For decades, medical practice for the elderly has been developed in lots of countries such as United States, Japan and so on [1]. Furthermore, useful radiological evaluation methods have been used easily for daily exams including computed tomography (CT) associated with reconstruction method [2]. Among them, simple hepatic cysts (SHC) are often found with typically thin-walled and saccular lesion with fluid-filled cavities [3]. They are frequently detected by usual diagnostic exams of CT and ultrasonography (US). When the size of liver cysts become larger, some cases will feel abdominal pain, discomfort, nausea, or vomiting.

The treatment of SHC consists of percutaneous aspiration of the liver cyst followed by sclerotherapy or surgery [4]. In this case, it is important to decide which treatment to use and how to respond to the condition while monitoring the progress. The patients with small cysts showed no recurrence, regardless of whether they received drainage only or with drainage plus sclerotic treatment [5]. Thus, the discussion has been continued for the necessity of additional sclerotic treatment [6].

During our clinical practice for the elderly patients, we have followed 91-years old men for hypertension, frailty and SHC for years. His characteristics include the history of overcoming the frailty by daily resistance training and aerobic training for long [7]. His SHC was treated by percutaneous aspiration and some perspectives are described in this article.

Medical History

The patient is a 91-year-old man. He has been taking antihypertensive agent (OHA) since he was 80 years old. At his first visit, he had weak muscles in his legs and hips, making it difficult for him to walk satisfactory. When I asked him about his QOL and ADL when he was younger, he could run 100m in 12 seconds and had good motor skills in various sports. Then, I was convinced that he can recover his physical ability by daily muscle training. Then, I advised him to train himself by pedaling, taking a walk and resistance training every day.

For medical problem, he was detected to have large SHC at the age of 85 years, and followed up for several years. When he was 90 years old, SHC was enlarged. Then, he was introduced to a nearby secondary hospital for treatment of enlarged SHC.

Physical and Several Exams

A physical examination in November 2023 showed no abnormalities in speech, consciousness, cardiac, pulmonary, abdominal, and neurological examinations showed negative findings. Vitals signs were pulse 72/m, regular, blood pressure 134/82 mmHg and SpO2 98%. The patient's height was 169.0 cm, weight was 68 kg, and BMI was 23.8 kg/m².

The biochemical test data from 2019 to 2024 were summarized in Table 1. It shows no significant changes in the liver, kidneys, lipids, glucose metabolism, or complete blood count (CBC).

Table 1: Changes in Laboratory Data for 2017-2024.

His chest X-P and ECG showed unremarkable changes. He underwent the pulse wave velocity (PWV) examination. His ankle-brachial index (ABI) was 0.90/0.86 (right/left), which was borderline degree. No significant changes were observed in the pulse wave, and his cardio ankle vascular index (CAVI) remained stable over the 5-year period, generally ranging from 8.2 to 9.5 (Figure 1).

Figure 1: Pulse Wave Velocity (PWV) Exam. A) PWV Showed Unremarkable Changes, With Borderline ABI as 0.90/0.86 for 91 Years Old. B) CAVI Showed Ranging From 8.2 To 9.5, Indicating Stable Arteriosclerosis For Years.

An abdominal CT scan was performed in November 2018. The findings at that time were some cystic masses in the liver and some torsion in the gallbladder. Fatty replacement was prominent in the pancreas. Mild atrophy of the renal parenchyma, and a small low-attenuation nodule in the left adrenal gland were observed. There was calcification of the aortic wall and prostatic enlargement. Follow-up abdominal CT scan was performed in March and October 2023, where the CT images are shown in Figure 2. For abdominal CT finding, some hepatic cysts were observed, in which the maximum size of SHC showed 125mm x 105mm.

Figure 2: Findings of Abdominal CT Multiple Simple Liver Cysts Are Observed. The Maximum Size Was 125mm X 105mm In Oval Shape.

Clinical Problems and Progress

From mentioned above, the health problems can be summarized into three as follows.

#1 Hypertension; he has been stable for many years with taking oral hypertensive agent (OHA) of telmisartan 40 mg and amlodipine besilate 5 mg daily. Although the patient was 91 years old, his CAVI was 8.2 to 9.5, which indicates mild arteriosclerosis considering his age.

#2 Overcoming frailty and locomotor syndrome; he has trained his lower body for years through resistance training (RT) in his regular daily life.

#3 simple hepatic cyst (SHC); he has been currently undergoing further evaluation and treatment.

Abdominal CT scans were performed in 2018, and March/October 2023. The large cystic mass in the outside of the left lobe of the liver has expanded over the past five years, but no change has been seen in last six months. There is no significant difference in the other small cysts. The condition of the gallbladder is the same as last time, with constriction and mild wall thickening. The atrophy of the pancreatic parenchyma is also similar. There is no significant difference in the low absorption nodule of the left adrenal gland. The aortic wall showed the calcification as the same as before. His benign prostatic hyperplasia (BPH) with calcification was stable as before.

Current case was referred to a local secondary hospital for treatment. In Nov 2023, ultrasound-guided liver cyst puncture and drainage was performed. The operation was successfully completed. Cytological examination of the drainage fluid showed a class 2, with red blood cell (++) and foam cell (++). Screening findings showed a cystic finding with numerous red blood cells and foam cells, without atypical cells. After the procedure, he seemed to show no retention of the liver cyst, after drainage. If the cyst will increase again in the future, the treatment of anhydrous ethanol injection method will be applied into the cyst.

Ethical Standards

This report has been complied with the ethic guideline for Declaration of Helsinki [8]. Moreover, several comments were shown for the protected regulation of the information. The principle included the ethical regulation for the practice and clinical research. Some guidelines were applied from the presentation of Japanese Ministry. The governmental offices were the Ministry of Education, Culture, Sports, Science Technology (MEXT) and the Ministry of Health, Labor and Welfare (MHLW). Current authors have set the ethical committee for this report. It exists in Sakamoto Hospital, Kagawa, Japan. The main medical staffs included the director of the hospital, physicians in charge, head nurse, head pharmacist, dietitian, and also legal professional. They have fully discussed enough, and satisfactory agreed for the protocol. The informed consent by the document was given from the patient.

Regarding the current case, the characteristic aspects include #1 stable hypertension, #2 overcoming frailty with his daily training, and #3 successful treatment of simple hepatic cysts (SHC). His continuous great effort has brought him success for #1 and #2. Concerning #3, this case is more than 90 years old, and then the treatment seemed to be adequate for general clinical situation. Some perspectives will be also presented as below.

From the latest report, the similar case was observed [9]. The case was 72-year-old male patient with large hepatic cyst of 130mm in diameter. He was treated by drainage with decrease to 12 mm in large in 9 months. The symptom of chest discomfort was relieved after the treatment. In this case minocycline hydrochloride was injected in the cyst through the drainage tube. Generally, SHC are often diagnosed as benign liver lesions and they have been found about 18% of general population who underwent CT scan in the abdomen [10,11]. As for the etiology, they arise from congenitally aberrant bile duct associated with clear, bile-like fluid [12]. For the treatment for symptomatic cases, percutaneous drainage with or without sclerotherapy has been the standard measure as minimally invasive method [13].

Concerning the latest report of percutaneous drainage method for SHC, 79 cases were investigated by multicenter retrospective study [5]. Among 79 cases treated percutaneously, 11 cases (13.9%) showed the recurrence of liver cysts. By statistics analyses, the only significant factor leading to the recurrence was the maximum diameter of liver cysts (p=0.004). From operating analysis, the cut-off value of the cyst diameter for symptom recurrence was detected as 16.5cm. When the case has < 16.5cm, there was no additional efficacy of sclerotherapy on drainage for treatment method. In contrast, when the case has ≥16.5 cm, there were cumulative symptoms rate were significantly lower treated with sclerotherapy minocycline hydrochloride or ethanolamine oleate. From efficacy and safety points of view, sclerotherapy with either agent will be recommended for case with liver cysts diameter of > 16.5cm.

When we consider SHC and compare percutaneous drainage with sclerotherapy and laparoscopic cyst deroofing, the persistent symptoms showed 3.5% vs 2.1%, respectively [13]. The difference seemed to be small, and then the former would be safer for the elderly patients. Concerning the substrates using sclerotherapy, three kinds of matter have been known, which are absolute ethanol (AE) previously, 5% ethanolamine oleate (EO) or minocycline hydrochloride (MCH). Various discussion has been observed for the less incidence of recurrence among drainage only, drainage + AE, EO or MCH so far [6]. Formerly, AE was often used for sclerotic therapy, in which a number of drawbacks were found [14]. When AE is injected into the cyst, it can filter the cyst wall and may end up in the bloodstream. When cyst diameter is <16.5 cm, no additional efficacy of sclerotherapy was shown. In contrast, when cyst diameter is ≥16.5 cm, symptomatic recurrence was significantly lower in Tx of EO or MCH, than drainage alone or Tx of AE [5]. Consequently, the recommended conclusion showed that the drainage with Tx of EO or MCH seemed to be effective for liver syst cases with ≥16.5 cm.

 Some limitation may be observed for this case. His problem of SHC was found 5 years ago, and has been followed up until now. His lifestyle has been stable with continuous endeavor for long. Clinical progress will be followed up from various points of view.

 In summary, 91-year-old male case was presented in this article. Clinical problems included simple hepatic cysts (SHC), hypertension, moderate arteriosclerosis and stable lifestyle with training. It is expected that current report will be useful reference in the future.

Conflict of Interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

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