Experience with hepatic hemangioendothelioma in infancy and childhood

A Case of Infantile Hepatic Hemangioendothelioma/Hemangioma at Maharaj Nakorn Chiang Mai Hospital

Infantile hepatic hemangioendothelioma/hemangioma is the most common benign hepatic vascular tumor of infancy, comprising approximately 1% of all childhood tumors. The tumor can present during the fetal or neonatal period as a hepatic mass. Common presentations include abdominal distension and a palpable hepatic mass. Clinico-radio-pathological correlation is essential for a definite diagnosis. Frequent complications such as congestive heart failure, thrombocytopenia, anemia, and Kasabach-Merritt syndrome should be investigated. Chemotherapy has been reported as an effective treatment option. Surgical resection has an essential role for symptomatic patients with medical treatment failure or other certain conditions such as refusal to take medication. Furthermore, prenatal diagnosis is essential for better patient outcomes due to prompt treatment in the neonatal period. We report a case of a female infant at 39 weeks of gestation who was delivered from a 32-year-old mother. The infant was in utero diagnosed by ultrasonography with a hepatic mass, most likely hemangioma. The mass was resected after birth and it was diagnosed as infantile hepatic hemangioendothelioma type II. The course of the disease was excellent and the patient was cured after treatment.

Hemodynamic failure as an indication to urgent liver transplantation in infants with giant hepatic hemangiomas or vascular malformations--report of four cases

The aim of this study was to present acute hemodynamic failure as a rare indication for liver transplantation in neonates and infants with liver hemangiomatosis. We report four patients aged one to six months with giant liver hemangiomas, with huge arterio-venous shunting within these malformations. In three, many skin hemangiomas were found. All children developed right ventricular failure. In two, a trial of pharmacological reduction was attempted with corticosteroids and cyclophosphamide. In one patient, the arterio-venous fistulas were embolized without any improvement in hemodynamic status. Two children underwent rescue hepatic artery surgical ligation, which did not prevent heart and then multiorgan failure including liver failure. After unsuccessful conventional therapy, all infants were considered for urgent liver transplantation; in three cases, it was performed with a living-related donor, and in one case with a deceased donor. All patients are alive and well with the follow-up between nine and 37 months after transplantation. Liver transplantation should be considered as a rescue treatment in children with hepatic vascular malformations leading to hemodynamic insufficiency when conventional therapy is unsuccessful and multiorgan failure develops.

Monosegmental living-donor liver transplantation for infantile hepatic hemangioendothelioma

Infantile hepatic hemangioendothelioma (IHHE) is a rare vascular tumor that presents before the age of 6 months. The patients with IHHE suffer from high-output congestive heart failure caused by major arteriovenous fisutulas in the liver, which leads to respiratory compromise and results in a high mortality rate despite medical treatments. A case of 4-month-old baby with liver failure caused by IHHE is reported. The baby received an urgent liver transplantation from a living donor. A monosegmental graft was used to mitigate graft-to- recipient size mismatching. The surgical procedure of monosegmental living donor liver transplantation also is discussed.

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.

Hemangioma of the liver in children: proliferating vascular tumor or congenital vascular malformation?

BACKGROUND

Hepatic vascular tumors (HVT) are the most common benign liver tumors present in infancy and childhood commonly associated with high output cardiac failure. Pediatric HVT usually are divided into infantile hemangioendothelioma (IHE), cavernous hemangioma (HC), and arteriovenous malformations (AVM). The aim of this study was to analyze clinical and histologic features of pediatric HVT in relation to treatment strategies.

PROCEDURE

During last 12 years, 17 children have been treated because of HVT. The diagnosis of HVT was established in all on the basis of clinical and imaging data. A retrospective analysis of clinical records and histopathology divided 17 into: Group 1, neonates; and Group 2, infants and older children.

RESULTS

Radiologic imaging revealed the vascular nature of the tumors in all patients. All nine from Group 1 were symptomatic from AVMs and seven were operated upon. Only one of eight children from Group 2 presented symptoms of AVM requiring surgery; four of five in this group had surgery because of the risk of malignancy. Within Group 1, a mixture of proliferating IHE with microscopic features of AVM was found in most. In three neonates with HVT immunologic and clinical features of cytomegalovirus (CMV) hepatitis were noted. In two Group 2 patients, pure HC was present and in another, the diagnosis of angiosarcoma was established after biopsy of a peritoneal metastasis.

CONCLUSIONS

HVT in children demonstrate internal morphologic heterogeneity and an age-related behavior of the disease. We also confirm the proliferative nature of all hemangioendotheliomas (HEs) in children. Further studies on the tumorigenesis of these lesions are needed.

The "skinny aorta"

This article reviews the imaging findings of focal narrowing of the descending thoracic and/or abdominal aorta and stresses the clinical manifestations that may help differentiate specific entities. Various entities including coarctation of the aorta, Takayasu's arteritis, neurofibromatosis, radiation therapy, and infantile hemangioendothelioma are discussed and key differential points are emphasized.

Case report: infantile hemangioendothelioma

During a routine physical exam, an 18-day-old male infant was noted to have persistent abdominal distention and prominent vascular markings over his abdominal wall. Laboratory studies were significant for an elevated alpha-fetoprotein level of 7051 ng/ml and mild anemia. Abdominal ultrasound and CT scan demonstrated a large, heterogeneous mass in the lateral segment of the left lobe of the liver. Although the patient did not have congestive heart failure or coagulopathy, surgical resection was performed to rule out malignancy. Histopathologic examination revealed a type I infantile hemangioendothelioma. This case report reviews the presentation and treatment of infantile hemangioendotheliomas and the differential diagnosis of neonatal hepatic neoplasms.

Infantile hemangioendothelioma

Primary hepatic tumors are uncommon in children and account for only three per cent of the tumors in children. Infantile hemangioendothelioma is a rare benign hepatic tumor arising from mesenchymal tissue. Most of the cases present before six months. An unusual presentation and progression of infantile hemangioendothelioma is reported in a 19-month-old female child. The diagnosis was arrived at by radiological and histopathological examination. The patient underwent excision surgery, following which made an uneventful recovery. On follow-up at six months, patient was asymptomatic with no evidence of recurrence.

Successful treatment with cyclophosphamide of life-threatening diffuse hemangiomatosis involving the liver

A female neonate with diffuse hemangiomatosis and hepatic hemangiomas had cardiac insufficiency develop and had failure to thrive. Her disease was unresponsive to prednisone. She received two courses of cyclophosphamide 10 days apart and a final course 2.5 weeks later. Twelve days after the second course of cyclophosphamide, her liver was significantly smaller. She is now 6-years-old, well-developed, and has no signs of hepatomegaly, malnourishment, or heart failure. Cyclophosphamide appears to be a safe, effective, and rapid treatment of life-threatening hemangiomas of infancy.

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.

Hepatic vascular anomalies in infancy: a twenty-seven-year experience

OBJECTIVE

Infantile hemangioma and arteriovenous malformation (AVM) of the liver have a similar presentation but a different natural history, and therefore require different treatment. This study was undertaken to clarify differential diagnosis and management of these two biologically distinct vascular disorders.

STUDY DESIGN

We retrospectively analyzed the records of 43 children with hepatic vascular anomalies treated during the past 27 years.

RESULTS

Ninety percent were hemangiomas (n = 39); 10% were AVM (n = 4). Infants with AVM or large solitary hemangioma had hepatomegaly, congestive heart failure, and anemia as presenting symptoms at birth. Multiple hepatic hemangiomas manifested at 1 to 16 weeks of age with the same clinical triad, plus multiple cutaneous lesions (19/23). The mortality rate after treatment of hepatic AVM was 50% (2/4). The mortality rates after treatment of liver hemangiomas were as follows: resection of solitary lesions, 20% (2/10); embolization, 43% (3/7); corticosteroids, 30% (3/10); and interferon alfa-2a, 15% (2/13).

CONCLUSION

Solitary hepatic hemangioma cannot always be distinguished from hepatic AVM without radiologic studies. Multiple hepatic hemangiomas are differentiated from hepatic AVM by coexistence of multiple cutaneous hemangioma and by radiologic imaging. We recommend combined embolization and surgical resection for hepatic AVM and for solitary symptomatic hemangioma, if drug therapy fails. Pharmacologic treatment is used for symptomatic multiple liver hemangiomas. Embolization allows interim control of heart failure. A decreased mortality rate after interferon alfa-2a therapy is encouraging.

MR imaging of hepatic hemangiomas of infancy and changes seen with interferon alpha-2a treatment

The purpose of this study was to describe the appearance on magnetic resonance (MR) imaging of hepatic hemangioma, and how the appearance changes in infants who have received interferon alpha-2a (IFN) treatment. We retrospectively studied 16 MR examinations in seven infants (mean age 3.2 months; range 5 days to 13 months) who were symptomatic with hepatic hemangiomas. Five of these seven patients had MR examinations both before and after treatment with IFN. In six of the seven patients, the hepatic hemangiomas were multicentric; they were usually discrete, well-defined nodules, best seen on T2-weighted images as high intensity lesions. One patient had a large solitary heterogeneous lesion. They all exhibited fast flow (seen as flow voids on spin-echo images and high signal intensity structures on gradient-recalled echo images) and enlarged hepatic arteries and veins. There was enlargement of the proximal abdominal aorta with distal tapering. Treatment was followed by accelerated regression of the hemangiomas in size and number and variable shrinkage of the enlarged vessels. As the tumor nodules regressed, they were replaced by normal-appearing hepatic parenchyma; neither fat nor fibrosis was detected by MR imaging.

Growth, hemorrhage, and regression of multiple intracerebral vasoformative tumors: report of an unusual case

A rare case of multiple hemorrhagic vascular tumors of the cerebrum and cerebellum is reported. Computed tomographic scans in a 16-year-old girl revealed multifocal brain lesions with "jewel ring"-like areas of contrast enhancement. An old hematoma cavity was found inside the surgical specimen. Histologically, it was a vascular tumor composed of anastomosing vascular channels with proliferating endothelial cells and hemorrhages at different stages. Upon further histopathological study, this lesion could not be classified as any known vascular tumor entity, although it resembled some vascular tumors, such as cavernous hemangioma and hemangioendothelioma. The patient received steroid and alpha interferon treatment. The lesions initially increased in number once, then resolved 10 months after onset. The neuroradiological and histopathological features in the present case were characteristic, and the clinical course was unusual.

Hepatic artery ligation for hepatic vascular tumors with arteriovenous and arterioportal venous shunts in the newborn: successful management of two cases and review of the literature

The authors report their experience with hepatic artery ligation in two newborns, as well as relevant findings from a literature review. A 2-day-old boy had progressive cardiac and respiratory difficulty. A firm liver was palpable, with an overlying thrill. Sonography and arteriography showed diffuse arteriovenous shunting in both liver lobes. Hepatic artery ligation provided remarkable hemodynamic and clinical improvement. Another boy was admitted 3 weeks after birth because of bilious vomiting with abdominal distension and bloody stools. Abdominal examination showed a large liver with a systolic bruit and thrill. X-rays showed cardiac enlargement and dilated bowel loops with air-fluid levels. Arteriography and sonography showed arteriovenous and arterioportal venous shunting. Laparotomy was performed, and a large vascular malformation was palpated in both liver lobes. The entire bowel was congested and cyanotic, but there were no signs of obstruction. This patient had acute portal hypertension imitating intestinal obstruction. Ligation of the hepatic artery improved the color of the bowel, and the thrill disappeared. Five and nearly 4 years after the operation, both boys are growing normally without medication or diet. Sonography showed almost complete resolution of the hemangiomas.

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.

A rare coexistence of a multicentric hepatic hemangioendothelioma with a large brain hemangioma in a preterm infant

A preterm infant with a rare association of a multicentric hepatic hemangioendothelioma (MHH) and a large brain hemangioma is described. The imaging investigations and their findings are discussed. It is recommended that whole-body radionuclide imaging with 99mTc-labeled red blood cells is employed immediately following ultrasonography to confirm the suspected diagnosis of MHH and to detect other unsuspected hemangiomas.

Abdominal tumors in infancy and childhood

Detection of an abdominal mass in a child is an alarming finding for both parent and practitioner. Diagnostic studies including ultrasonography, computed tomography, and magnetic resonance imaging provide an accurate diagnosis in most cases. The current treatment of Wilms' tumor results in an 85% to 90% survival. Hepatoblastoma and neuroblastoma often present in an advanced stage and require preoperative chemotherapy before resection is attempted. Improved survival for children with these tumors awaits better detection, chemotherapy, and understanding of the biology of their growth.

Diffuse neonatal haemangiomatosis in a newborn child

Diffuse neonatal haemangiomatosis is a severe disease with a high mortality. It is characterized by multiple haemangiomas at birth affecting the skin and visceral organs. A case of diffuse neonatal haemangiomatosis in a newborn child with a favourable outcome after steroid treatment is described.

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.

Hepatic hemangiomas

There are 2 main and different forms of hepatic hemangiomas--those of early childhood and those of later adult life. The former, called infantile hepatic hemangioendothelioma, may be life-threatening due to arteriovenous shunting in extensive lesions resulting in cardiac failure. Although they may resolve spontaneously, if cardiac failure develops, they must be treated aggressively by arterial ligation or embolization. The adult form rarely gives rise to symptoms and should be left alone. Spontaneous rupture is extremely rare but may follow needle biopsy and it is in this group of patients that the occasional death has been reported. Biopsy should, therefore, be avoided. Symptomatic lesions should be resected in a specialized center where the morbidity and mortality of liver resection is acceptably very low.

Infantile hepatic hemangiomas. Clinical features, radiologic investigations, and treatment of 20 patients

The clinical features, radiologic investigation, and treatment of 20 infants with hepatic hemangiomas are presented. Palpable abdominal mass (n = 18) and cardiac failure (n = 11) were the common presenting features. Nine patients had hyperconsumptive coagulopathy. Seven patients had other hemangiomas. Ultrasound (n = 15) showed the number and distribution of the hemangiomas within the liver. Hypoechoic and hyperechoic elements were present in addition to prominent vascular channels and diminished caliber of the distal aorta. Radionuclide sulfur colloid (n = 12) and labeled red blood cell (n = 7) studies showed the distribution and vascularity of the hemangiomas. Computed tomography (n = 8) revealed central hypointensity with marked peripheral enhancement after contrast. Arteriography now performed only as a prelude to therapeutic embolization demonstrated hypervascularity in each patient, contrast pooling in six and early draining veins in five. Magnetic resonance scanning (n = 3) showed decreased signal intensity on T1 images and high intensity signal on T2. In two patients, there was resolution or improvement of the hemangiomas without therapy. Four patients had surgery (lobectomy [2], trisegmentectomy [1], and surgical evacuation of a central hematoma [1]). Steroids and radiation were given to seven patients, and one patient also required therapeutic embolization. Steroids were the initial therapy in five patients, one of whom later required therapeutic embolization and another cyclophosphamide. Two patients were treated initially with radiation therapy, one of whom also needed emergency hepatic artery ligation. Seventeen of the 20 patients are alive and well from 6 months to 14 years after diagnosis.