Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis

Perilesional enhancement of liver cavernous hemangiomas in magnetic resonance imaging

OBJECTIVE

To evaluate on magnetic resonance imaging (MRI) the occurrence rate of temporal perilesional parenchymal enhancement (PPE) associated with hepatic hemangiomas in a large consecutive series and to determine which aspects are associated with this observation.

MATERIALS AND METHODS

Institutional review board approved this retrospective study. A computerized search of the MRI database was performed for consecutive patients between January 2008 and January 2012. The study population included 513 liver hemangiomas in 224 patients (104 males and 120 females; mean age of 55.2 ± 13.5 years; age range 24-89 years). Two readers independently reviewed the frequency of PPE, size, speed of enhancement and location of each hemangioma. Marginal models with generalized estimating equation were used. Wald test was applied to verify if the model coefficients were significant.

RESULTS

80/513 (15.6%) hemangiomas showed PPE. The incidence of PPE was significantly higher (p < 0.05) in hemangiomas with Type1 speed of enhancement (51/80, 63.8%) than in those with Type2 or Type3. 66/80 (82.5%) hemangiomas with PPE were subcapsular (p < 0.05). Conversely, the majority (280/433, 64.7%) of hemangiomas without PPE were deep in location (p < 0.001). Lesser proportion of hemangiomas with PPE was located in segment IVa (p < 0.05).

CONCLUSION

PPE is not uncommonly seen along with hepatic hemangiomas. This appearance is most frequently observed in rapidly enhancing small lesions with a subcapsular location.

Enucleation of a Giant Hemangioma of Liver: Old School Revisited

Hemangiomas are the most frequent benign hepatic tumours and are usually found in patients aged between 40 and 60 years, more frequently in women. In 30-35% of patients, the lesions are multiple. If the lesions are larger than 4-10 cm, they are coined as "giant" hemangioma. Here, we present a case of giant hemangioma treated with enucleation of the lesion and the advantages of the procedure.

Lack of anti-tumor activity by anti-VEGF treatments in hepatic hemangiomas

Recently, anti-vascular endothelial growth factor (anti-VEGF) agents have been described in the literature as a valid treatment option for symptomatic liver hemangiomas, but only limited evidence supports this notion. The purpose of this study was to elucidate whether or not the administration of anti-VEGF agents can reliably achieve a size reduction in liver hemangiomas. We examined patients with incidental hemangiomas who received anti-angiogenic agents for the treatment of other malignancies. Our study population consisted of 17 colorectal cancer patients and one lung cancer patient carrying 21 hemangiomas who received bevacizumab, and seven renal cell carcinoma patients carrying nine hepatic hemangiomas who received sunitinib. We have measured the liver hemangioma volume on both the pre-treatment and post-treatment computed tomography images and then calculated the volume alteration rates. No statistically significant difference (P = 0.365) in the volume of the liver hemangiomas was observed before (1.1-168.8 cm(3); mean ± SD 19.8 ± 39.7 cm(3)) or after (1.2-163.6 cm(3); 19.3 ± 38.0 cm(3)) bevacizumab treatment. The volume reduction rate ranged from -35.0 to 11.2 % (mean ± SD -1.3 ± 10.8 %). The sunitinib treatment group also showed no statistically significant difference (P = 0.889) in hemangioma volume before (1.2-6.5 cm(3); 3.0 ± 1.8 cm(3)) or after (1.2-6.0 cm(3); 3.0-1.7 cm(3)) treatment. The volume reduction rate ranged from -13.3 to 7.7 % (median: mean ± SD -2.5 ± 6.6 %). We did not observe liver hemangioma shrinkage after bevacizumab or sunitinib treatment. Our data do not support the application of anti-VEGF agents for the treatment of hepatic hemangiomas.

Perfusion CT imaging of the liver: review of clinical applications

Perfusion computed tomography (CT) has a great potential for determining hepatic and portal blood flow; it offers the advantages of quantitative determination of lesion hemodynamics, distinguishing malignant and benign processes, as well as providing morphological data. Many studies have reported the use of this method in the assessment of hepatic tumors, hepatic fibrosis associated with chronic liver disease, treatment response following radiotherapy and chemotherapy, and hepatic perfusion changes after radiological or surgical interventions. The main goal of liver perfusion imaging is to improve the accuracy in the characterization of liver disorders. In this study, we reviewed the clinical application of perfusion CT in various hepatic diseases.

[Modern diagnostics of cystic liver lesions and hemangiomas]

CLINICAL ISSUE

Cystic liver lesions incorporate a broad heterogeneous group of mostly benign but also malignant abnormalities. The radiological aim is the non-invasive diagnosis with the use of different imaging modalities to determine the type of lesion.

STANDARD RADIOLOGICAL METHODS

The common generally asymptomatic incidental findings of cystic lesions on ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) must be classified on the basis of specific imaging features. Such a differentiation is essential because the clinical consequences and the appropriate therapy can vary depending on the underlying pathology. Due to the morphological overlap of many cystic lesions, conventional radiological methods are often insufficient.

METHODICAL INNOVATIONS

The huge advances in cross-sectional imaging (multidetector CT, MRI with special sequences and different contrast agents and MR cholangiopancreatography) in combination with the clinical history usually enable a non-invasive diagnosis. Pathognomonic morphological and hemodynamic lesion features, as well as a knowledge of the pathomechanisms, help to differentiate this broad spectrum of entities.

ACHIEVEMENTS

In this article the different entities of cystic liver lesions, together with the appropriate diagnostic method for detection and distinction and including their strengths and limitations, are demonstrated.

PRACTICAL RECOMMENDATIONS

A well-founded knowledge about the development of various cystic liver lesions and the suitable choice of imaging method facilitate a non-invasive diagnosis.

Diffuse infiltrative laryngoesophageal and peritoneal venous malformations mimicking carcinomatosis with a subclavian vein aneurysm

Venous malformations are benign vascular lesions that can occur in any part of the body. Esophageal venous malformations can extend into the peritoneum, so preoperative imaging can be decisive in diagnosis and treatment. The characteristic manifestations of venous malformations are transmural phleboliths, centripetal enhancement on dynamic CT, and bluish mucosa on endoscopy. We report a rare case of female patient diagnosed with venous malformations involving laryngoesophagus, mediastinum, and peritoneum, which mimicked carcinomatosis, in addition to a left subclavian vein aneurysm.

Focal liver lesions: Practical magnetic resonance imaging approach

With the widespread of cross-sectional imaging, a growth of incidentally detected focal liver lesions (FLL) has been observed. A reliable detection and characterization of FLL is critical for optimal patient management. Maximizing accuracy of imaging in the context of FLL is paramount in avoiding unnecessary biopsies, which may result in post-procedural complications. A tremendous development of new imaging techniques has taken place during these last years. Nowadays, Magnetic resonance imaging (MRI) plays a key role in management of liver lesions, using a radiation-free technique and a safe contrast agent profile. MRI plays a key role in the non-invasive correct characterization of FLL. MRI is capable of providing comprehensive and highly accurate diagnostic information, with the additional advantage of lack of harmful ionizing radiation. These properties make MRI the mainstay for the noninvasive evaluation of focal liver lesions. In this paper we review the state-of-the-art MRI liver protocol, briefly discussing different sequence types, the unique characteristics of imaging non-cooperative patients and discuss the role of hepatocyte-specific contrast agents. A review of the imaging features of the most common benign and malignant FLL is presented, supplemented by a schematic representation of a simplistic practical approach on MRI.

Clinical Translation of an Albumin-Binding PET Radiotracer 68Ga-NEB

Suitably labeled Evans blue dye has been successfully applied to evaluate cardiac function, vascular permeability, and lymphatic imaging in preclinical settings. This study documented the first-in-human application of 68Ga-1,4,7-triazacyclononane-N,N',N″-triacetic acid (NOTA)-NEB.

METHODS

The NOTA-conjugated truncated form of Evans blue, NEB, was labeled with 68Ga and tested in BALB/C mice for dynamic PET and ex vivo biodistribution studies. Three healthy volunteers (2 men and 1 woman) underwent 90-min whole-body dynamic PET. The absorbed doses for major organs and whole body were calculated using OLINDA/EXM software. Eleven patients with focal hepatic lesions diagnosed by enhanced CT or MR imaging were subjected to whole-body PET/CT acquisitions at 30 min after intravenous injection of 111-148 MBq (3-4 mCi) of 68Ga-NEB.

RESULTS

NEB dye was labeled with 68Ga (half-time, 68 min) with high yield and purity. After intravenous injection, 68Ga-NEB formed a complex with serum albumin, thus most of the radioactivity was retained in blood circulation. The tracer was demonstrated to be safe in both healthy volunteers and recruited patients without side effects or allergies. Among the 11 patients, hemangiomas showed much higher 68Ga-NEB signal intensity than the surrounding normal hepatic tissues, whereas no apparent difference between lesions and hepatic tissues was identified on 18F-FDG PET. All other focal hepatic lesions including hepatocellular carcinoma, hepatic cysts, and neuroendocrine tumor liver metastases showed negative 68Ga-NEB contrast to hepatic tissues.

CONCLUSION

As a blood-pool imaging agent, 68Ga-NEB is safe to use in the clinic, and our preliminary studies demonstrate the value of differentiating hepatic hemangioma from other benign or malignant focal hepatic lesions. Easy labeling with different positron emitters of various half-lives, excellent pharmacokinetics, and imaging quality warrant further clinical applications of NEB-based PET tracers.

Benign solid tumors of the liver: management in the modern era

BACKGROUND

Recently, there has been a growing interest in solid benign liver tumors as the understanding of the pathogenesis and molecular underpinning of these lesions continues to evolve. We herein provide an evidence-based review of benign solid liver tumors with particular emphasis on the diagnosis and management of such tumors.

METHODS

A search of all available literature on benign hepatic tumors through a search of the MEDLINE/PubMed electronic database was conducted.

RESULTS

New diagnostic and management protocols for benign liver tumors have emerged, as well as new insights into the molecular pathogenesis. In turn, these data have spawned a number of new studies seeking to correlate molecular, clinicopathological, and clinical outcomes for benign liver tumors. In addition, significant advances in surgical techniques and perioperative care have reduced the morbidity and mortality of liver surgery. Despite current data that supports conservative management for many patients with benign liver tumors, patients with severe preoperative symptomatic disease seem to benefit substantially from surgical treatment based on quality of life data.

CONCLUSION

Future studies should seek to further advance our understanding of the underlying pathogenesis and natural history of benign liver tumors in order to provide clinicians with evidence-based guidelines to optimize treatment of patients with these lesions.

Magnetic resonance imaging of a small vessel hepatic hemangioma in a cirrhotic patient with histopathologic correlation

The authors report and discuss a rare case of a small vessel hepatic hemangioma in a 59-year-old patient with liver cirrhosis, which was pre-procedurally characterized as indeterminate due to atypical magnetic resonance imaging (MRI) features. This manuscript reviews the MRI features with pathologic correlation, emphasizes the importance of accurate characterization of liver lesions, and discusses the role of biopsy. We believe this is the first reported case of a small vessel hemangioma in liver cirrhosis with imaging and histopathologic correlation.

The ins and outs of liver imaging

Different imaging modalities including ultrasonography, computed tomography (CT), and MR imaging may be used in the liver depending on the clinical situation. The ability of dedicated contrast-enhanced liver MR imaging or CT to definitively characterize lesions as benign is crucial in avoiding unnecessary biopsy. Liver imaging surveillance in patients with cirrhosis may allow for detection of hepatocellular carcinoma at an earlier stage, and therefore may improve outcome. This article reviews the different imaging modalities used to evaluate the liver and focal benign and malignant hepatic lesions, and the basic surveillance strategy for patients at increased risk for hepatocellular carcinoma.

Hyperechoic and hypoechoic hepatic hemangiomas smaller than 3 cm seldom coexist

PURPOSE

The purpose of this study was to determine whether hyperechoic and hypoechoic hepatic hemangiomas coexist.

METHODS

Archives of 456 patients with multiple smaller (≤3 cm) hepatic hemangiomas were reviewed, including sex, age, imaging study (ultrasound [US], computed tomography [CT], and magnetic resonance imaging [MRI]), follow-up, and laboratory test. Patients with chronic liver disease or other malignancy and diameter of lesion larger than 3 cm were excluded. The mean age of the patients was 41.8 ± 13.9 years (range, 18-78 years). The liver was observed with US; undetermined cases were evaluated by using CT and/or MRI. The follow-up time was from 35 to 39 months (mean, 36.3 months). Echo patterns, patterns of enhancement on CT and MRI, and associated findings of the hepatic hemangiomas were studied.

RESULTS

The number of hemangiomas was from 2 to 6, including 154 patients with 2 lesions, 196 patients with 3 lesions, 78 patients with 4 lesions, 18 patients with 5 lesions, and 10 patients with 6 lesions. Among them, hyperechoic accounts for 71.93% (328/456), hypoechoic 27.85% (127/456), and hyperechoic and hypoechoic coexistence 0.22% (1/456). There were significant differences of distribution between the hyperechoic and hypoechoic coexistence and other echo patterns (all P < 0.001). Diameter of the hemangioma was from 8.6 and 30.0 mm (15.5 ± 4.9 mm).

CONCLUSIONS

Hyperechoic and hypoechoic hemangiomas rarely coexist in the liver. In the event that hypoechoic and hyperechoic lesions are simultaneously found in the liver, CT, MRI, or contrast-enhanced US should be performed for a definitive diagnosis.

α6-Integrin is required for the adhesion and vasculogenic potential of hemangioma stem cells

Infantile hemangioma (IH) is the most common tumor of infancy. Hemangioma stem cells (HemSC) are a mesenchymal subpopulation isolated from IH CD133+ cells. HemSC can differentiate into endothelial and pericyte/smooth muscle cells and form vascular networks when injected in immune-deficient mice. α6-Integrin subunit has been implicated in the tumorgenicity of glioblastoma stem cells and the homing properties of hematopoietic, endothelial, and mesenchymal progenitor cells. Therefore, we investigated the possible function(s) of α6-integrin in HemSC. We documented α6-integrin expression in IH tumor specimens and HemSC by RT-qPCR and flow cytometry. We examined the effect of blocking or silencing α6-integrin on the adhesive and proliferative properties of HemSC in vitro and the vasculogenic and homing properties of HemSC in vivo. Targeting α6-integrin in cultured HemSC inhibited adhesion to laminin but had no effect on proliferation. Vessel-forming ability in Matrigel implants and hepatic homing after i.v. delivery were significantly decreased in α6-integrin siRNA-transfected HemSC. In conclusion, α6-integrin is required for HemSC adherence to laminin, vessel formation in vivo, and for homing to the liver. Thus, we uncovered an important role for α6 integrin in the vasculogenic properties of HemSC. Our results suggest that α6-integrin expression on HemSC could be a new target for antihemangioma therapy.

What is changing in indications and treatment of hepatic hemangiomas. A review

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

MR imaging of benign focal liver lesions

Focal liver lesions (FLLs) are commonly encountered on routine imaging studies. Most lesions detected are benign, but many are indeterminate at the time of initial imaging. This article reviews the important role of MR imaging for the detection and characterization of various benign FLLs while illustrating typical imaging appearances and potential pitfalls in interpretation. The utility of diffusion-weighted imaging and hepatocyte-specific contrast agents is also discussed.

P4 radiology of hepatobiliary diseases with gadoxetic acid-enhanced MRI as a biomarker

A recent paradigm shift in radiology has focused on the globalization of so-called P4 radiology. P4 radiology represents delivery of imaging results that are predictive, personalized, pre-emptive and participatory. The combination of the P4 approach and biomarkers is particularly pertinent to MRI, especially with technological advances such as diffusion-weighted imaging. The development of new liver-specific MRI contrast media, particularly gadoxetic acid, demonstrate specific pharmacokinetic properties, which provide combined morphologic and functional information in the same setting. The evaluation of hepatobiliary pathology beyond morphology gives rise to the possibilty of using gadoxetic acid-enhanced MRI as an imaging biomarker of hepatobiliary diseases. The integration of functional imaging with an understanding of complex disease mechanisms forms the basis for P4 radiology, which may ultimately lead to individualized, cost-effective, targeted therapy for patients. This will enable radiologists to determine the prognosis of the disease and estimate early response to treatment, with the participation of all the required medical disciplines.

MRI of hepatic epithelioid hemangioendothelioma (HEH)

PURPOSE

To investigate magnetic resonance imaging (MRI) characteristics of hepatic epithelioid hemangionendothelioma (HEH).

MATERIALS AND METHODS

The study was exempted from formal Ethics Committee approval due to its retrospective and noninvasive nature. Eleven patients with histology-proven HEH were collected from six different institutions in a 5-year time period. In all patients a contrast-enhanced MR study was available. Two experienced reviewers in consensus retrospectively noted potential MR findings of HEH. Reviewers separately analyzed morphological findings, tumor signal intensity, HEH contrast enhancement pattern, and tumor appearance on hepatobiliary phase and diffusion-weighted imaging (DWI). The frequency of various findings was calculated.

RESULTS

The most frequent presentation was a peripheral distribution of the lesions (72.7%), target appearance on T2-weighted images (63.6%), low signal intensity on T1-weighted images (63.6%), ring or target-like enhancement at dynamic study (63.6%), and coalescence of nodules and capsular retraction (45.4%). Lack of hepatobiliary enhancement (5/8 patients) or "entrapment" hepatobiliary enhancement (3/8 patients) as well as target appearance at DWI (5/6 patients) was also observed in our series.

CONCLUSION

Although quite variable imaging appearances were seen, a target appearance on the T2-weighted image, ring or target enhancement at dynamic study, lack of enhancement or "entrapment" at hepatobiliary phase, and target appearance on DWI are frequent findings of HEH.

Hepatic haemangioma: common and uncommon imaging features

The haemangioma, the most common non-cystic hepatic lesion, most often discovered by chance, may in certain situations raise diagnostic problems in imaging. In this article, the authors first demonstrate that the radiological appearance of the hepatic haemangioma, in its typical form, is closely related to three known histological sub-types. They then show that certain atypical features should be known in order to establish a diagnosis. They also observe the potential interactions between the haemangioma, an active vascular lesion, and the adjacent hepatic parenchyma. Finally, they discuss the specific paediatric features of hepatic haemangiomas and illustrate the case of a hepatic angiosarcoma.

Successful liver resection in a giant hemangioma with intestinal obstruction after embolization

Hepatic hemangiomas are the most common benign tumor of the liver. Most hepatic hemangiomas remain asymptomatic and require no treatment. Giant hepatic hemangiomas with established complications, diagnostic uncertainty and incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. We present a case of a giant hemangioma with intestinal obstruction following transcatheter arterial embolization, by which the volume of the hemangioma was significantly reduced, and it was completely resected by a left hepatectomy. A 21-year-old Asian man visited our hospital for left upper quadrant pain. Examinations at the first visit revealed a left liver hemangioma occupying the abdominal cavity, with a maximum diameter of 31.5 cm. Embolization of the left hepatic artery was performed and confirmed a decrease in its size. However, the patient was readmitted to our hospital one month after embolization for intestinal obstruction. A left hepatectomy was completed through a herringbone incision, and safely removed a giant hemangioma of 26.5 cm × 19.5 cm × 12.0 cm in size and 3690 g in weight. Pre-operative arterial embolization is effective for reducing tumor size, but a close follow-up to decide the time for hepatectomy is important.

Management of giant liver hemangiomas: an update

Liver hemangiomas are the most common benign liver tumors and are usually incidental findings. Liver hemangiomas are readily demonstrated by abdominal ultrasonography, computed tomography or magnetic resonance imaging. Giant liver hemangiomas are defined by a diameter larger than 5 cm. In patients with a giant liver hemangioma, observation is justified in the absence of symptoms. Surgical resection is indicated in patients with abdominal (mechanical) complaints or complications, or when diagnosis remains inconclusive. Enucleation is the preferred surgical method, according to existing literature and our own experience. Spontaneous or traumatic rupture of a giant hepatic hemangioma is rare, however, the mortality rate is high (36-39%). An uncommon complication of a giant hemangioma is disseminated intravascular coagulation (Kasabach-Merritt syndrome); intervention is then required. Herein, the authors provide a literature update of the current evidence concerning the management of giant hepatic hemangiomas. In addition, the authors assessed treatment strategies and outcomes in a series of patients with giant liver hemangiomas managed in our department.

Diagnosis and management of giant hepatic hemangioma: the usefulness of contrast-enhanced ultrasonography

Giant hepatic hemangiomas, though often asymptomatic, may require intervention if rapid growth occurs. The imaging studies including the computed tomography, magnetic resonance imaging, and ultrasonography, and so on are effective for the diagnosis and the management of this tumor; however, due to its size and various patterns of these studies, we need to carefully consider the therapeutic methods. Compared to the cost needed for these modalities, recently developed and approved Perflubutane- (Sonazoid-) based contrast agent enhanced ultrasonography is reasonable and safe. The major advantage is the real-time observation of the vascular structure and function of the Kupffer cells. By this procedure, we can carefully follow the tumor growth or character change in a hemangioma and decide the timing of therapeutic intervention, since abdominal pain, abdominal mass, consumptive coagulopathy, and hemangioma growth are the signs for the therapeutic intervention. We reviewed recent reports about Sonazoid-based enhancement and also showed the representative images collected in our department. This is the first review showing the detailed findings of the giant hemangiomas using Perflubutane (Sonazoid). This review will help the physician in making the decision, and we hope that Sonazoid will gain widespread acceptance in the near future.

Evaluation of liver lesions

The differential diagnosis of a liver mass is large and requires understanding of the clinical and imaging features of liver lesions. A detailed history, physical examination, hepatic biochemical tests, and imaging studies are all essential in making the diagnosis. Decisions regarding specific imaging modalities for diagnoses, the use of liver biopsy, therapeutic options, and appropriate follow-up are all determined by the presentation of the lesion and associated patient characteristics.

[Benign focal hepatic lesions]

A profound knowledge of the various benign focal hepatic lesions and selection of the most suitable radiological examination modality is essential for achieving an accurate characterization of a hepatic lesion and in turn will determine the further patient management. This will avoid unnecessary agitation to both patient and the referring clinician and limits time-consuming, costly and risky biopsies to an absolute minimum. The following article will discuss the typical and atypical appearances of the most frequent and clinically relevant benign focal hepatic lesions with ultrasound, computed tomography and magnetic resonance imaging.

Liver hemangioma and vascular liver diseases in patients with systemic lupus erythematosus

AIM: To investigate whether systemic lupus erythematosus (SLE) is associated with benign focal liver lesions and vascular liver diseases, since these have been occasionally reported in SLE patients.

METHODS: Thirty-five consecutive adult patients with SLE and 35 age- and sex-matched healthy controls were evaluated. Hepatic and portal vein patency and presence of focal liver lesions were studied by colour-Doppler ultrasound, computerized tomography and magnetic resonance were used to refine the diagnosis, clinical data of SLE patients were reviewed.

RESULTS: Benign hepatic lesions were common in SLE patients (54% vs 14% controls, P < 0.0001), with hemangioma being the most commonly observed lesion in the two groups. SLE was associated with the presence of single hemangioma [odds ratios (OR) 5.05; 95% confidence interval (CI) 1.91-13.38] and multiple hemangiomas (OR 4.13; 95% CI 1.03-16.55). Multiple hemangiomas were associated with a longer duration of SLE (9.9 ± 6.5 vs 5.5 ± 6.4 years; P = 0.04). Imaging prior to SLE onset was available in 9 patients with SLE and hemangioma, showing absence of lesions in 7/9. The clinical data of our patients suggest that SLE possibly plays a role in the development of hemangioma. In addition, a Budd-Chiari syndrome associated with nodular regenerative hyperplasia (NRH), and a NRH associated with hepatic hemangioma were observed, both in patients hospitalized for abdominal symptoms, suggesting that vascular liver diseases should be specifically investigated in this population.

CONCLUSION: SLE is associated with 5-fold increased odds of liver hemangiomas, suggesting that these might be considered among the hepatic manifestations of SLE.

Is hepatotropic contrast enhanced MR a more effective method in differential diagnosis of hemangioma than multi-phase CT and unenhanced MR?

BACKGROUND

Cavernous hemangiomas are the most frequent neoplasms of the liver and in routine clinical practice they often need to be differentiated from malignant tumors and other benign focal lesions. The purpose of this study is to evaluate whether diagnostic accuracy of magnetic resonance imaging (MRI) of hepatic hemangiomas, showing atypical pattern on US, improves with the use of Gd-BOPTA in comparison with contrast-enhanced multi-phase computed tomography (CT).

METHODS

178 consecutive patients with ambiguous hepatic masses showing atypical hyperechoic pattern on grey-scale US, underwent unenhanced and contrast-enhanced multi-phase multi-detector CT and MR (1.5T) with the use of liver-specific contrast medium gadobenate dimeglumine (Gd-BOPTA). After intravenous contrast administration arterial (HAP), venous-portal (PVP), equilibrium phases (EP) both in CT and MR and additionally hepatobiliary phase (HBP) in MR were obtained. 398 lesions have been detected including 99 hemangiomas and 299 other lesions.

RESULTS

In non-enhanced MDCT examination detection of hemangiomas was characterized by sensitivity of 76%, specificity of 90%, PPV of 71%, NPV of 92% and accuracy of 86%.Non-enhanced MR examination showed sensitivity of 98%, specificity of 99%, PPV of 99%, NPV of 99% and accuracy of 99%.After intravenous administration of contrast medium in MR the mentioned above parameters did not increase significantly.

CONCLUSION

Gd-BOPTA-enhanced MR in comparison with unenhanced MRI does not improve diagnostic accuracy in discriminating hemangiomas that show non-specific appearance in ultrasound examination. Unenhanced MR as a method of choice should directly follow US in course of diagnostic algorithm in differentiation of hemangiomas from other liver tumors.

A case of a ruptured sclerosing liver hemangioma

Hemangiomas are the most common benign tumors found in the liver, typically asymptomatic, solitary, and incidentally discovered. Although vascular in nature, they rarely bleed. We report a case of a 52-year-old woman with a previously stable hemangioma who presented to our hospital with signs and symptoms indicative of spontaneous rupture. We review the literature, focusing on diagnosis and management of liver hemangiomas.

Conservative and operative management of benign solid hepatic tumours: a successful stratified algorithm

BACKGROUND

The progress of modern imaging studies has improved the diagnostic approach of benign liver tumours, leading to a tailored approach with increased conservative management.

METHODS

One hundred and thirty-two patients suffering from benign hepatic tumours were enrolled in this study, including an operative (group I, 49 patients) and a conservative (group II, 83 patients) management. Patients' tumour and treatment features were analyzed.

RESULTS

The mean patients' age was 39 years. Indication for resection based on diagnosis of tumour nature (hepatic cell adenoma or uncertain diagnosis) and significant tumour-related abdominal pain was 15% out of 33 patients with hepatic haemangioma, 21.7% out of 60 patients with focal nodular hyperplasia and 78.4% out of 37 patients with hepatocellular adenoma. Mortality was nihil in group I. Complications and transfusion rates were related to the performance of major hepatectomy, when required for huge tumours. With a 95.5% of complete patients' follow-up during a mean of 92 months in group I and 87 months in group II, no misdiagnosis or evolution towards malignancy was encountered. Interestingly, 87.9% of all observed benign liver tumours remained stable, decreased in size or disappeared. None of the remaining lesions required surgery.

CONCLUSION

A restrictive policy of surgical management of benign liver tumours based on clinical symptoms, tumour size and nature on imaging studies (including dubious lesions) and tumour biopsies in selected cases is safe and reliable with a low-operative mortality in resected patients and satisfactory disease-control in the vast majority of observed benign liver tumours.

Reappraisal of surgical indications and approach for liver hemangioma: single-center experience on 74 patients

BACKGROUND

Liver hemangiomas are rarely large, symptomatic, or presenting atypical imaging patterns. Surgery is rarely needed; indications and choice of the best technique remain not precisely defined.

METHODS

Features of hemangiomas and surgical indications were assessed in 74 patients (mean follow-up 63.2 months). In 40 operated patients, the results of liver resection versus enucleation were compared.

RESULTS

Most hemangiomas (60/74, 81.1%) showed no size increment. In 40 operated patients (40/74, 54.1%) the mean tumor size (11.9 cm, range 2.6-46.0) was larger than in nonoperated patients (11.9 vs 6.0 cm, P = .0002). Surgical indications were specific symptoms, tumor enlargement, Kasabach-Merritt syndrome, and uncertain diagnosis. Mortality (nil), morbidity (10.0%), and transfusion rate (15.0%) were similar for 28 liver resections versus 12 enucleations; bleeding was more related to large hemangioma size than to the choice of either technique. Liver ischemia techniques, autotransfusion, and intraoperative blood salvage reduced the risk of transfusion.

CONCLUSIONS

Surgery is rarely indicated, has a low risk, and has similar results for liver resection versus enucleation. Risk of bleeding is related more to the large size of the hemangioma than to the type of surgery (resection or enucleation). In these patients, management, the need for surgery, and the choice of technique should be carefully individualized.

Solitary hepatic lymphangioma: report of a case

A 52-year-old woman presented with upper abdominal pain. Abdominal ultrasonography showed a 4-cm well-defined mass containing solid and cystic components in segment IV of the liver, and contrast-enhanced T1-weighted magnetic resonance imaging revealed heterogeneous enhancement within the tumor, indicating a solid or fibrous component. There were no cystic lesions in any other organs. A partial hepatectomy was performed, based on a preoperative diagnosis of sclerosing hemangioma and biliary cystadenoma or cystadenocarcinoma. Pathologically, the tumor appeared to be a multilocular and cystic lesion lined by attenuated endothelial- like cells with no atypia. Immunohistochemistry demonstrated the endothelial-like cells to be positive for the lymphatic-specific markers D2-40, LYVE-1, and Prox-1, which proved helpful for confirming the diagnosis as solitary hepatic lymphangioma. This case is presented with details of the pathologic and radiologic findings, because solitary hepatic lymphangioma is an extremely rare tumor and no previous reports have provided details of the immunohistochemical characteristics.

Solitary hepatic lymphangioma: report of a case

A 52-year-old woman presented with upper abdominal pain. Abdominal ultrasonography showed a 4-cm well-defined mass containing solid and cystic components in segment IV of the liver, and contrast-enhanced T1-weighted magnetic resonance imaging revealed heterogeneous enhancement within the tumor, indicating a solid or fibrous component. There were no cystic lesions in any other organs. A partial hepatectomy was performed, based on a preoperative diagnosis of sclerosing hemangioma and biliary cystadenoma or cystadenocarcinoma. Pathologically, the tumor appeared to be a multilocular and cystic lesion lined by attenuated endothelial- like cells with no atypia. Immunohistochemistry demonstrated the endothelial-like cells to be positive for the lymphatic-specific markers D2-40, LYVE-1, and Prox-1, which proved helpful for confirming the diagnosis as solitary hepatic lymphangioma. This case is presented with details of the pathologic and radiologic findings, because solitary hepatic lymphangioma is an extremely rare tumor and no previous reports have provided details of the immunohistochemical characteristics.

[Atypical evolution of liver hemangioma: a report of two cases]

We present and illustrate two cases of atypical evolution of liver hemangiomas studied with magnetic resonance imaging. In the first case, the lesion was associated with capsular retraction and became progressively smaller until it completely disappeared. The second case involved a woman taking birth control pills in whom the lesion grew progressively larger, doubling its diameter.

Superextended hepatectomy for resection of multiple giant hemangiomas: report of a case

Most liver hemangiomas are small, asymptomatic, and require no treatment. Symptoms such as right upper quadrant abdominal pain and fullness are associated only with liver hemangiomas larger than 4 cm in diameter. Serious complications such as jaundice, Kasabach-Merritt syndrome, and rupture are rare. Surgical resection is the only effective treatment, but it is advocated only for patients with incapacitating symptoms or complications. We report a case of successful superextended hepatectomy with resection of segments III-VIII for multiple, bilobar hemangiomas. A 45-year-old woman, who had undergone transcatheter arterial embolization (TAE) for inoperable multiple giant liver hemangiomas 4 years earlier, was referred to our hospital for investigation of abdominal distension and consumption coagulopathy. Because of her severe and progressive symptoms despite treatment, the other hospital had considered her as a candidate for liver transplantation, which she had refused. After careful preoperative assessment of the future liver remnant volume and function, we considered that resection was possible. Based on our review of large surgical series in the literature from 1970, this is the first report of a superextended hepatectomy for a benign liver tumor.