Cancer Hospital & Research Centre however revealed multiple cystic spaces lined by cuboidal to columnar epithelium secreting mucin with typical ovarian-like stroma confirming the diagnosis of hepatobiliary mucinous cystic neoplasm, non-invasive, non-cancerous. The patient had a superficial surgical site infection post operatively and developed from multidrug resistant Klebsiella species, which was well responded to by targeted antibiotic therapy.
Conclusion
The case illustrates an uncommon radiological manifestation of hepatobiliary mucinous cystic neoplasm showing typical hydatid imaging characteristics. The presence of a giant lesion and water-lily sign along with daughter cyst-like structures is an extremely rare diagnostic pitfall. In complex cystic liver lesions, histopathology is the gold standard for diagnosis. Complete surgical removal and early diagnosis is critical for optimal management and prevention of recurrence.
References
1. Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: radiologic and pathologic features and complications. Radiogr Rev Publ Radiol Soc N Am Inc. 2000;20(3):795–817. doi:10.1148/radiographics.20.3.g00ma06795 PubMed PMID: 10835129.
2. Bailey & Love’s Short Practice of Surgery, 27th Edition: The Collector’s edition [Internet]. CRC Press; 2018 [cited 2026 May 8]. Available from: https://www.taylorfrancis.com/books/9781315111087 doi:10.1201/9781315111087
3. Quigley B, Reid MD, Pehlivanoglu B, Squires MH, Maithel S, Xue Y, et al. Hepatobiliary Mucinous Cystic Neoplasms With Ovarian Type Stroma (So-Called “Hepatobiliary Cystadenoma/Cystadenocarcinoma”): Clinicopathologic Analysis of 36 Cases Illustrates Rarity of Carcinomatous Change. Am J Surg Pathol. 2018 Jan;42(1):95–102. doi:10.1097/PAS.0000000000000963
4. Chenin M, Paisant A, Lebigot J, Bazeries P, Debbi K, Ronot M, et al. Cystic liver lesions: a pictorial review. Insights Imaging. 2022 Jul 15;13(1):116. doi:10.1186/s13244-022-01242-3 PubMed PMID: 35838923; PubMed Central PMCID: PMC9287528.
5. Jeong D, Jiang K, Anaya DA. Mucinous Cystic Neoplasm of the Liver Masquerading as an Echinococcal Cyst: Radiologic-pathologic Differential of Complex Cystic Liver Lesions. J Clin Imaging Sci. 2016;6:12. doi:10.4103/2156-7514.179426 PubMed PMID: 27195178; PubMed Central PMCID: PMC4860451.
6. Cicerone O, Basilico G, Tassi C, Antoniacomi C, Lucev F, Corallo S, et al. Mucinous cystic neoplasms of the liver: Literature review and case series. World J Clin Oncol. 2025 Aug 24;16(8):108557. doi:10.5306/wjco.v16.i8.108557 PubMed PMID: 40901324; PubMed Central PMCID: PMC12400184.
7. Quigley B, Reid MD, Pehlivanoglu B, Squires MH, Maithel S, Xue Y, et al. Hepatobiliary Mucinous Cystic Neoplasms With Ovarian Type Stroma (So-Called “Hepatobiliary Cystadenoma/Cystadenocarcinoma”): Clinicopathologic Analysis of 36 Cases Illustrates Rarity of Carcinomatous Change. Am J Surg Pathol. 2018 Jan;42(1):95–102. doi:10.1097/PAS.0000000000000963
8. Hutchens JA, Lopez KJ, Ceppa EP. Mucinous Cystic Neoplasms of the Liver: Epidemiology, Diagnosis, and Management. Hepatic Med Evid Res. 2023;15:33–41. doi:10.2147/HMER.S284842 PubMed PMID: 37016682; PubMed Central PMCID: PMC10066895.
9. Buetow PC, Buck JL, Pantongrag-Brown L, Beck KG, Ros PR, Adair CF. Solid and papillary epithelial neoplasm of the pancreas: imaging-pathologic correlation on 56 cases. Radiology. 1996 Jun;199(3):707–11. doi:10.1148/radiology.199.3.8637992
10. Nagtegaal ID, Odze RD, Klimstra D, Paradis V, Rugge M, Schirmacher P, et al. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020 Jan;76(2):182–8. doi:10.1111/his.13975 PubMed PMID: 31433515; PubMed Central PMCID: PMC7003895.
11. Arnaoutakis DJ, Kim Y, Pulitano C, Zaydfudim V, Squires MH, Kooby D, et al. Management of biliary cystic tumors: a multi-institutional analysis of a rare liver tumor. Ann Surg. 2015 Feb;261(2):361–7. doi:10.1097/SLA.0000000000000543 PubMed PMID: 24509187; PubMed Central PMCID: PMC4655107.
12. Besim H, Karayalçin K, Hamamci O, Güngör C, Korkmaz A. Scolicidal agents in hydatid cyst surgery. HPB Surg World J Hepatic Pancreat Biliary Surg. 1998;10(6):347–51. doi:10.1155/1998/78170 PubMed PMID: 9515230; PubMed Central PMCID: PMC2423906.
13. Simo KA, Mckillop IH, Ahrens WA, Martinie JB, Iannitti DA, Sindram D. Invasive biliary mucinous cystic neoplasm: a review. HPB. 2012 Nov;14(11):725–40. doi:10.1111/j.1477-2574.2012.00532.x PubMed PMID: 23043661; PubMed Central PMCID: PMC3482668.
14. Mortelé KJ, Ros PR. Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiogr Rev Publ Radiol Soc N Am Inc. 2001;21(4):895–910. doi:10.1148/radiographics.21.4.g01jl16895 PubMed PMID: 11452064.
15. Devaney K, Goodman ZD, Ishak KG. Hepatobiliary cystadenoma and cystadenocarcinoma. A light microscopic and immunohistochemical study of 70 patients. Am J Surg Pathol. 1994 Nov;18(11):1078–91. PubMed PMID: 7943529.
Downloads
Published
How to Cite
License
Copyright (c) 2026 Dr Sheeza Ahmed, Muhammad Suliman Sajid, Dr Uzair Asad, Muhammad Auns, Muhammad Haris, Dr Shayan Asmat, Dr Rafia Javed, Dr Muhammad Amir Sohail, Dr Muhammad Osama Afzal, Muhammad Zohaib Haider
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to contact@ijms.org
Infringing material
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to contact@ijms.org
