Diagnostic dilemma in the preoperative differential diagnosis of recurrent hepatic echinococcosis with a concomitant pancreatic cystic lesion: a case report

Cystic echinococcosis (CE) is a zoonotic parasitic disease that most commonly affects the liver, whereas pancreatic involvement is extremely rare. When recurrent hepatic cystic echinococcosis is accompanied by an indeterminate pancreatic cystic lesion, differentiating pancreatic echinococcosis from other pancreatic cystic lesions can be difficult. A 36-year-old woman with a previous history of surgery for hepatic hydatid disease presented with intermittent right upper abdominal pain. Serologic testing was positive for Echinococcus granulosus-specific IgG. Ultrasonography, computed tomography, and magnetic resonance imaging showed recurrent hepatic cystic echinococcosis lesions classified as CE2, CE4, and CE5, together with a 16 mm non-enhancing cystic lesion in the pancreatic body. Pancreatic echinococcosis could not be excluded preoperatively. The patient underwent right hepatectomy, common bile duct exploration, and cholecystectomy. Right hepatectomy was selected because the recurrent giant right hepatic lesion was closely related to the biliary structures and conservative surgery would probably have left a large residual cavity. The pancreatic lesion was assessed intraoperatively by inspection and palpation, but intraoperative ultrasonography was not performed. Because the lesion showed no typical features of hydatid disease, pancreatic resection was avoided. Histopathology confirmed hepatic cystic echinococcosis. At 1-month follow-up, computed tomography showed no obvious enlargement of the pancreatic lesion; however, this short follow-up period was insufficient to determine its biological behavior. In endemic areas, careful differential diagnosis is essential when recurrent hepatic cystic echinococcosis is accompanied by an indeterminate pancreatic cystic lesion. Intraoperative assessment and postoperative imaging follow-up may help avoid unnecessary pancreatic resection when the lesion lacks typical features of hydatid disease or malignancy. However, short-term radiologic stability is not sufficient to confirm benign behavior. Because pathological confirmation was unavailable and follow-up was limited to one month, the exact nature of the pancreatic lesion remains uncertain. Therefore, serum tumor marker assessment, EUS with or without EUS-FNA when appropriate, and continued long-term imaging surveillance are essential for safe management.