OBJECTIVES: Differential diagnosis between a benign cystic hepatic lesion, biliary cyst, and a potentially malignant lesion or biliary cystadenoma, is difficult. The aim of this study was to evaluate imaging features of atypical cystic liver lesions and the role of imaging techniques in determining a specific diagnosis. METHODS: Twenty-six patients with atypical cystic hepatic lesions were included in this study. All patients underwent surgery and pathological diagnosis was atypical hepatic cyst (n = 18), biliary cystadenoma (n = 4), hydatic cyst (n = 3), and ciliated hepatic foregut cyst (n = 1). We systematically reviewed US (n = 24), CT (n = 24), and MRI (n = 8) examinations. RESULTS: Septum were seen in both cystadenomas (US: n = 4, CT: n = 1) and hepatic cysts (US: n = 11, CT: n = 6). No mural nodules were seen. A thin wall was noted in both hepatic cysts (n = 2) and cystadenomas (n = 3). The intrahepatic biliary tract was dilated in 3 patients with hepatic cysts, 1 patient with cystadenoma, and 2 patients with hydatic cysts. Calcifications were noted in 1 patient with hepatic cyst, 3 patients with hydatic cysts, and in the case of ciliated hepatic foregut cyst. We found an associated typical hepatic cyst in 77% of cases (14/18) with atypical hepatic cysts; this was never found in other atypical cystic lesions (P < 0.01). CONCLUSION: In this series, no imaging features provided a differential diagnosis of atypical hepatic cysts and cystadenomas. The presence of associated typical hepatic cysts is helpful in suggesting the diagnosis of hepatic cyst.