Hepatic artery ligation for hepatic hemangiomatosis of infancy

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.

Liver neoplasia in children

Management of pediatric liver tumors has significantly improved over the last 2 decades. The management options for hepatocelluar carcinoma (HCC) are not well defined. In the pediatric context, the main clinical aims are to reduce chemotherapy toxicity (predominantly ototoxicity and nephrotoxicity) in children treated for hepatoblastoma and to investigate additional modes of treatment for HCC. An increasing number of children develop HCC in the background of chronic liver disease, and screening methods need to be better observed.

Hepatic hemangioendothelioma: clinical experience and management strategy

PURPOSE

This study sought to define management strategies based on clinical experience in treating infantile hepatic hemangioendothelioma.

METHODS

A retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was performed.

RESULTS

Thirteen patients (median age, 14 days) with hemangioendothelioma were identified. Congestive heart failure (P<.03) and abdominal mass (P<.081) were predictive of 5-month mortality rates. Ultrasonography and computerized axial tomography were the diagnostic modalities most commonly used. Treatment strategies consisted of medical management (steroids and alpha-interferon) and interventional modalities (hepatic artery ligation or embolization, resectional surgery, or orthotopic liver transplantation). Patients who underwent resectional surgery, with or without orthotopic liver transplantation, had a lower 5-month mortality rate (P<.02) and a greater 2-year survival rate (P<.003) than did those who underwent hepatic artery ligation or embolization. Early morbidity and mortality tended to be a consequence of the primary lesion, whereas late morbidity and mortality were reflective of the treatment modality used.

CONCLUSIONS

In cases of failed medical management, resectional therapy should be used when possible. If partial hepatectomy is not technically achievable, hepatic artery embolization should be used either as definitive therapy or as a temporizing measure until orthotopic liver transplantation is possible.

Infantile hepatic hemangioendothelioma: the role of surgery

Of 16 infants with infantile hepatic hemangioendothelioma, 14 (88%) presented before age 3 months. For seven cases (44%), the diagnosis was suspected from antenatal ultrasonographic findings. Two (13%) presented with asymptomatic hepatomegaly. The most common presenting features were high-output cardiac failure in 11 (69%), consumptive coagulopathy in 12 (75%), and anemia in 12(75%). Sixty-three percent of the children had associated cutaneous hemangiomata, and disseminated hemangiomatosis was noted in two (13%). Medical measures were effective in stabilizing seven (44%) cases with high-output congestive cardiac failure and/or consumptive coagulopathy. Partial right hepatectomy was successful for four patients; the only death occurred in a newborn, after intraperitoneal rupture of the hepatic hemangioma. Embolization was used in two children to induce involution. Spontaneous involution occurred in two patients. Initially, hepatic hemangiomas should be treated conservatively, with surgery reserved for intractable cardiac failure and/or refractory consumptive coagulopathy.

Hemangioendothelioma of the liver in infants

Hemangioendotheliomas are the most common type of hepatic vascular tumors that present in infancy. Eleven infants (nine boys, two girls) were referred for definitive management from 1970 through 1990. Ten were symptomatic, and the majority required intensive medical therapy because of cardiac failure. All were treated surgically. Three underwent partial hepatectomy for unilobar disease, and eight had ligation of the hepatic artery because of bilobar disease. There were two deaths (18%) in the early part of the series. Ligation of the hepatic artery was completely successful in controlling cardiac failure in six infants and was partially successful in one. There are two surgical options for treating symptomatic hepatic hemangioendotheliomata in infancy. Bilobar multifocal disease can be treated successfully by ligation of the hepatic artery; if localized, hemangioendothelioma can be resected, with rapid control of symptoms.

Infantile hepatic hemangioendotheliomas: significance of portal venous and systemic collateral arterial supply

This report describes four infants with hepatic hemangioendotheliomas and cardiac failure who had extensive portal venous and systemic collateral arterial supply complicating hepatic arterial embolization. One patient with diffuse hepatic hemangioendothelioma and extensive portal vein supply but minimal systemic collateral arteries showed no improvement after technically successful hepatic artery embolization and died with disseminated intravascular coagulation and sepsis. A second infant with extensive portal vein and collateral supply died without undergoing embolization. Two patients had portal vein-hepatic vein fistulas as well as an extensive systemic arterial supply. Both infants tolerated staged hepatic and collateral artery embolization, although one patient died of congestive heart failure, probably related to pulmonary hemangiomas. The authors conclude that angiographic study of the potential collateral vessels and portal venous circulation should be performed before embolization. Patients with shunting from the portal vein to the hepatic vein and minimal systemic arterial collateral circulation should not undergo hepatic artery embolization.

Infantile hepatic haemangioma: investigation and treatment

Infantile hepatic haemangiomas are benign tumours which tend to regress in late infancy. We describe five infants with hepatic haemangioma, three of whom developed congestive cardiac failure. Technetium-99m labelled red blood cell scan was useful in the diagnosis and follow-up of the lesion. The three symptomatic infants were treated with prednisone (2 mg/kg per day) for 2 months in addition to digoxin and diuretics. Significant clinical improvement occurred within 3 weeks in each case. We conclude that the red blood cells scan is a good non-invasive diagnostic test and recommend corticosteroids as initial management for symptomatic infantile hepatic haemangiomas.

Diffuse infantile haemangiomatosis: clinicopathological features and management problems in five fatal cases

The clinicopathological features of five fatal cases of diffuse haemangiomatosis presenting in neonatal life or early infancy are presented. The infants all had multiple skin haemangiomas as well as deep-seated lesions in many different tissues that caused protean clinical manifestations and management problems. Because the outlook may be improved by early diagnosis and application of new modes of treatment, any infant with multiple cutaneous haemangiomas should be closely assessed for possible visceral involvement. Development of hepatomegaly, high-output cardiac failure, unexplained anaemia or thrombocytopenia in these infants should immediately suggest disseminated disease. Early recognition with implementation of steroid and/or antiangiogenic therapy, embolization and/or surgery is essential to improve the chances of survival.

Infantile hemangioendothelioma of the pelvis associated with Kasabach-Merritt syndrome

A case of infantile hemangioendothelioma of the pelvis in a newborn male infant is described. Shortly after delivery, a large abdominal mass was found by external examination. CT scan revealed a hypervascular retroperitoneal pelvic mass invading the lumbar spinal column. Exploratory laparotomy was performed and biopsy revealed infantile hemangioendothelioma. The tumor was associated with profound thrombocytopenia, intratumoral hemorrhage, and right hydroureteronephrosis. After treatment with high dose steroids, Cytoxan, and external beam radiation for 2 months, the patient was discharged with persistent thrombocytopenia requiring platelet transfusions. The hydroureteronephrosis has also not improved. The literature on this subject is reviewed.

Hepatobiliary tumours of childhood: investigation and management

The most commonly encountered complications include wound infections, subphrenic collections and bile leaks from the cut liver surface. Stress ulceration of the stomach or duodenum is also not uncommon. Inadvertent bile duct damage has also been reported after major resection in children. The results of surgery for benign lesions are very good and usually depend simply on technical expertise. The results for malignant lesions, however, remain poor. Six series, including our own experience, reported in the last 5 years have shown an overall survival rate of 43% for patients whose tumours were resected for cure. It is difficult to compare results as authors differ in their presentation of results, but details of the series are listed in Table 7. There were no definite prognostic factors to be drawn from these series other than that children with the fibrolamellar variant of hepatocellular carcinoma fared better than those with other hepatomas. It is a sad fact that overall 56% of patients in these series presented with unresectable disease. Mahour et al. described seven patients with unresectable disease who were treated by either chemotherapy alone or in combination with radiotherapy, followed by 'second look' laparotomy and resection. Five of these patients were alive and disease-free for a minimum of 2.5 years after surgery. Thus it is necessary to adopt an aggressive approach to these tumours if one is to see any improvement on the overall figures.

Experience with hepatic hemangioendothelioma in infancy and childhood

This report describes our experience with 16 infants and children with a mean age of 7 months and a median age of 6 weeks with hepatic hemangioendothelioma. Fifteen patients presented with hepatomegaly. Seven had congestive heart failure and four had associated cutaneous lesions. Although diagnosis was clinically evident in 15 of the 16 patients, arteriography and computerized tomography (CT) were diagnostic. A variety of treatment approaches were used including radiation, resection, systemic steroids, hepatic artery ligation, angiographic embolization, and various combinations of these modalities. The following information was gained from this experience. CT with enhancement is as specific a diagnostic tool as hepatic arteriography. Angiographic and CT appearances do not correlate with prognosis. Most patients can be treated successfully with steroids; those who do not respond should have other approaches tried such as embolization or ligation. The angiographic appearance determines whether embolization therapy is worthwhile, as we found that hemangioendotheliomatosis with portal as well as hepatic arterial supply will not respond to embolization. The survival rate in this series was 80%.

Kasabach-Merritt syndrome

Eight infants with hemangiomata associated with severe consumption coagulopathy are reviewed; three died. The presentations and method of management are discussed. The varied response to different modalities of therapy initiated this report and led to a search of the world literature in an attempt to identify the pattern of response, if any, to particular therapy. From our own experience with two cases and from the review of the literature, it appears that radiotherapy alone or in combination with steroids gives a superior overall treatment in terms of reducing the death rate.

Hepatic artery aneurysm in a child

The present report refers to a child hospitalized because of nonspecific symptomatology, who was found to have aneurysms of both hepatic arteries. A year after simple proximal ligature of both hepatic arteries, the child remains symptom-free and developing normally. Proximal ligation appears to be a simple and effective technique for treating hepatic artery aneurysm in children in preference to direct approach of the vascular pathology.

Computed tomography, management, and follow-up in infantile hemangioendothelioma of the liver in infants and children

Hepatic hemangioma (hemangioendothelioma) is a rare but most common benign vascular tumor of the pediatric age group. Prompt diagnosis and treatment prevent complications. Familiarity with various CT patterns should facilitate correct diagnosis of hemangioendothelioma of the liver in infants and children and avert angiography.

Diagnosis and management of massive hepatic hemangiomas in childhood

Twelve patients diagnosed as having hepatic hemangiomas during 1960 to 1982 at the Royal Children's Hospital, Melbourne are reviewed. This rare benign vascular tumor can present considerable problems in both diagnosis and management and has a high reported mortality. Our experience over this 23-year period demonstrates some of the difficulties in diagnosis and suggests a plan of management. Eight patients were diagnosed when five weeks of age or less, the youngest was 24 hours old. One was diagnosed at four months of age. In the remaining three patients, the diagnosis was made at postmortem. Ten patients had prominent hepatomegaly, nine had congestive cardiac failure and in one of these the onset was delayed four weeks. Thrombocytopenia was present in five and jaundice in four patients. Four patients had associated cutaneous or visceral hemangiomas. Seven patients underwent selective hepatic arteriography, and two of these had prior ultrasound examinations of the liver. Management of congestive cardiac failure included steroids, radiotherapy, hepatic resection, and in one patient, hepatic artery ligation. One patient with diffuse hepatic hemangiomas did not require any specific therapy and resolved spontaneously over two years. The four patients in whom hepatic resection was performed survived.

Diagnosis and management of cavernous hemangioma of the liver

Cavernous hemangiomas are the most common benign tumors of the liver, which are now seen more often thanks to common use of newer imaging techniques. A review of the literature on cavernous hemangiomas of the liver, including our own experience with 14 cases, provides data as a touchstone for discussion of the incidence, etiology, symptoms, pathology, diagnosis including ultrasound, radionuclide imaging, computed tomography and angiography, management including resection, hepatic artery ligation, radiation and corticosteroid, and the natural history of these lesions. The author concludes that surgical resection of cavernous hemangiomas should be undertaken with due concern for the relation between the severity of symptoms and the operative risks involved.