Color and power Doppler sonography of liver hemangiomas: a dream unfulfilled?

Safety and Feasibility of Transarterial Bleomycin-Lipiodol Embolization in Patients with Giant Hepatic Hemangiomas

Giant hepatic hemangiomas present a significant clinical challenge, and effective treatment options are warranted. This study aimed to assess the safety and feasibility of transarterial bleomycin-lipiodol embolization in patients with giant hepatic hemangiomas. A retrospective analysis was conducted on patients with giant hepatic hemangiomas (>5 cm). Transarterial chemoembolization (TACE) was performed using 7-20 cc of lipiodol mixed with 1500 IU of bleomycin. Safety outcomes, including post-embolization syndrome (PES), hepatic artery dissection, systemic complications, and access site complications, were evaluated. Radiation doses were also measured. Feasibility was assessed based on the achieved hemangioma coverage. Seventy-three patients (49 female, 24 male) with a mean age of 55.52 years were treated between December 2014 and April 2023. The average hospitalization duration was 3.82 days, and 97.3% of lesions were limited to one liver lobe. The average bleomycin dose per procedure was 1301.5625 IU, while the average lipiodol dose was 11.04 cc. The average radiation dose was 0.56 Gy. PES occurred after 45.7% of TACE procedures, with varying severity. Complications such as hepatic artery dissection (three cases), access site complications (two cases), and other complications (one case) were observed. No treatment-related mortality occurred. Hemangioma coverage exceeding 75% was achieved in 77.5% of cases. The study results suggest that transarterial bleomycin-lipiodol embolization is a safe and feasible treatment option for a heterogeneous group of patients with giant hepatic hemangiomas. This approach may hold promise in improving outcomes for patients with this challenging condition.

Natural history of hepatic hemangiomas as a guide for surgical indication

Background

Generally, hemangiomas are asymptomatic and most lesions are incidentally diagnosed on abdominal ultrasonography. The indications for surgery are still debated mainly due to limited data about the natural history of hepatic hemangiomas. The aim of this study is to investigate the natural history of hepatic hemangiomas, the effects of age and sex on their growth, and their tendency to increase in size or causing symptoms or complications as a guide for surgical indication. In this current study, combined retrospective and prospective analysis was conducted on 186 Egyptian adult patients having 244 hepatic hemangiomas who attended to the outpatient clinics. Follow-up was performed to observe the accurate site, size, number, rate of growth of the lesions, and their tendency to cause symptoms or complications.

Results

Ninety-one percent of patients were asymptomatic and 9% were symptomatic. During follow-up, 48% of patients showed an increase in tumor diameter, 22% decreased, and 30% were stable. The growth rate at 18–45-year group showed an increasing trend that was higher in females; it was 3.3 ± 2 mm/year for males and 3.9 ± 1.8 mm/year for females. At ˃ 45 year group, the female patients showed a decreasing trend (− 2.1 ± 1.1 mm/year) while in males showed an increasing trend that was slower than in 18–45-year group (2.6 ± 1.7 mm/year).

Conclusion

Growth pattern of liver hemangiomas is affected by age and sex. The majority of hemangiomas are asymptomatic and complications are rare. Hemangioma size alone is not an indication for surgery in asymptomatic patients. Surgical indications are limited to patients with severe symptoms, complications, or suspicious lesions. Most hemangiomas can be managed conservatively even giant hemangiomas.

Superb microvascular imaging technology for ultrasound examinations: Initial experiences for hepatic tumors

PURPOSE

To explore whether superb microvascular imaging (SMI) technology could be helpful for the evaluation of hepatic tumors.

MATERIALS AND METHODS

Our institutional review board approved this study, and informed consent was obtained from all of the patients. Twenty-three patients with 29 hepatic tumors were enrolled in our study. The tumors consisted of hemangiomas (n=15), focal nodular hyperplasias (FNHs) (n=7), and hepatocellular carcinomas (n=7). All lesions were pathologically (n=2) or radiologically (n=27) confirmed. The mean tumor diameter was 1.9cm (range, 0.9cm to 5.0cm). Using SMI technology, all lesions were scanned and categorized into subgroups according to the flow pattern on the SMI.

RESULTS

The hemangiomas exhibited nodular rim patterns (33%) and spotty dot-like patterns (20%), and both of these findings were very specific for the diagnosis of hemangioma. The FNHs exhibited spoke-wheel patterns (43%) and radiating vessel patterns (29%) that were very specific findings for the diagnosis of FNH. The other tumors did not exhibit any specific patterns on SMI.

CONCLUSION

Evaluations of the inner vascularities of hepatic tumors with the SMI technique were feasible, and the SMI features were significantly different between the different types of hepatic tumors. These differences could aid the diagnoses of hepatic tumors with US.

A Case of Cavernous Hemangioma of the Gallbladder Treated With Single-Incision Laparoscopic Cholecystectomy

Although hepatic hemangiomas are common, gallbladder (GB) hemangiomas are extremely rare. We present a case of a cavernous GB hemangioma, which was detected during routine ultrasonography screening. The 51-year-old female patient was asymptomatic and had no relevant medical history. The preoperative imaging findings, including those of endoscopic ultrasonography, suggested that malignancy was highly unlikely in this submucosal tumor. Thus, we performed a single-incision laparoscopic cholecystectomy as a diagnostic and curative procedure. The postoperative pathological examination confirmed a GB hemangioma. In this case, the preoperative diagnosis was quite difficult, especially because of this rare presentation of a GB hemangioma. This is probably why the definitive diagnosis is established postoperatively in most previously reported cases of GB hemangioma.

A comparative study of contrast enhanced ultrasound and contrast enhanced magnetic resonance imaging for the detection and characterization of hepatic hemangiomas

This study aims to compare contrast enhanced ultrasound (CEUS) and contrast enhanced magnetic resonance imaging (CEMRI) for the detection and characterization of hepatic hemangiomas. Included in this retrospective study were 83 histopathologically confirmed lesions of hemangioma in 66 hospitalized patients who underwent both CEUS and CEMRI and received surgery. The enhancement patterns on CEUS and CEMRI in each lesion were compared and analyzed. In addition, data obtained by the two modalities were then compared with the pathological findings to determine their value in differential diagnosis of hepatic hemangiomas. CEUS diagnosed 78 lesions of hemangioma against 80 by CEMRI. There were no statistical significant differences in the diagnostic value between CEUS and CEMRI in terms of sensitivity (88.0% vs. 92.8%), specificity (99.0% vs. 99.4%), accuracy (97.3% vs. 98.4%), positive predictive value (93.6% vs. 96.3%), and negative predictive value (98.0% vs. 98.8%) (p > 0.05, all). In the arterial phase, the main enhancement pattern on both CEUS and CEMRI was peripheral nodular enhancement (73 vs. 76), but lesions with diffuse enhancement on CEUS outnumbered those on CEMRI (3 vs. 1) and lesions with circular enhancement on CEMRI outnumbered those on CEUS (3 vs. 2). In the portal venous phase and delayed phase, the main enhancement pattern was hyperechoic change on CEUS and hyperintense on CEMRI (66 vs. 65), some lesions presented isoechoic change (12 vs. 15). These results suggested CEUS, an equivalent to CEMRI, may have an added diagnostic value in hemangiomas.

Transcatheter Arterial Embolization Alone for Giant Hepatic Hemangioma

Giant hepatic hemangioma is a benign liver condition that may be treated using surgery. We studied the digital subtraction angiographic (DSA) characteristics of giant hepatic hemangioma, and the effectiveness of transcatheter arterial embolization (TAE) alone for its treatment. This was a retrospective study of 27 patients diagnosed with giant hepatic hemangioma and treated with TAE alone (using lipiodol mixed with pingyangmycin) at the Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, between January 2010 and March 2013. The feeding arteries were identified using DSA. All patients were followed up for between three weeks and 12 months. Changes in tumor diameter and symptoms were observed. The 27 patients included had giant hepatic hemangiomas ranging from 5.3 to 24.5 cm (mean, 11.24±5.08 cm) in the right (n = 13), left (n = 1) or both (n = 13) lobes. Preoperative hepatic angiography showed multiple abnormal vascular lakes in the early phase, known as the “early leaving but late returning, hanging nut on a twig” sign. On the day after TAE, hepatic transaminase levels were increased (ALT: 22.69±17.95 to 94.88±210.32 U/L; ALT: 24.00±12.37 to 99.70±211.54 U/L; both P<0.05), but not total bilirubin. Six patients complained of abdominal pain, and 12 experienced transient fever. In the months after TAE, tumor size decreased (baseline: 11.24±5.08; 3 months: 8.95±4.33; 6 months: 7.60±3.90 cm; P<0.05), and the patients’ condition improved. These results indicated that TAE was effective and safe for treating giant hepatic hemangioma. TAE may be a useful alternative to surgery for the treatment of hepatic hemangioma.

Hypervascular benign and malignant liver tumors that require differentiation from hepatocellular carcinoma: key points of imaging diagnosis

Most liver tumors are benign and hypervascular, and it is important to avoid unnecessary interventions for benign lesions. This review describes the typical and atypical imaging features of common hypervascular benign liver tumors and outlines a general approach to distinguishing between benign and malignant hepatic lesions. There are many types of benign liver tumors that need to be differentiated from hepatocellular carcinoma (HCC). Therefore, it is very important to know the imaging characteristics of benign tumors. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging is helpful in diagnosing hypervascular pseudotumors, focal nodular hyperplasia, and nodular lesions associated with alcohol-induced hepatitis. There are also some hypervascular malignant tumors, such as cholangiocarcinoma, cholangiolocellular carcinoma, mixed type tumors, and metastatic liver tumors, which also required differentiation from HCC.

Current consensus and guidelines of contrast enhanced ultrasound for the characterization of focal liver lesions

The application of ultrasound contrast agents (UCAs) is considered essential when evaluating focal liver lesions (FLLs) using ultrasonography (US). Microbubble UCAs are easy to use and robust; their use poses no risk of nephrotoxicity and requires no ionizing radiation. The unique features of contrast enhanced US (CEUS) are not only noninvasiveness but also real-time assessing of liver perfusion throughout the vascular phases. The later feature has led to dramatic improvement in the diagnostic accuracy of US for detection and characterization of FLLs as well as the guidance to therapeutic procedures and evaluation of response to treatment. This article describes the current consensus and guidelines for the use of UCAs for the FLLs that are commonly encountered in US. After a brief description of the bases of different CEUS techniques, contrast-enhancement patterns of different types of benign and malignant FLLs and other clinical applications are described and discussed on the basis of our experience and the literature data.

Colour Doppler sonography of hepatic haemangiomas with arterioportal shunts

OBJECTIVES

To determine the frequency of intratumoural flow and peritumoural hepatofugal portal flow using colour Doppler sonography (CDS) on hepatic haemangiomas with arterioportal shunt (APS), and to investigate possible factors that may affect the capability of CDS to depict such findings.

METHODS

The study included 45 patients (35 men, 10 women; mean age, 56 years) with hepatic haemangiomas with APS on CT or MRI. Locating the tumour on greyscale sonography, the depth, size and echogenicity of the tumour were evaluated. CT or MR images were evaluated for fatty liver. CDS was performed to determine the presence of intratumoural flow and peritumoural hepatofugal portal flow. Differences in frequency of intratumoural flow and peritumoural hepatofugal portal flow according to the depth, size, echogenicity and fatty liver were evaluated by Student's t-test and Fisher's exact test.

RESULTS

On CDS, intratumoural flow and peritumoural hepatofugal portal flow were found in 66.7% and 60%, respectively. The tumour depth was the significant variable that affected the capability of CDS to depict such findings. The frequencies of intratumoural flow and peritumoural hepatofugal portal flow were as high as 88% and 80% for shallow (≤30 mm) lesions, and they were 40% and 35% for deep (>30 mm) lesions (p=0.0012; p=0.0051).

CONCLUSION

CDS can commonly depict intratumoural flow and peritumoural hepatofugal portal flow in patients with hepatic haemangiomas with APS. Therefore, CDS should be routinely performed when an incidental mass is encountered during the screening sonography, especially when the lesion is shallow.

Surgical Treatment of Giant Hepatic Hemangiomas: Technical Point of View

Hepatic hemangiomas are the most common benign tumors of the liver. Surgical treatment can be difficult as a result of the high risk of intraoperative hemorrhage. The present study reviewed clinical features of patients with hepatic hemangioma and surgical techniques used in their treatment. Eight patients with giant hepatic hemangiomas underwent hepatectomies at the Asan Medial Center between January 2006 and March 2009. Patient demographic, clinical, and surgical characteristics and outcomes were reviewed retrospectively. Seven females and one male patient underwent hepatectomies during the study period. The median age was 48.5 years (range, 33 to 58 years). Indications for surgical interventions were abdominal pain (62.5%), an abdominal mass (37.5%), Kasabach-Merritt syndrome (25%), and increased hemangioma size (25%). The hemangiomas were usually multiple (87.5%) and bilobar (75%) and had a median size of 14.5 cm (range, 7 to 29 cm). All patients underwent major hepatic resection with early vascular control using the Glissonean pedicle transection method (GPTM), the liver hanging maneuver (LHM), and preparation for total vascular exclusion (TVE). There was no major morbidity or mortality. The minor morbidity rate was 25 per cent with transfusion rate of 37.5 per cent. Early vascular control using the GPTM, the LHM, and preparation for TVE is essential for safe resection of large hepatic hemangiomas.

Liver haemangiomas undetermined at grey-scale ultrasound: contrast-enhancement patterns with SonoVue and pulse-inversion US

The objective of this study was to describe the spectrum of contrast-enhancement patterns of hepatic haemangiomas undetermined at grey-scale ultrasound (US) on SonoVue-enhanced pulse-inversion (PI) US. Twenty patients (11 women, nine men) with 35 haemangiomas (size range: 1-7 cm; mean: 3.1 cm) undetermined at baseline US underwent PI at low M.I. (0.05-0.08) after i.v. injection of SonoVue. All haemangiomas were confirmed by typical helical computed tomography (CT) and/or magnetic resonance imaging (MRI) findings. US examinations were videotaped and then reviewed by two experienced radiologists blinded to the final diagnosis. Readers evaluated by consensus the baseline echogenicity and the dynamic enhancement pattern of each lesion, in comparison with adjacent liver parenchyma. After administration of SonoVue, 31/35 (88%) haemangiomas showed peripheral hyperechoic nodules in the arterial phase, followed by progressive centripetal fill-in, which was complete in 25/35 cases and incomplete in 6/35 cases. Three out of 35 (9%) haemangiomas showed rapid and complete fill-in in the arterial phase, which persisted in the portal and delayed phases. Finally, 1/35 haemangiomas (3%) showed a rim of arterial contrast enhancement with progressive and complete centripetal fill-in in portal-venous and delayed phases. In conclusion, PI after the administration of SonoVue enabled the depiction of typical contrast-enhancement patterns in haemangiomas undetermined at baseline US.

Hémangiome caverneux pédiculé géant du foie : à propos d’un cas et revue de la littérature

Cavernous hepatic haemangioma is the most frequent benign liver tumour, but the giant pedunculated form is rare because only 17 cases have been described in the literature. We report our experience of one case, and compare it to the 17 other described cases. Age, incidence and size of the lesion were the same as results in the literature. Our patient has had a left hepatic lobectomy because of an uncertain diagnosis. We discuss the diagnosis and the different treatments.

Potential for Differential Diagnosis with Gadolinium-Ethoxybenzyl-Diethylenetriamine Pentaacetic Acid-Enhanced Magnetic Resonance Imaging in Experimental Hepatic Tumors

RATIONALE AND OBJECTIVES

To investigate whether dynamic and delayed magnetic resonance imaging (MRI) with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA), a hepatobiliary MRI contrast agent, has potential for the differential diagnosis of experimental hepatic tumors.

METHODS

Twelve male rats received N-nitrosomorpholine solution as drinking water to induce hepatic tumors. After injection of Gd-EOB-DTPA, rats were subjected to dynamic and delayed MRI. The relative enhancement (RE) was calculated, and the time of the maximum RE (Tmax) was evaluated. After MRI, liver was histologically analyzed.

RESULTS

One hundred sixty-three hepatic tumors 3-12 mm in diameter were induced after 18 weeks of treatment with 0.01 wt/vol% of N-nitrosomorpholine, and 81 of them were evaluated. The RE in hyperplastic nodules (HPNs) was significantly higher than that in moderately or poorly differentiated hepatocellular carcinomas (HCCs) in the late phase, whereas there was no significant difference in RE between well-differentiated HCCs and HPNs. The average Tmax in HPNs was about 13 minutes, whereas that of each differentiated HCCs was about 1 minute.

CONCLUSIONS

It was possible to differentiate benign HPNs and malignant HCCs (especially well-differentiated HCCs) by evaluating the change of RE or comparison of Tmax with Gd-EOB-DTPA-enhanced MRI.