Diagnosis and management of cavernous hemangioma of the liver

CmPn/CmP Signaling Networks in the Maintenance of the Blood Vessel Barrier

Cerebral cavernous malformations (CCMs) arise when capillaries within the brain enlarge abnormally, causing the blood-brain barrier (BBB) to break down. The BBB serves as a sophisticated interface that controls molecular interactions between the bloodstream and the central nervous system. The neurovascular unit (NVU) is a complex structure made up of neurons, astrocytes, endothelial cells (ECs), pericytes, microglia, and basement membranes, which work together to maintain blood-brain barrier (BBB) permeability. Within the NVU, tight junctions (TJs) and adherens junctions (AJs) between endothelial cells play a critical role in regulating the permeability of the BBB. Disruptions to these junctions can compromise the BBB, potentially leading to a hemorrhagic stroke. Understanding the molecular signaling cascades that regulate BBB permeability through EC junctions is, therefore, essential. New research has demonstrated that steroids, including estrogens (ESTs), glucocorticoids (GCs), and metabolites/derivatives of progesterone (PRGs), have multifaceted effects on blood-brain barrier (BBB) permeability by regulating the expression of tight junctions (TJs) and adherens junctions (AJs). They also have anti-inflammatory effects on blood vessels. PRGs, in particular, have been found to play a significant role in maintaining BBB integrity. PRGs act through a combination of its classic and non-classic PRG receptors (nPR/mPR), which are part of a signaling network known as the CCM signaling complex (CSC). This network couples both nPR and mPR in the CmPn/CmP pathway in endothelial cells (ECs).

Proton beam therapy for a giant hepatic hemangioma: A case report and literature review

Background

Hepatic hemangiomas are benign tumors with a favorable prognosis, but giant hepatic hemangiomas can cause abdominal symptoms and are indicated for treatment. Most cases are treated with surgery, but radiotherapy has also been used. However, to date, there have been no reports of proton beam therapy for a hepatic hemangioma.

Case presentation

A 46-year-old woman had a tumor of 80 × 80 mm in the left medial lobe of the liver, which was diagnosed as a giant hemangioma based on the contrast pattern. Therapy was required for a giant hepatic hemangioma with symptoms, but the patient refused blood transfusion due to religious reasons, which made surgical resection difficult. Therefore, she was referred to our hospital for proton beam therapy. At her first visit, liver function was Child-Pugh A (5 points) and there was no elevation of tumor markers. Proton beam therapy of 28.6 Gy (RBE) given in 13 fractions was performed without interruption. The only observed acute radiation toxicity was Grade 1 dermatitis. One year after proton beam therapy, the hemangioma had significantly decreased, and a complete response has been maintained for 15 years based on ultrasound and MRI.

Conclusion

This case is the first reported use of proton beam therapy for a hepatic hemangioma. The outcome suggests that this treatment may be effective for a giant liver hemangioma.

Giant hepatic hemangioma case report: When is it time for surgery?

We describe a case of a 30-year-old man who complained intermitted pain in right abdominal flank; a large cavernoumatos hemangioma – up to 6 cm in size – was revealed in the fifth hepatic segment using Ultrasonography and MRI (Magnetic Resonance Imaging).

Indications for treatment – based on imaging features and clinical data – are briefly discussed in our report, providing also a review of existing literature.

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Giant hemangiomas can become an invalidant condition.

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Magnetic Resonance Imaging is the most sensitive radiological technique.

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Giant hemangiomas are suscettibile of a laparoscopic approach

Gadoxetate disodium-enhanced MRI of the liver: part 1, protocol optimization and lesion appearance in the noncirrhotic liver

OBJECTIVE

The purpose of this article is to review the pharmacokinetic and pharmacodynamic properties of gadoxetate disodium (Gd-EOB-DTPA), to describe a workflow-optimized pulse sequence protocol, and to illustrate the imaging appearance of focal lesions in the noncirrhotic liver.

CONCLUSION

Gd-EOB-DTPA allows a comprehensive evaluation of the liver with the acquisition of both dynamic and hepatocyte phase images. This provides potential additional information, especially for the detection and characterization of small liver lesions. However, protocol optimization is necessary for improved image quality and workflow.

Approach to Solid Liver Masses in the Cirrhotic Patient

Liver masses in cirrhosis are increasingly being recognized with the use of new imaging modalities. The majority of these lesions are detected by ultrasound, enhanced CT and MRI. The most likely diagnosis of a solid liver lesion in a cirrhotic liver is hepatocellular carcinoma, followed by high grade or low grade dysplastic nodule, and cholangiocarcinoma. Lymphoma and liver metastasis are extremely rare. Diagnosis is made by contrast enhanced ultrasound, multi detector (MDCT) and MRI. Fine needle core biopsy (FNCB) or aspiration (FNAB) or both may be required in doubtful cases. If uncertainty persists on the nature of the lesion, surgical liver resection is recommended. This review discusses the main characteristics of the most common solid liver masses in cirrhotic patient.

Characteristics of common solid liver lesions and recommendations for diagnostic workup

Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.

Contrast-enhanced ultrasound of histologically proven liver hemangiomas

Differentiation of small and atypical hemangiomas from other hepatic masses using imaging methods can be difficult, especially in patients with underlying malignant disease. Therefore, contrast-enhanced ultrasound was assessed in patients with histologically confirmed hemangiomas with respect to contrast-enhancing kinetics and tumor characteristics. In 58 patients with indeterminate hepatic lesions demonstrated with at least 2 imaging methods (ultrasound/computed tomography/magnetic resonance imaging), ultrasound-guided liver biopsy revealed hemangioma. In all patients a hepatic neoplasm had been suspected because of underlying malignant disease (n=41), liver cirrhosis (n=15), or growth of the lesion (n=2). All patients underwent nonlinear, low mechanical index real-time contrast-enhanced ultrasound scanning with bolus injections of SonoVue. Peripheral nodular arterial enhancement was detected in 43 patients (74%), whereas the typical metastatic peripheral rim-like enhancement was not observed at all. Strong homogenous arterial enhancement was found in 9 of 58 (16%) patients. In 6 patients (10%), the arterial contrast enhancement pattern could not be determined because of the very small size of the lesions or fibrotic nodules. Forty-five (78%) of the hemangiomas showed homogenous centripetal filling within 180 seconds.

CONCLUSION

Contrast-enhanced ultrasound demonstrates typical hemangioma imaging characteristics, that is, peripheral nodular contrast enhancement and iris-diaphragm sign in a high percentage of patients with undetermined lesions. This technique may therefore improve noninvasive functional characterization and differentiation of hemangiomas.

Features of hepatic cavernous hemangioma on planar and SPECT Tc-99m-labeled red blood cell scintigraphy

PURPOSE

To determine the value and diagnostic accuracy of planar and SPECT Tc-99m-labeled red blood cell (Tc-99m RBC) scintigraphy in the investigation of suspected hepatic cavernous hemangioma as found on ultrasound.

PATIENTS AND METHODS

One hundred patients, 89 women (89%) and 11 men (11%), between 22 and 67 years old (mean age, 38 years) were evaluated for liver masses found on abdominal ultrasound. All the patients had previous Tc-99m RBC scintigraphy. The size of the lesions ranged from 1 to 9 cm. The final diagnosis was reached through cytologic biopsy, or histopathologic tests (or all of these).

RESULTS

One hundred thirty lesions were found. With regard to the distribution of the lesions, 116 (89%) were single; 14 (3%) were multiple, with 118 (91%) in the right lobe and 12 (9%) in the left lobe; 83 (64%) were posterior; and 47 (36%) were anterior. With respect to the pattern of radioactivity fill-in, 86 (66%) lesions were typical and 44 (34%) were atypical. The results of Tc-99m RBC scintigraphy showed sensitivity, specificity, and positive and negative predictive and accuracy values of 97%, 83%, 98%, 77%, and 96% respectively. The use of SPECT improved the sensitivity value by 11% for lesions of 1 to 2 cm.

CONCLUSIONS

Tc-99m RBC scintigraphy is the noninvasive technique most helpful in the diagnosis of hepatic hemangioma, especially in those at risk for lesion rupture or bleeding. SPECT should be performed whenever planar imaging fails to show the lesion by 2 hours. The use of ultrasound should precede scintigraphy for two important reasons: the size and the location of the lesion. Location of the lesion (anterior or posterior) is important for optimal gamma camera acquisition parameters. Lesions less than 1 cm are cannot be detected because they are beyond the limit of spatial resolution of the gamma camera we used.

Evaluation of the solid hepatic mass

With the expanding use of abdominal imaging studies, evaluation of solid hepatic masses has become a common clinical challenge. In this review, the clinicopathologic characteristics of the most common causes of solid hepatic masses have been discussed. As the case scenarios demonstrate, the appropriate selection of imaging techniques and proper management of an individual patient depend on the clinical context. Often, complementary radiologic studies are necessary to narrow the differential diagnosis. Percutaneous biopsy or surgery is frequently required to confirm the diagnosis and to exclude malignancy definitively. The evaluation and management of solid hepatic masses is a cooperative venture that requires a multidisciplinary approach.

Nuclear imaging of solid hepatic masses

This review has focused on the unique role of radionuclide scintigraphy in characterization of hepatic mass lesions. Radionuclide scintigraphy, unlike most other imaging modalities, is based on specific physiological and biochemical properties of each pathological entity that affects the liver. Hepatic scintigraphy, with its widespread availability, noninvasive nature, and relatively low cost is a powerful adjunct to other imaging techniques in the investigation of hepatic mass lesions. We have reviewed clinical presentation and characteristic findings of most hepatic lesions and have described reported findings with all available imaging modalities with particular emphasis on hepatic scintigraphy (Table 1) as well as a suggested algorithm for workup of solid hepatic masses (Fig 6). Additionally, the role of newer, more specialized techniques including PET scanning, 123I-labeled VIP, and 111In-labeled DTPA-D-Phe-octreotide scanning are reviewed. Hepatic nuclear scintigraphy continues to play an important role in the management of patients with solid hepatic masses.

Correlative imaging of the liver and hepatobiliary system

Many imaging techniques can be used to assess the liver and hepatobiliary system. Each modality has individual strengths and limitations, which usually vary depending on the specific clinical situation. This review discusses several specific common clinical situations where imaging of the liver and biliary system is necessary and describes the various imaging options. Space-occupying liver lesions are discussed, and particular attention is paid to the assessment of liver metastasis, hepatoma, and incidentally discovered liver lesions such as hemangioma, adenoma, and focal nodular hyperplasia. The value of ultrasound, computed tomography, magnetic resonance imaging, and scintigraphic techniques in this patient population is described. Isolated sulfur colloid hepatic scintigraphy is not of great value in the evaluation of these patients. Therefore, this review describes in some detail the value of physiological liver scintigraphy, including gallium and iminodiacetic acid (IDA) scanning as well as dynamic flow imaging of the liver such as hepatic artery perfusion scintigraphy and tagged red cell scintigraphy. Imaging of the biliary tree also is described. The roles of ultrasound and scintigraphy are compared and contrasted as related to the diagnosis of acute cholecystitis, common duct obstruction, and postoperative complications.

Focal liver lesions

Preview Solid focal lesions of the liver can present numerous diagnostic challenges, and once diagnosis is made, careful decision making is needed to assure cost-effective management. In this article, the authors consider five solid lesions: hemangioma, focal nodular hyperplasia, liver cell adenoma, primary hepatocellular carcinoma, and metastatic cancer. Cystic lesions are assessed in a companion article on page 149.

Radiation therapy in the unresectable cavernous hemangioma of the liver

Hemangioma is the most common benign neoplasm of the liver, for which a 'wait and see' policy has been advised when it is small or without symptoms. Surgery is the treatment of choice of these tumors when marked symptomatology is present. However, some of these lesions cannot be excised due to their size, multiplicity, location or medical conditions. In these patients, radiotherapy has been reported to give good results with minor morbidity, suspending the tumor growth and decreasing the symptomatology. Seven symptomatic patients were treated with radiotherapy with a dose of 15-30 Gray in 15-22 fractions. Improvement of the quality of life was observed in all patients and the regression of the tumor volume was confirmed by computed tomography in five, with a follow-up ranging from 40 to 67 months.

Ultrasonographic features of hepatocellular pseudotumour in the cirrhotic liver

Eight cases of hepatocellular pseudotumours (HPT) were encountered in 6 years during which time 140 hepatectomies were performed for hepatocellular carcinoma (HCC). All were found during screening of cirrhotic patients. The ultrasonographic pattern of HPT was similar to that of HCC and their correct diagnosis was impossible by ultrasonography alone. A space-occupying lesion in the cirrhotic liver which is detected by ultrasonography but not by computed tomography and angiography may be a hepatocellular pseudotumour. This diagnosis is particularly likely if the serum alpha-fetoprotein level is normal.