Hepatic haemangioma-prenatal imaging findings, complications and perinatal outcome in a case series

Management of Neonatal Hepatic Hemangiomas: A Single-Center Experience Focused on Challenging Cases

Background: Management of hepatic hemangioma (HH) in infancy ranges from close monitoring to surgical resection. We analyzed the clinical characteristics and outcomes of HH according to its treatment options, with particular focus on challenging cases. Methods: Data of patients diagnosed with HHs in their first year of life and followed up for at least 1 year were retrospectively reviewed and divided into treatment and observation groups. Serial imaging results, serum alpha-fetoprotein (AFP) levels, medications, and clinical outcomes were compared. The detailed clinical progress in the treatment group was reviewed separately. Results: A total of 87 patients (75 in the observation group and 12 in the treatment group) were included. The median HH size at the initial diagnosis and the maximum size were significantly larger in the treatment group than the observation group (2.2 [0.5-10.3] cm vs. 1.0 [0.4-4.0] cm and 2.1 [0.7-13.2] vs. 1.1 [0.4-4.0], respectively; all p < 0.05]. The median initial and last serum AFP levels were significantly higher in the treatment group than in the observation group (76,818.7 vs. 627.2 and 98.4 vs. 8.7, respectively; all p < 0.05). Serum AFP levels in both groups rapidly declined during the first 3 months of life and were almost undetectable after 6 months. Among the challenging cases, a large (14 × 10 × 6.5 cm sized) focal HH was successfully treated using stepwise medical-to-surgical treatment. Conclusions: Patients with large HH and mild symptoms can be treated using stepwise pharmacotherapy. More aggressive surgical treatment of tumors unresponsive to initial pharmacotherapy may help shorten the treatment period and improve outcomes.

Pediatric hepatic hemangiomas: spectrum and prognostic significance of initial ultrasound findings

BACKGROUND

Hepatic hemangiomas may be associated with serious complications; however, it is unknown whether ultrasound (US) features can predict complications.

OBJECTIVE

To analyze initial US features of hepatic hemangiomas predictive of complications.

MATERIALS AND METHODS

This is a single-center retrospective cohort study of clinical, biological, and imaging data of infants with hepatic hemangioma between 2000 and 2018. Patients were categorized as having or not having any complication(s). Associations between initial US features and complications were analyzed through logistic regression. Receiver operating characteristic (ROC) curve analyses were performed to determine optimal cutoff values for continuous variables. Stepwise forward logistic regression was used to construct risk prediction models with training and validation sets. Model calibration and discrimination were evaluated using Hosmer-Lemeshow tests, area under the ROC curve, and overall accuracy.

RESULTS

Of 112 infants with hepatic hemangioma, 67 (60%) had focal, 32 (28%) had multifocal, and 13 (12%) had diffuse lesions, with complication rates of 51%, 34%, and 92%, respectively, mostly cardiac (54/57, 95%). The US characteristics of the hemangiomas were diverse. Risk factors for complications included diffuse subtype; large tumor volume (focal forms); elevated peak systolic hepatic arterial velocity (PSV); and hepatic vein dilation. For focal forms, initial tumor volume  >40 ml and PSV >100 cm/s had >70% sensitivity and specificity, respectively, to predict complications; a model including these variables had 75% overall accuracy in the validation set. For multifocal/diffuse forms, a PSV >115 cm/s had sensitivity and specificity to predict complications of  >70%; a model including this variable had 78% overall accuracy in the validation set.

CONCLUSION

Diffuse subtype, large tumor volume, elevated hepatic arterial PSV, and hepatic vein dilation are risk factors for complications of hepatic hemangiomas.

Unusual presentation of a case of fetal hepatic mass: a case report

BACKGROUND

Giant hepatic hemangiomas are rare and can cause serious complications that contribute to a high risk of perinatal mortality. The purpose of this article is to review the prenatal imaging features, treatment, pathology, and prognosis of an atypical fetal giant hepatic hemangioma and to discuss the differential diagnosis of fetal hepatic masses.

CASE PRESENTATION

A gravida 9, para 0 woman at 32 gestational weeks came to our institution for prenatal ultrasound diagnosis. A complex, heterogeneous hepatic mass measuring 5.2 × 4.1 × 3.7 cm was discovered in the fetus using conventional two-dimensional ultrasound. The mass was solid and had both a high peak systolic velocity (PSV) of the feeding artery and intratumoral venous flow. Fetal magnetic resonance imaging (MRI) revealed a clear, hypointense T1-W and hyperintense T2-W solid hepatic mass. Prenatal diagnosis was very difficult due to the overlap of benign and malignant imaging features on prenatal ultrasound and MRI. Even postnatally, neither contrast-enhanced MRI nor contrast-enhanced computed tomography (CT) was useful in accurately diagnosing this hepatic mass. Due to persistently elevated Alpha-fetoprotein (AFP), a laparotomy was performed. Histopathological examination of the mass showed atypical features such as hepatic sinus dilation, hyperemia, and hepatic chordal hyperplasia. The patient was ultimately diagnosed with a giant hemangioma, and the prognosis was satisfactory.

CONCLUSIONS

When a hepatic vascular mass is found in a third trimester fetus a hemangioma should be considered as a possible diagnosis. However, prenatal diagnosis of fetal hepatic hemangiomas can be challenging due to atypical histopathological findings. Imaging and histopathological assays can provide useful information for the diagnosis and treatment of fetal hepatic masses.

Hepatic hemangiomas in childhood: the spectrum of radiologic findings. A pictorial essay

Hepatic hemangiomas (HHs) are the most common benign liver tumors in infancy, but despite their frequent occurrence, their radiologic appearance may be particularly challenging to assess, owing to unique anatomical and development features that distinguish their subtypes in the pediatric population. There are 3 main patterns of the lesions recognized in HHs: focal, multifocal and diffuse. Medical care strategies range from simple observation to surgery, and a timely diagnosis is crucial to establish the most appropriated clinical management and therapy. Ultrasound (US) is typically the first level examination of pediatric vascular anomalies, able to meet a satisfactory diagnosis and has proved very helpful to assess for involution through serial imaging. CT and MRI are second-level methods seldom performed, offering an anatomical panoramic view and clarification when US is non-conclusive. Histologic confirmation is rarely required. HHs show a variable sonographic appearance, with hypoechoic (mostly) or hyperechoic solitary\multifocal mass and wide features. Hepatic vessels assessment reveals an abnormal flow, enlarged vasa, decreased resistive index (RI) values, scarce blood supply distally to lesions and hyper vascular regions inside them. In this pictorial essay, we review HHs subtypes in further details, illustrate US, CT and MRI findings and clarify a recurrent dispute over the existing terminology.

Prenatal diagnosis and management of a giant intrahepatic arteriovenous malformation-Sonographic findings, clinical implications, and treatment

Prenatal detection of complex giant hepatic arteriovenous malformation requires an examination of the affected fetal hemodynamic situation with emphasis on the affected arterial supply pattern. Early pediatric surgeon presentation is needed, as timely surgical intervention appears to be essential.

Spontaneous evolution patterns of focal congenital hepatic hemangiomas: a case series of 25 patients

BACKGROUND

Hepatic hemangiomas are the most common benign liver tumors of infancy. They are termed congenital if fully developed at birth or infantile if they appear in the first weeks of life. Previous studies suggested that most focal hepatic hemangiomas are congenital in nature, exhibit no postnatal growth and have an evolution that parallels their cutaneous counterparts. They are subdivided by pattern of involution, whether rapidly involuting (RICH), partially involuting (PICH) or non-involuting (NICH) congenital hemangiomas. In our experience, some focal hepatic hemangiomas show postnatal growth, behaving like infantile forms.

OBJECTIVES

To analyze the spontaneous evolution of focal congenital hepatic hemangiomas with quantification of tumor volume changes over time and to identify initial postnatal ultrasound (US) imaging biomarkers predictive of their evolution pattern.

MATERIALS AND METHODS

A retrospective review of clinical, imaging and pathology data of children diagnosed with focal congenital hepatic hemangioma (prenatal diagnosis or age at diagnosis <7 days and/or glucose transporter protein 1 [GLUT1]-negative tumor) diagnosed between 2000 and 2018 was performed with analysis of tumor volume changes over time. Exclusion criteria were treatment inducing a tumor volume change (hepatic artery embolization, propranolol, or corticosteroids), imaging follow-up less than 1 month or fewer than two US examinations. Volumetric analysis was based on US and cross-sectional imaging. Lesion volumes were estimated using the standard ellipsoid formula. A 35% margin of error was assumed for tumor volume variation to account for variability in measurements. Imaging studies, including US, computed tomography, and magnetic resonance imaging, were reviewed and initial postnatal US features were correlated with evolution pattern.

RESULTS

Twenty-five patients with focal congenital hepatic hemangiomas were included. The median follow-up time was 46.5 months (range: 4-144 months). Eight (32%) lesions showed postnatal growth before involuting, without signs of intralesional hemorrhage, as do cutaneous infantile hemangiomas. The other 17 (68%) lesions exhibited a strict decrease in volume with age, of which 15 underwent complete involution (8 before age 18 months and 7 after age 18 months) and 2 underwent partial involution. The different evolution patterns of focal congenital hepatic hemangiomas showed overlapping imaging features and we found no initial US feature to be significantly associated with postnatal growth. However, large vascular spaces with marked vascularity at US were noted in three of the eight rapidly involuting lesions.

CONCLUSION

Focal congenital hepatic hemangiomas are not the equivalent of cutaneous RICH, as some may increase in size and tumor regression may be rapid or slow. The different evolution patterns of focal congenital hepatic hemangiomas show overlapping US features.

Contribution of magnetic resonance imaging to the prenatal diagnosis of common congenital vascular anomalies

BACKGROUND

Screening ultrasound (US) has increased the detection of congenital vascular anomalies in utero. Complementary magnetic resonance imaging (MRI) may improve the diagnosis, but its real utility is still not well established.

OBJECTIVES

We aimed to describe the imaging findings on prenatal US and MRI of the most frequent congenital vascular anomalies (lymphatic malformations and congenital hemangiomas) to assess the accuracy of prenatal US and MRI exams for diagnosis and to evaluate the relevance of the additional information obtained by complementary fetal MRI.

MATERIALS AND METHODS

All confirmed postnatal congenital vascular anomalies detected in the last 10 years at 3 university hospitals were retrospectively identified. The prenatal diagnosis was compared with the final diagnosis for both methods and the clinical relevance of additional MRI information was evaluated. A second MRI in advanced pregnancy was performed in fetuses with lesions in a sensitive anatomical location and the clinical relevance of the additional information was evaluated.

RESULTS

Twenty-four cases were included in the study, 20 lymphatic malformations and 4 hemangiomas. MRI slightly improved the diagnosis of lymphatic malformation, 85% vs. 80% at US, especially for abdominal lesions. Both methods had a low identification rate (25%) for tumors. MRI performed late in five fetuses with lymphatic malformation allowed optimized management at birth.

CONCLUSION

MRI improves the diagnosis of congenital lymphatic malformations whereas hemangiomas remain difficult to identify in utero. The main role of MRI is to provide high-defined anatomical data to guide management at birth.

Prenatal diagnosis and treatment of intrahepatic arteriovenous fistulas: case reports and the literature review

Background: Congenital arteriovenous intrahepatic fistulas, which are hepatic hemangiomas and arteriovenous malformations (AVMs) are rare and they confused with each other. Knowledge of prenatal medical treatment of AVMs is insufficient.Objectives: First is to emphasize the distinction between hepatic hemangioma and AVMs. Second is discussion of the first case of hepatic AVM that responded well to steroid-propranolol treatment in the prenatal period.Methods: Color Doppler ultrasonography, fetal and postnatal MR were used for diagnosis.Results: The first case is a giant hepatic hemangioma diagnosed and progressively growing in the prenatal period and gradually shrinking in the postnatal period. The second case was hepatic AVM with no signs of heart failure during the prenatal period and postnatal right extended hepatectomy was performed as the anastomosis was enlarged and intraportal collateral vessels were developed. The third case is the first hepatic AVM which reaches a term that was prenatally diagnosed and responded to treatment with marked reduction.Conclusion: Color flow and pulse Doppler imaging have a key role in the prenatal diagnosis of arteriovenous fistulas. Intrahepatic AVM are abnormal intrahepatic vascular network formation primarily fed by the hepatic artery or its branches and drained by the hepatic venous system. This vascular region looks like a mass, but it does not contain a solid area, which allows the separation of hepatic AVMs from hepatic hemangiomas. Steroid and propranolol therapy should be considered in management.

Giant hepatic hemangioma in the fetus: case reports and updated review of the literature

OBJECTIVES

To describe three cases of giant fetal hepatic hemangioma detected by prenatal ultrasound in the third trimester of pregnancy and further confirmed by fetal magnetic resonance imaging (MRI). An updated review of the literature was also carried out.

RESULTS

In one case, there was an unexpected intrauterine demise at 35 weeks. The other two women delivered liveborn infants at term. The first of these two neonates had a stormy neonatal course and underwent endovascular embolization with limited clinical success. The infant presented multiple medical complications and was discharged home at five months of age. The second infant had an uneventful postnatal course. Subsequent follow-up scans showed progressive shrinkage of the lesion with no associated complications. A review of the English literature revealed a total of 42 cases prenatally diagnosed by ultrasound. The most relevant clinical and ultrasound findings are presented and the diverse perinatal outcomes related to this condition are discussed.

CONCLUSIONS

Fetal hepatic hemangiomas are exceedingly rare vascular tumors; however, they can be associated with several life-threatening conditions. They are usually detected by ultrasound, either incidentally or in the context of nonimmune hydrops secondary to high-output cardiac failure. Our review documents the increasing role of fetal MRI in the prenatal diagnosis and management of these cases. However, the improvement in prenatal diagnostic imaging techniques has not been associated with a better perinatal prognosis in the reported cases.

Giant Hepatic Hemangioma and Placental Chorangiosis: A Unique Case of Stillbirth?

INTRODUCTION

Hepatic hemangiomas (HH) are benign vascular tumors, and when large, may contribute to fetal morbidity/mortality. Chorangiosis is placental villus capillary hypervascularity, probably linked with fetal hypoxia.

CASE REPORT

We present a macrosomic stillbirth at 39 + 3 weeks of gestation with congestive heart failure (CHF) and myocardial infarction. A giant right hepatic lobe HH was present, along with placental chorangiosis.

CONCLUSION

A common pathogenetic pathway between congenital HH and placental chorangiosis has not been reported. Our case suggests that the effects of HH and chorangiosis increase the risk of late fetal loss due to the high-output CHF.

Guidance Document for Hepatic Hemangioma (Infantile and Congenital) Evaluation and Monitoring

OBJECTIVE

To define the types of hepatic hemangiomas using the updated International Society for the Study of Vascular Anomalies classification and to create a set of guidelines for their diagnostic evaluation and monitoring.

STUDY DESIGN

We used a rigorous, transparent consensus protocol defined by an approved methodology, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology, and gastroenterology.

RESULTS

In the first section, we define the subtypes of hepatic hemangiomas based on the clinical course, histology, and radiologic characteristics. We recommend against using the term "hemangioma" for any vascular malformations affecting the liver or any hypervascular tumors that are not characterized by the approved definitions. We recommend against using the term "hemangioendothelioma" for infantile or congenital hemangioma. The following 2 sections dedicated to infantile hepatic hemangioma and to congenital hepatic hemangioma individually describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations.

CONCLUSIONS

Although institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting children and the possible complications that require screening during the monitoring period should be standard. As children with hepatic hemangiomas are managed by different medical and surgical specialties, we offer an expert opinion multidisciplinary consensus based on current literature and on data extracted from the liver hemangioma registry.

Ultrasound findings in rapidly involuting congenital hemangioma (RICH) - beware of venous ectasia and venous lakes

BACKGROUND

Bleeding, ulceration and cardiac failure can occur in rapidly involuting congenital hemangioma (RICH). Bleeding intensity ranges from superficial to life-threatening.

OBJECTIVE

To determine whether there are sonographic criteria associated with an increased risk of bleeding, ulceration or cardiac failure in RICH in order to identify children who need close monitoring or prophylactic treatment.

MATERIALS AND METHODS

This retrospective single-center study included RICH patients over a period of 13 years. We evaluated sonographic features of RICH on B-mode and Doppler ultrasound. We correlated the occurrence of bleeding, ulceration and cardiac failure with four sonographic findings: (1) visible vessel, (2) venous ectasia, (3) venous lake and (4) arteriovenous shunting.

RESULTS

We included 24 patients. Ulceration occurred in five cases, bleeding in four cases, one of which was life-threatening. Cardiac failure was observed more frequently in RICH with venous lakes (P=0.028). Bleeding and ulceration appeared more frequently in RICH with venous ectasia and venous lakes. Cardiac failure was associated with the presence of venous ectasia. All children with cardiac failure or ulceration had arteriovenous shunts.

CONCLUSION

RICH with venous lakes on ultrasound is prone to develop bleeding, cardiac failure and ulceration. This association was only significant for cardiac failure.

Huge fetal hepatic Hemangioma: prenatal diagnosis on ultrasound and prognosis

Background

Although huge fetal hepatic hemangiomas are rare, they can cause fatal complications. The purpose of this study is to describe the imaging features and prognosis of these tumors.

Methods

Imaging data were collected for 6 patients with huge fetal hepatic hemangiomas treated at our hospital. Imaging modalities included prenatal magnetic resonance imaging and ultrasound and postnatal color Doppler ultrasound and contrast-enhanced computed tomography (CT).

Results

Among the 93,562 fetuses of 92,126 pregnant women examined at our hospital, 6 had huge hepatic hemangiomas (incidence rate, 0.64/10,000), as confirmed via postnatal color Doppler imaging and contrast-enhanced CT. Five fetuses had solitary lesions, whereas 1 (fetus 2) had multiple lesions. Four fetuses had lesions in the right liver lobe and 1 had a lesion in the left liver lobe, and 1 (fetus 2) had lesions in both lobes. All lesions showed centripetal enhancement on postnatal contrast-enhanced CT, which was more intense peripherally. Following postnatal treatment with oral propranolol, with or without dexamethasone or interventional therapy with the medical sclerosant pingyangmycin, all lesions decreased in size, with calcification plaques appearing 6 months after treatment.

Conclusions

Huge hepatic hemangiomas have typical ultrasonographic features and can be diagnosed prenatally. Treatment with propranolol, with or without dexamethasone, may result in a favorable prognosis.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1635-7) contains supplementary material, which is available to authorized users.

Congenital hepatic haemangioma leading to multiple organ failure in a neonate

We report a case of a premature male newborn who died from multiple organ failure due to a large congenital hepatic haemangioma that was diagnosed by imaging. Congenital haemangioma is a vascular tumour. The liver is the second organ involved after the skin. This tumour can be asymptomatic but can also lead to death.

[Radiological evaluation of congenital tumors]

In this article, we consider tumors that are diagnosed during pregnancy or in the first three months of life. This is a heterogeneous group of neoplasms with special biological and epidemiological characteristics that differentiate them from tumors arising in children or adults. In the last two decades, the prenatal detection of congenital tumors has increased due to the generalized use of prenatal sonographic screening. Advances in imaging techniques, especially in fetal magnetic resonance imaging, have enabled improvements in the diagnosis, follow-up, clinical management, and perinatal treatment of these tumors. This image-based review of the most common congenital tumors describes their histologic types, locations, and characteristics on the different imaging techniques used.