Management of haemangioma of the liver: comparison of results between surgery and observation

Cavernous haemangioma of the liver was diagnosed in 33 patients using hepatic angiography between 1978 and 1988. Thirteen of these patients underwent surgery. There were no deaths after operation; morbidity included upper gastrointestinal bleeding in two patients and liver dysfunction in one. The follow-up study showed no evidence of recurrence in any of the 13 patients up to 143 months after operation. In the operated patients, a small haemangioma was left in the liver of two for anatomical reasons, but the size of these tumours showed no change over 3 years. The remaining 20 patients had no specific treatment for haemangioma and were followed up for between 18 months and 8 years. Of these 20 patients, 19 had tumours of less than 5 cm in size. As there was no enlargement or rupture of haemangiomas of less than 5 cm, it was felt that these could be observed. Cases having a potential for exposure to trauma, rapid tumour growth, or displaying severe symptoms should be considered for surgical treatment; this can be justified due to low morbidity and no mortality.

Symptomatic vertebral hemangiomas

Symptomatic vertebral hemangiomas are rare. Several therapeutic modalities for vertebral hemangiomas with neurologic deficit have been described. Personal experience with laminectomy followed by radiation therapy in four patients and radiation therapy in one patient is reported. Considering our results, literature and theoretical aspects a proposal for treatment of symptomatic vertebral hemangiomas is made.

Computed tomographic findings in two patients with vascular hamartomas

The clinical, computed tomographic (CT) and histological findings of two patients with vascular hamartomas are presented. The appearances on CT of the two lesions were markedly different. Although both lesions were histopathologically benign, one showed a more disorganized architecture on histology and clinically behaved in a more aggressive manner. The CT findings in this case reflected the histological picture and could have been interpreted as a malignant process if viewed in isolation. Review of the literature and the cases presented suggest that the CT appearances of vascular hamartomas can be diverse, and to avoid a misdiagnosis the radiological features should be considered in conjunction with the clinical and histopathological findings.

[A case of brainstem vascular malformation with isolated trochlear nerve palsy as the initial symptom]

We report a 46-year-old, non-hypertensive man who suddenly developed isolated right trochlear nerve palsy. His diplopia was most prominent in the left lower gaze, and partially alleviated by head tilt to the left or by anteflexion of the neck. His CT scans showed a small high density area consistent with a hemorrhage in the lateral side of the right mesencephalic tectum. His MRI (T2-weighted images) showed a lesion consisting of mixed high- and iso-intensity areas with linear low intensity areas. The margin of the lesion was irregular and nodular. Cerebral angiography (prolonged injection) showed small feeding arteries (or capillaries) in the late arterial phase and dilated draining veins in the venous phase. No tumor stain, early draining veins, or capillary brushes were present. We thought he had an angioma (vascular malformation). AVM seemed unlikely. Review of the literature revealed that trochlear nerve palsy caused by a mesencephalic angioma is extremely rare. MRI and cerebral angiography (prolonged injection) seemed useful for the diagnosis of angiomas (Vascular malformations).

False-positive hepatic blood pool scintigraphy in metastatic colon carcinoma

A rare false-positive red blood cell scintigram occurred in a 49-year-old woman with two metastases from a primary adenocarcinoma of the sigmoid colon. Although the blood flow and static planar images were unremarkable, a 1-hour postinjection SPECT study showed a focus of increased activity in the inferior right lobe and a second photopenic focus in the dome. Following a trisegmentectomy, pathologic examination revealed the two metastases with no evidence of a hepatic hemangioma. Microscopy, however, showed a discrete area of nonspecific reactive changes (focal sinusoidal dilation and congestion) immediately adjacent to teh metastasis in the inferior right lobe. It is postulated that the SPECT focus of increased activity occurred secondary to the labeled blood pool within the area of sinusoidal dilation, rather than within the adjacent metastasis.

Hemangioma of the nasal vault: MR and CT features

Six patients with a history of epistaxis (five patients) or nasal obstruction (one patient) were found to have a capillary hemangioma of the nasal vault that involved one or more nasal turbinates. Four patients underwent computed tomographic (CT) examination; two of these also underwent magnetic resonance (MR) imaging. Four others underwent only MR imaging. At CT and MR, all of the lesions were well circumscribed and intensely enhancing, with contralateral deviation of the nasal septum. Remodeling of the surrounding bone was present in three patients. On T1-weighted MR images, the masses were intermediate in signal intensity. Varying degrees of T2 shortening were shown on T2-weighted MR images, with an appearance that suggested the presence of blood products surrounding an inner matrix of higher-signal-intensity tumor. Intense enhancement at CT and MR assisted differentiation of tumor from retained sinonasal secretions. In two patients, external carotid arteriography revealed small foci of pooling contrast material; in one of these patients, arteriovenous shunting was also present. Pathologic examination in all patients demonstrated capillary hemangiomas with varying degrees of fibrosis and hemosiderin deposition.

Life-threatening hematochezia from a rectosigmoid vascular malformation in Klippel-Trenaunay syndrome: long-term palliation using an argon laser

Recurrent severe hemorrhage from intestinal vascular malformations, although extremely rare, may be associated with significant morbidity and mortality. The treatment may require extensive surgical resection, vascular embolization, and repeated blood transfusions. An adolescent boy with the Klippel-Trenaunay syndrome involving the pelvis and left leg presented with recurrent life-threatening hematochezia associated with defecation. Endoscopy documented that the bleeding originated from the submucosal venous angiomata in the region of the hemorrhoidal plexus. An argon laser was used to systematically coagulate the venous angiomata involving the distal 7 cm of the anorectal canal. Postoperative minor rectal bleeding and rectal tenesmus resolved in a few days. The patient has had only one brief episode of hematochezia in more than 4 years of follow-up. The use of the argon laser has provided effective palliation of colorectal vascular malformations with minimal morbidity but more importantly has allowed the preservation of normal anorectal function.

Technetium-99m-d,1-hexamethylpropyleneamine oxime (HMPAO) uptake and glutathione content in brain tumors

Technetium-d, HMPAO SPECT was performed in 70 patients suffering from intracerebral tumors of various histologic types (glioma n = 30, meningioma n = 19, metastases n = 10, angioma n = 3, neuroma n = 2, lymphoma n = 2, neurocytoma n = 1, epidermoid n = 1, gliosis n = 1, cholesteatoma n = 1). Tumor classification was histologically verified in all subjects except in two cases with inoperable angiomas. SPECT was performed under resting state conditions with a dual-head rotating camera (SIEMENS ZLC 37) following intravenous injection of 18-25 mCi 99mTc-d, 1-HMPAO. Regional tracer deposit was expressed in terms of a cerebellar index (CBI). Significantly higher regional HMPAO uptake was found in meningiomas when compared with gliomas of different malignancy (ANOVA p less than 0.05). Within gliomas, regional uptake increased with malignancy (n.s.). In 23 patients, a total of 32 tumor specimens were obtained for histochemical analysis of glutathione (GSH) content using high-pressure liquid chromatography. A significant correlation (least square method, p less than 0.001) between CBIs and GSH values was found, supporting the hypothesis that GSH is the predominant factor for the conversion of the lipophilic complex to hydrophilic derivates.

[Photon-emission tomography (SPECT) in the detection of hepatic hemangiomas of small size]

By means of ultrasonography it is possible to detect hepatic lesions of few millimeters, however, it doesn't give a precise diagnosis. The role of planar scintigraphy in the diagnosis of hepatic hemangioma has already been established, although it has limitations which are partially solved by means of SPECT. 46 patients with different pathologies and 9 healthy volunteers have been studied. In the 19 confirmed hemangiomas, planar scintigraphy showed a sensitivity of 73.6% versus 84.2% for SPECT, mostly due to lesions less than 2.5 cm. Besides that, SPECT allowed a correct visualization of abdominal and intrahepatic major vessels, although lesions less than 1.5 cm are difficult to evaluate.

Right-ventricular hemangioma causing serious outflow-tract obstruction

A 28-year-old woman had a partially nonexertional dyspnea and a murmur of pulmonary stenosis. Echocardiography and magnetic resonance imaging revealed a mass causing a nearly completely pulmonary outflow-tract obstruction. The mass was successfully resected and the pathological diagnosis of a mixed capillary and cavernous polypoid hemangioma was made. This case represents one of the very rare cases of a right-ventricular hemangioma in adults in which obstruction of the outflow-tract was initially evident. Non-invasive diagnosis and an exploratory operation with resection is the procedure of choice.

Symptomatic vertebral haemangiomas: report of two cases

The authors reported two cases of vertebral haemangiomas with spinal cord compression. The first case deteriorated during her pregnancy. Plain radiography of the thoracic spine gave the hint for the diagnosis and computed axial tomography showed the lesion. She was treated via surgical removal with minimal improvement of her paraparesis. The second case was diagnosed after operation because there was no abnormality over the relevant vertebra and the myelogram demonstrated an extradural mass lesion compressing the lower thoracic spinal cord. The patient improved satisfactorily after total removal of the tumour. Both surgical specimens were classical pictures of haemangiomas histologically.

Radiological-pathological correlation of mass lesions in the liver

Thirty two human livers were removed at autopsy. These included 7 with space-occupying or tumour-like lesions, namely one with multiple cysts, three with haemangiomas, a lobated liver with multiple nodules of focal nodular hyperplasia, one with a metastasis which also had a small haemangioma and one with a hepatocellular carcinoma. Fine particle barium diluted 2:1 with water was injected by hand to fill the arterial system. In the lobated liver, the portal system was also filled. High definition radiographs of liver slices showed arteriographic detail not visible on angiography. The arteriographic appearances were correlated with the macroscopic and microscopic pathology. Liver cysts compress the arteries and arterioles but an apparent halo on the whole liver radiograph was shown to be spurious on a 1 cm thick high definition film. The small vessel pattern of haemangiomas is well demonstrated accounting for the hyperechoic sonograms but hypoechoic areas may also occur due to involution of or haemorrhage into tumours. The small lesions of focal nodular hyperplasia had a poor arterial supply but filled from a portal venous injection. Metastases had a peripheral network of small vessels, central necrosis and normal sized peripheral arteries with no large artery entering the tumour. In hepatocellular carcinoma, a large artery was demonstrated entering the tumour which was considerably more vascular than the metastases. These features should aid in distinguishing these lesions on sonography.

Splenic lesions: sonographic patterns, follow-up, differential diagnosis

This report concerns 172 patients with sonographically diagnosed benign and malignant splenic lesions. A variety of echopatterns was observed, but a differential diagnosis was often impossible without contributory clinical data. Thirteen patients underwent ultrasound-guided fine-needle biopsy for histological confirmation or therapy. In 14 cases splenectomy was performed for treatment or final diagnosis. Twenty-three patients had malignant space-occupying lesions of the spleen. 26 cases presented with normal splenic size, 47 showed splenomegaly of different extent. Lymphoma was the main basic illness in 60 patients. Thirteen cases presented with splenic metastases from other neoplasms. 71 malignant splenic lesions were hypoechoic when compared with normal splenic echotexture. Only two patients exhibited hyperechoic metastases. In three cases a 'halo' sign was seen. In 99 patients benign focal lesions of the spleen were diagnosed. These included splenic infarction (n = 36), dysontogenetic cysts (n = 23), splenic abscesses (n = 7), splenic calcification (n = 13), and hyperechoic lesions (n = 17) most probably representing splenic hemangioma.

Diagnosis of hepatic hemangiomas with 99mTc-labeled red blood cell scanning: value of SPECT

99mTc-labeled red blood cell (RBC) scanning is considered a highly specific technique for the study of hepatic hemangiomas. However, planar imaging displays poor sensitivity for the identification of small lesions. The authors consider a survey group of 119 patients, of whom 66 with a presumed diagnosis of hepatic hemangioma, for a total of 77 lesions ranging from 0.8 to 15 cm in diameter. The study was conducted with three-phase planar imaging and single photon emission computed tomography (SPECT). The results, which confirm a high specificity of 99mTc-RBC scanning (100%) in the study of hepatic hemangiomas, show that SPECT significantly improves the detection of these lesions (71%) compared to the delayed static study (52%), with the largest gain for lesions between 2-3.5 cm (83% versus 51%). However, also SPECT has difficulty in detecting lesions of less than 2 cm. With regard to three-phase imaging, the authors point out that the pattern considered characteristic for hepatic hemangiomas (perfusion blood-pool mismatch) is infrequent (13%).

Lower limb bone hemangiomas in children: report of two cases

Hemangiomas of the bone are rare lesions, accounting for approximately 1% of all primary bone tumors. Hemangiomas occur fairly frequently in the vertebral bodies and the skull, but are unusual in other bones. We report two cases of unusual and fairly rare aspects of this vascular tumor in children. Both cases involved recurrences, which led to a wide bone resection in case 1 and to several curettages in case 2. In these two cases the histological type of hemangioma was capillary. In reviewing the literature we found no indication of wide resection of the benign forms in children.

Neoplastic disease of the spine

In summary, MR imaging has become the single most effective modality for the evaluation of spinal neoplasms by virtue of its ability to image the spinal cord directly and noninvasively. In this fashion, one can localize mass lesions relative to the spinal cord; in conjunction with the patient's clinical history, it is thus possible to provide a brief yet accurate differential diagnosis. Intravenous paramagnetic contrast enhancement also may prove extremely useful in further delineating such lesions. In addition, it has demonstrated a high sensitivity to primary and secondary tumors of the bony spine through its ability to detect subtle T1 signal changes in the vertebral marrow space.

Combined (team) approach to hemangioma management: arteriography with superselective embolization plus YAG laser/sapphire-tip resection

Thirteen patients have been treated over a 2-year period utilizing a team approach between the radiology and surgical services. Initial diagnostic evaluation is directed at determining the size and anatomic extent of the hemangioma; clinical assessment of coagulation and hemodynamic status is also performed. Arteriography with superselective embolization precedes the surgical procedure, usually by 24 hours. The YAG laser with contact sapphire-tip scalpels is then utilized for resection and reconstruction of the hemangioma. Total removal of hemangioma was achieved in 9 of 13 patients, and partial or subtotal removal was achieved in the remainder. Blood loss and complications were minimal.

[A case of retroperitoneal fibrosis associated with renal angiomyolipoma]

The authors performed intraperitoneal transposition of the right ureter in a patient who suffered from dilatation of the renal cavity-system due to retroperitoneal fibrosis. One and a half year later an angiomyolipoma was eliminated from the left kidney of the patient. Describing the associated occurrence of these 2 infrequent diseases the authors deal with the problem of etiology, diagnosis and treatment.

[Ultrasonography in diseases of lymph nodes and soft tissues of the neck]

A study of 55 patients affected by neoplasia of the head and neck or clinically evident laterocervical swellings was carried out in order to evaluate the diagnostic value of ultrasonography in the study of cervical lymph nodes and soft tissues, excluding thyroid or salivary pathologies. The analysis of results confirmed that, in line with previously published findings, ultrasonography is a reliable method of diagnosing lesions and correctly identifying the affected organ, but then it is considerably less reliable in defining the type of lesion. In view of this, it is reasonable to propose a more widespread use of ultrasonographically guided needle biopsy which, in addition to being a rapid and non-traumatic method, would allow precisely target samples to be taken from those lesions with a doubtful or unusual clinical or ultrasonic appearance.