Hepatic hemangiomas

The role of liver transplantation in the care of primary hepatic vascular tumours in children

Liver transplantation (LT) is the standard of care for many liver conditions, such as end-stage liver diseases, inherited metabolic disorders, and primary liver malignancies. In the latter group, indications of LT for hepatoblastoma and hepatocellular carcinoma evolved and are currently available for many non-resectable cases. However, selection criteria apply, as the absence of active metastases. Evidence of good long-term outcomes has validated the LT approach for managing these malignancies in the context of specialist and multidisciplinary approach. Nevertheless, LT's role in treating primary vascular tumours of the liver in children, both benign and malignant, remains somewhat controversial. The rarity of the different diseases and the heterogeneity of pathological definitions contribute to the controversy and make evaluating the benefit/risk ratio and outcomes quite difficult. In this narrative review, we give an overview of primary vascular tumours of the liver in children, the possible indications and the outcomes of LT.

Emergent orthotopic liver transplantation for hemorrhage from a giant cavernous hepatic hemangioma: case report and review

INTRODUCTION

Cavernous hemangiomas represent the most common benign primary hepatic neoplasm, often being incidentally detected. Although the majority of hepatic hemangiomas remain asymptomatic, symptomatic hepatic hemangiomas can present with abdominal pain, hemorrhage, biliary compression, or a consumptive coagulopathy. The optimal surgical management of symptomatic hepatic hemangiomas remains controversial, with resection, enucleation, and both deceased donor and living donor liver transplantation having been reported.

CASE REPORT

We report the case of a patient found to have a unique syndrome of multiorgan cavernous hemangiomatosis involving the liver, lung, omentum, and spleen without cutaneous involvement. Sixteen years following her initial diagnosis, the patient suffered from intra-abdominal hemorrhage due to her giant cavernous hepatic hemangioma. Evidence of continued bleeding, in the setting of Kasabach-Merritt Syndrome and worsening abdominal compartment syndrome, prompted MELD exemption listing. The patient subsequently underwent emergent liver transplantation without complication.

CONCLUSION

Although cavernous hemangiomas represent the most common benign primary hepatic neoplasm, hepatic hemangioma rupture remains a rare presentation in these patients. Management at a center with expertise in liver transplantation is warranted for those patients presenting with worsening DIC or hemorrhage, given the potential for rapid clinical decompensation.

Adult Kasabach-Merritt Syndrome due to Hepatic Giant Hemangioma

Cavernous hemangiomas are the most common benign tumors of the liver. They can reach enormous sizes and cause various complications. Kasabach-Merritt syndrome is a rare but serious complication characterized by consumptive coagulopathy caused by the hemangioma; mortality rate ranges between 10 and 37%. More than 80% of cases occur within the first year of life. Goals of the treatment are to control the coagulopathyand thrombocytopenia as well as to eradicate the hemangioma. Different nonsurgical treatment regimens are performed, includingsystemic corticosteroids, irradiation and various chemicals. Surgery should be limited to symptomatic or complicated cases. Although difficult, resection of the tumor is usually curative. Here we present a 44-year-old woman with giant hepatic hemangioma causing Kasabach-Merritt syndrome managed by enucleation.

Indicações e resultados da ressecção cirúrgica do hemangioma hepático: indications and results

OBJETIVO: Apresentar os resultados do tratamento cirúrgico em pacientes portadores de hemangioma hepático. MÉTODO: Foram estudados 20 pacientes portadores de hemangioma hepático cavernoso, operados entre fevereiro de 1991 e fevereiro de 2005. A idade dos pacientes variou de 16 a 72 anos (média de 42 anos) com predomínio do sexo feminino (80%), sendo que 85% deles eram sintomáticos. Todos os pacientes foram submetidos à ultrassonografia abdominal (US) e à tomografia computadorizada contrastada (TC). Utilizou-se incisão abdominal subcostal bilateral associada à incisão mediana. RESULTADOS: Durante o período de seguimento clínico não se constataram recidiva de sintomas ou de hemangioma. A morbidade pós-operatória representada por infecção da ferida cirúrgica foi observada em um (5%) paciente, insuficiência hepática leve em 40% e moderada em 15% que apresentaram evolução clínica satisfatória com o tratamento clínico instituido; em um (5%) verificou-se a ocorrência de bilioma que necessitou drenagem por punção abdominal. A maioria dos pacientes retornou as atividades habituais até o 3º. mês de pós-operatório. Não ocorreram óbitos nesta série de pacientes. CONCLUSÃO: A ressecção cirúrgica do hemangioma hepático, gigante ou sintomático, é opção de tratamento segura e eficaz, sendo que a extensão da ressecção varia de acordo com a localização e tamanho.

[Corticotherapy and giant hemangioma of the liver. Return to the normal values of cytokines]

We report the case of a 36 year-old woman presenting with a giant liver hemangioma revealed by febrile hepatomegaly and weight loss. The patient presented an inflammatory syndrome without hyperleucytose, anemia and a moderate anicteric cholestasis. Plasma concentrations of interleukine-6 were very high whereas interleukine-1 levels were relatively low and TNF levels were normal. Eight weeks of corticosteroid treatment (prednisone 40 mg/d) resulted in disappearance of symptoms after 48 hours and biological anomalies after 6 weeks. Clinical and radiological follow-up, for respectively 36 and 24 months, did not show any relapse of symptoms or evolution of the hemangioma.

Hepatectomia parcial em cirurgia pediátrica

OBJETIVO: Embora, atualmente, as indicações de hepatectomias em crianças sejam menos frequentes, em alguns casos elas constituem a melhor opção terapêutica. O objetivo deste trabalho é relatar a experiência de dez anos com grandes ressecções hepáticas em pacientes pediátricos. MÉTODO: Foram analisados os dados de doze pacientes submetidos a lobectomia hepática nos serviços de Cirurgia Pediátrica do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo e do Hospital Santa Lydia, em Ribeirão Preto (SP) de 1985 a 1995. RESULTADOS: Foram realizadas oito lobectomias esquerdas e quatro lobectomias direitas. Dez crianças foram operadas por neoplasia e duas por complicações de traumatismo hepático. A idade das dez crianças portadoras de neoplasia variou de seis dias a dezesseis meses, sendo em média 3,8 meses. O diagnóstico histopatológico foi hemangioendotelioma em cinco (50%), hepatoadenoma em dois (20%), hepatoblastoma em dois (20%) e hepatocarcinoma em um (10%). O peso do tumor correspondeu em média a 7,1% do peso do paciente. A duração média da cirurgia foi de 2 horas e 58 minutos. O seguimento pós-operatório variou até 141 meses, sendo em média 76,5 meses. Sete pacientes receberam transfusão de sangue intra-operatória, correspondente a 23,3% de sua volemia, em média. Um deles apresentou recidiva de tumor, necessitando reoperação. Nenhum dos doze pacientes apresentou complicações pós-operatórias. CONCLUSÃO: A hepatectomia parcial é um procedimento difícil tecnicamente, que, no entanto, pode ser realizado com segurança, mesmo em hospitais que não disponham de recursos tecnológicos sofisticados, desde que o cirurgião esteja bem preparado para enfrentar suas dificuldades.

Benign Neoplasms of the Liver

Tumors of the liver often are discovered incidentally in asymptomatic individuals during diagnostic imaging or exploratory laparotomy performed for alternative reasons. Hemangiomas are the most common benign liver tumors, followed in prevalence by focal nodular hyperplasia (FNH); other benign tumors are rare. The growth and development of hemangiomas, FNH, and hepatic adenomas especially, have been linked to hormonal (eg, estrogen) stimulation. Differentiating between benign and malignant neoplasms of the liver can be challenging. Radiologic imaging is essential for preliminary identification and classification of hepatic tumors, but tissue biopsy or surgical excision sometimes is required for a definitive diagnosis. Individuals with hemangioma or FNH usually are asymptomatic, have a benign course, and can be managed conservatively. In contrast, hepatic adenomas need to be followed more carefully and often are excised to provide symptomatic relief, remove the risk of rupture, and avoid potential malignant transformation. Liver transplantation in patients with benign hepatic neoplasms is exceedingly uncommon, and is recommended only when alternative methods of treatment are not feasible or have failed to control significant symptoms.

Surgical treatment of giant haemangioma of the liver

BACKGROUND

The treatment of giant symptomatic haemangioma of the liver is still controversial. This retrospective study reviewed the results of surgical treatment.

METHODS

Twenty-eight patients with symptomatic giant haemangioma of the liver were treated by liver resection (n = 24) or liver transplantation (n = 4). The median diameter of the haemangiomas was 11 (range 5-20) cm.

RESULTS

Complications occurred in five of the 24 patients treated by partial liver resection, although all survived and remain alive and well more than 2 years after surgery. In six patients there was residual haemangioma in the liver remnant which did not enlarge during the 2-year follow-up. In four patients the haemangioma was considered irresectable and liver transplantation was performed. One died after a 'two-stage' liver transplantation; the remaining three patients are alive and well, 1, 4 and 9 years after transplantation.

CONCLUSION

Liver resection is the treatment of choice for giant haemangioma of the liver where possible. In selected cases liver transplantation is indicated.

Infantile hepatic haemangioendothelioma

Three cases of infantile hepatic haemangioendotheliomas are described. Two demonstrate the natural history of regression of this benign tumour with no associated complication. The last case demonstrates life-threatening complications, which included cardiac failure, thrombocytopenia, disseminated intravascular coagulation and bleeding. Imaging modalities with plain films, ultrasound, computed tomography and angiograms are presented. Pathological findings in two of the cases are also described.

Multiple hepatic hemangiomas with significant arterioportal venous shunting

A patient with multiple hepatic hemangiomas and significant arterioportal shunting who was successfully treated by a left-hepatic lobectomy is presented herein. In hemangiomas with significant arterioportal venous shunting, it is essential to differentiate between hepatocellular carcinoma and hypervascular metastatic tumors because few typical findings of hemangioma can be recognized. Moreover, an increased hepatic arterial flow can increase the risk of spontaneous rupture as well as portal hypertension due to the increased inflow to the portal vein. Therefore, a definitive diagnosis should be made by liver biopsy when imaging alone is not sufficient to rule out malignancy. Furthermore, hepatic resection for hemangiomas with significant arterioportal venous shunting may be indicated due to the higher risk of rupture and the possibility of progressive portal hypertension.

Enucleation of giant hemangiomas of the liver. Technical and pathologic aspects of a neglected procedure

Cavernous hemangiomas are the most common benign tumors of the liver. Giant cavernous hemangiomas, defined as those larger than 4 cm in diameter, can reach enormous proportions. Newer imaging modalities, although often demonstrating characteristic features that strongly suggest the diagnosis, should not be augmented by biopsy because of the risk of hemorrhage. Elective surgical resection may be indicated for symptomatic giant lesions and for those with an atypical appearance where the diagnosis is in doubt. Between October 1986 and May 1991, we treated 10 patients with giant hemangiomas by enucleation or enucleation plus resection. Median operative blood loss was 800 mL (range, 200 to 3000 mL). One patient required reoperation for control of postoperative hemorrhage. Detailed pathologic examination has demonstrated an interface between hemangiomas and the normal liver tissue that allows enucleation. Enucleation is an underused procedure that if carefully performed allows resection of giant hemangiomas with a reduced blood loss and the preservation of virtually all normal hepatic parenchyma.

Hepatic cavernous haemangioma: a 10 year review

Between January 1981 and July 1991, 61 patients with hepatic haemangiomata were examined at Westmead Hospital. There were 14 males (22%) and 47 females (78%). The age range was 26-85 years with a median of 49 years. Forty-one had abdominal symptoms but these could be attributed to a haemangioma in only seven cases. There was at least one subcapsular lesion in 17 (28%). Six of the seven symptomatic lesions were subcapsular and five of these were giant haemangiomata (i.e. more than 4 cm in greatest diameter). One large symptomatic lesion was intrahepatic. No association was observed between hepatic haemangiomata and other hepatic or extrahepatic diseases. Haemangiomata were resected from six patients, four of whom were symptomatic. Symptoms improved in all four but did not resolve completely in any. Follow-up ranged from nil in five patients to 108 months in one. The median follow-up was 12 months after initial diagnosis. Ten patients showed evidence of change in their lesions or symptoms while under observation. Only three had worsening symptoms or suspected change in size of a haemangioma. This study highlights the benign, static nature of most hepatic haemangiomata. When this lesion is suspected, the diagnosis should be confirmed with ultrasound (US) and labelled red blood cell scanning (RBCS). Referral for evaluation by a specialist hepatobiliary surgery unit is necessary when symptoms are intolerable, increasing size is definitely demonstrated or the diagnosis is uncertain and cannot be established without specialized investigations. Bleeding into or from these lesions is rare.