Cystic mass in soft tissue: Is further investigation needed?

Infection with Echinococcus granulosus is extremely widespread in eastern and southern Europe, the Middle East, North Africa and South America.1 It involves mainly the liver, lung, spleen, kidneys and various intra-abdominal and retroperitoneal organs and quite rarely the soft tissues.2^–4 Cervical hydatid cyst is rare and often presents as a simple soft-tissue mass, which is usually asymptomatic. The definitive diagnosis is obtained only with an exploratory and curative cervicotomy.5 If the patient lives in an area where hydatid disease is endemic, any attempt to aspirate a benign-looking cyst should be delayed until the liver and lungs are examined radiologically for this disease.6 In 1999, Valverde6 reported 2 patients with neck hydatidosis for which fine-needle aspiration was performed, but this approach did not help in diagnosis. Both patients had normal findings on chest radiography and abdominal ultrasonography.

We treated a 35-year-old man who was admitted with a right-sided cystic cervical mass. He had first noticed it 2 months earlier, since when it had doubled in size. Otherwise he was healthy. He was producing cheese and yoghurt on his own farm.

On physical examination, a cystic mass 6-cm in diameter was noted just under the angulus of the right mandibula. His respiratory rate was 16 breaths/min. On auscultation, breath sounds were reduced over the left hemithorax. Findings of laboratory studies were normal and of serologic tests for Echinococcus granulosus were negative. Chest radiography showed a well-defined mass, 9 cm in diameter, in the mid-left lung. Magnetic resonance imaging (MRI) of the cervical region showed that the borders of the cystic cavity were well defined and that the common carotid artery was not infiltrated (Fig. 1). Computed tomography of the thorax and upper abdomen showed a 9-cm cystic mass of the upper lobe of the left lung and 4-cm cystic mass of the left lobe of the liver. The history of an association with domestic farm animals and the radiologic appearances suggested hydatid disease. Albendazole 10 mg/kg daily for 7 days was given orally before operation.

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FIG. 1

Magnetic resonance imaging showing the cystic mass in cervical soft tissue.

Through a left anterolateral thoracotomy, cyst enucleation and capitonnage were performed. Pathological examination of the operative specimen confirmed it as a hydatid cyst. Two weeks after thoracotomy the liver cyst in the left lobe was examined again and drained with ultrasonographic guidance. A 12-gauge flexible drainage catheter was placed in the cyst. After 4 days, the catheter was removed and the cervical cyst was removed without rupture. The patient was discharged 2 days later with a prescription of albendazole, 10 mg/kg daily. At 6-month follow-up there was no recurrence.

The cyst in the pulmonary parenchyma was 9 cm in diameter, almost large enough to be considered a giant hydatid cyst. The percutaneous approach with ultrasonographic guidance for the treatment of the liver cyst was preferred to avoid another operation under general anesthesia. Long-term results indicate that this approach to hydatid disease of the liver is effective and safe and not associated with major complications. For the cervical mass with a cystic component, we preferred MRI because it gives excellent radiologic data and alerts the surgeon of the need for a vascular procedure.

Combining surgical procedures with albendazole medication for preoperative and postoperative prophylaxis allow a good clinical approach and reduce the incidence of recurrence.

We believe that in a region where hydatid disease is endemic, any soft-tissue cystic mass should alert a physician to the possibility of echinococcosis. Further investigation by serologic tests and radiologic examination of liver and lung is essential.