What is changing in indications and treatment of hepatic hemangiomas. A review

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Clinical impact and role of major vessels involvement in laparoscopic resection for hepatic hemangioma

BACKGROUND

Severe bleeding remains a significant concern in laparoscopic resection for hepatic hemangioma. It is rarely reported that how the degree of major vessels involvement impacts on severe bleeding. The present study primarily aimed to analyze the impacts of the number of involved major vessels (NIMV) during laparoscopic surgery for hepatic hemangioma and evaluate the risk factors associated with increased bleeding.

METHODS

A database search was carried out for consecutive patients who underwent laparoscopic resection for liver hemangiomas at our department from January 2018 to December 2023. The collected data included demographics, characteristics of the hemangiomas, laboratory data, operation method, surgical and postoperative variables.

RESULTS

A total of 72 patients were enrolled in the study. 42 patients were categorized into the group with NIMV < 2, while 30 patients were divided into the group with NIMV ≥ 2. The group with NIMV ≥ 2 demonstrated a significant correlation with special segments, involved multiple segments and diameter of the hemangiomas (P < 0.01). And the perioperative variables including the extent of resection, operative time, blood loss, Pringle maneuver times, postoperative stay, drainage tube duration, and postoperative liver function (ALT, AST) also showed significant differences between the two groups (P < 0.05). Notably, NIMV ≥ 2 was identified as the most important independent risk factor for intraoperative blood loss ≥ 500 ml in laparoscopic surgery for hepatic hemangioma (P = 0.011). For NIMV ≥ 2, the independent risk factor was special segments in multivariate analysis (P = 0.000).

CONCLUSION

The involvement of multiple major vessels (NIMV ≥ 2) was significantly associated with special segments, resulting in increased intraoperative blood loss, operation difficulty, and delayed postoperative recovery. Moreover, it was identified as the single independent risk factor with a considerable risk for increased blood loss during laparoscopic resection for hepatic hemangioma.

Hepatic adenoma: evolution of a more individualized treatment approach

BACKGROUND

Hepatic adenomas (HAs) are benign, solid liver lesions, which carry a risk of hemorrhage and malignant transformation. This review article highlights the advances in the diagnosis and management of HAs.

METHODS

A comprehensive review was performed using MEDLINE/PubMed and Web of Science databases with a search period ending on September 30, 2023. Using PubMed, the terms "hepatocellular," "hepatic," and "adenoma" were searched.

RESULTS

HA has been classified into at least 8 subtypes based on molecular pathology, each exhibiting unique histopathologic features, clinical considerations, and risk of malignant transformation. The most common subtype is inflammatory HA, followed by hepatocyte nuclear factor 1α-inactivated HA, β-catenin exon 3-mutated HA (βex3-HA), β-catenin exon 7- or 8-mutated HA, sonic hedgehog HA, and unclassified HA. Magnetic resonance imaging is the best imaging method for diagnosis and can distinguish among HA subtypes based on fat and telangiectasia pathologic characteristics. The risk of malignant transformation varies among molecular subtypes, ranging from <1% to approximately 50%. Up to 42% of HAs present with spontaneous intratumoral hemorrhage and peritoneal hemorrhage. In general, only 15% to 20% of patients require surgery. HA larger than 5 cm are more likely to be complicated by bleeding and malignant transformation, regardless of subtype, and should generally be resected. In particular, βex3-HA carries a high risk of malignant transformation and can be considered a true precancerous lesion.

CONCLUSION

The management of HAs is based on a multidisciplinary approach. Clinical decision-making should integrate information on gender, tumor size, and HA subtyping. In the future, patients with HA will benefit from novel medical therapies tailored to the individual molecular subtypes.

Transarterial Bleomycin-Lipiodol Chemoembolization for the Treatment of Giant Hepatic Hemangiomas: An Assessment of Effectiveness

This study evaluates the effectiveness of superselective transcatheter arterial chemoembolization (TACE) using a bleomycin-lipiodol emulsion in treating giant hepatic hemangiomas. A retrospective review included 31 patients with a mean age of 53 ± 10.42 years who underwent TACE from December 2014 to October 2022, with follow-up imaging examinations to assess outcomes. Technical success was defined as successful embolization of all feeding arteries, and clinical success was defined as a reduction in hemangioma volume by 50% or more on follow-up imaging. This study observed a 100% technical success rate. Post-embolization syndrome was common, and two cases of asymptomatic hepatic artery dissection were noted. Clinical success was achieved in 80.6% of patients, with significant volume reduction observed in the majority. Conclusively, superselective transcatheter arterial chemoembolization with bleomycin-lipiodol emulsions is presented as a viable and effective treatment option for giant hepatic hemangiomas. With no procedure-related mortality and significant volume reduction in most cases, this method offers a promising alternative to surgical intervention. This study's findings suggest a need for further exploration and validation in larger-scale prospective studies.

Immunologic landscape of human hepatic hemangiomas and epithelioid hemangioendotheliomas

BACKGROUND

The missing requirement for resection for the majority of hepatic hemangiomas (HH) and tissue scarcity for rare diseases such as hepatic epithelioid hemangioendotheliomas (HEHE) complicate the characterization of the spatial immunovascular niche of these benign and malignant vascular neoplastic diseases.

METHODS

Two tissue cohorts containing 98 HHs and 13 HEHEs were used to study entity-specific and disease stage-specific endothelial cell (EC) phenotype and immune cell abundance. Using semiquantitative assessment, annotation-based cell classifiers, digital cell detection on whole slides, and tissue microarrays, we quantified 23 immunologic and vascular niche-associated markers and correlated this with clinicopathologic data.

RESULTS

Both HH and HEHE ECs were characterized by a CD31high, CD34high, FVIII-related antigenhigh expression phenotype with entity-specific expression differences of sinusoidal EC markers Stabilin1, Stabilin2, CD32, and Lymphatic Vessel Endothelial Hyaluronan Receptor 1 (LYVE-1). Cell detection identified an HH margin-prevailing immunologic response dominated by Myeloperoxidase+ (MPO+) macrophages, CD3+ and CD8+ T cell subsets, and B cells (CD20+, CD79A+). In HEHE, increased CD68+ and CD20+ cell demarcation of lesion margins was observed, while CD3+ and CD8+ T cells were equally detectable both marginally and intralesionally. Stage-specific pairwise correlation analysis of HH and HEHE revealed disease entity-specific immunologic infiltration patterns as seen by high CD117+ cell numbers in HH, while HEHE samples showed increased CD3+ T cell infiltration.

CONCLUSIONS

ECs in HH and HEHE share a continuous EC expression phenotype, while the expression of sinusoidal EC markers is more highly retained in HEHE. These phenotypic differences are associated with a unique and disease-specific immunovascular landscape.

Natural History of Hepatic Hemangiomas Larger Than 10 cm: Imaging Findings and Clinical Course of 22 Cases

INTRODUCTION

The natural history of a large hepatic hemangioma is important in determining the treatment strategy. Although several studies have assessed the natural history of hepatic hemangiomas, no study has focused on hepatic hemangiomas measuring >10 cm. The aim of this study was to assess the natural history of hepatic hemangiomas measuring >10 cm by evaluating imaging findings and clinical course.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) reports at Kyoto University Hospital, Kyoto, Japan, between January 2001 and March 2023 were retrospectively searched to find adult patients with hepatic hemangiomas >10 cm. Patients who were followed up without treatment for over six months were included. The maximum diameter of the hepatic hemangioma was compared between the baseline and the final CT or MRI. The clinical course of the patients was evaluated.

RESULTS

Twenty-two patients (17 women, five men; median age, 51 years) were identified. The median diameter of hepatic hemangiomas in the baseline study was 114 mm. Two patients had abdominal distention at the time of the baseline imaging, whereas the others were asymptomatic. After follow-up without treatment (the median; 95.5 months), enlargement, no change, shrinkage of hepatic hemangioma was observed in six, 11, and five patients, respectively. The median growth rate of hepatic hemangiomas was 2.5 mm/year. Two patients underwent liver resection for hepatic hemangioma, while the others were followed up without treatment. In four patients, symptoms appeared or worsened. Two patients died: one patient died from prostate cancer progression; the cause of death for the other was not confirmed.

CONCLUSION

Hepatic hemangiomas show a slow growth rate during follow-up, and shrinkage is occasionally observed. Some patients experience new symptoms or aggravation of symptoms; however, deaths associated with hepatic hemangiomas are uncommon.

Surgical indications for solid hepatic benign tumors: An updated literature review

Hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma are the most common benign solid liver tumors. However, their surgical indications have been the subject of debate. Minimally invasive liver resection reduces the cost of surgery and may lead to overtreatment of benign liver tumors. Recently, there has been a growing understanding of the etiology, pathogenesis, and natural history of these tumors. Great progress has also been made in imaging. The use of MRI and contrast agents has improved the accuracy of non-invasive diagnosis of these tumors, and especially in the identification of specific molecular subtypes of liver adenoma. These factors have resulted in alterations of surgical indications for these tumors. This article examines recent literature and it discusses the surgical indications for hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma while summarizing modifications in clinical management.

Surgery for symptomatic hepatic hemangioma: Resection vs. enucleation, an experience over two decades

Backgrounds/Aims

Hemangiomas are the most common benign liver lesions; however, they are usually asymptomatic and seldom require surgery. Enucleation and resection are the most commonly performed surgical procedures for symptomatic lesions. This study aims to compare the outcomes of these two surgical techniques.

Methods

A retrospective analysis of symptomatic hepatic hemangiomas (HH) operated upon between 2000 and 2021. Patients were categorized into the enucleation and resection groups. Demographic profile, intraoperative bleeding, and morbidity (Clavien-Dindo Grade) were compared. Independent t-test and chi-square tests were used for continuous and categorical variables respectively. p-value of < 0.05 was considered significant.

Results

Sixteen symptomatic HH patients aged 30 to 66 years underwent surgery (enucleation = 8, resection = 8) and majority were females (n = 10 [62.5%]). Fifteen patients presented with abdominal pain, and one patient had an interval increase in the size of the lesion from 9 to 12 cm. The size of hemangiomas varied from 6 to 23 cm. The median blood loss (enucleation: 350 vs. resection: 600 mL), operative time (enucleation: 5.8 vs. resection: 7.5 hours), and postoperative hospital stay (enucleation: 6.5 vs. resection: 11 days) were greater in the resection group (statistically insignificant). In the resection group, morbidity was significantly higher (62.6% vs. 12.5%, p = 0.05), including one mortality. All patients remained asymptomatic during the follow-up.

Conclusions

Enucleation was simpler with less morbidity as compared to resection in our series. However, considering the small number of patients, further studies are needed with comparable groups to confirm the superiority of enucleation over resection.

Thermal ablation of hepatic hemangioma: A multi-center experience with long-term outcomes

BACKGROUND

Thermal ablation, currently used extensively for liver tumors, also has been applied. successfully to hepatic hemangioma; however, it is still considered experimental because previous studies have comprised small sample sizes with short follow-up periods.

PURPOSE

We aimed to investigate the effectiveness, safety, and long-term outcomes of thermal ablation for hepatic hemangioma.

MATERIALS AND METHODS

From October 2011 to February 2021, the data of 357 patients with 378 hepatic hemangiomas treated by thermal ablation at six hospitals were analyzed in this retrospective study. The technical success, safety, and long-term follow-up results were analyzed.

RESULTS

A total of 252 patients (mean age, 49.2 ± 10.5 years) with 273 subcapsular hemangiomas underwent laparoscopic thermal ablation, whereas 105 patients with 105 hemangiomas located in the liver parenchyma underwent CT-guided percutaneous ablation. Of the 378 hepatic hemangiomas (5.0-21.2 cm), 369 lesions were subjected to one session of ablation, while 9 lesions were subjected to two sessions of ablation. Technical success was achieved in 100.0% of cases. Complete ablation was achieved in 361 of 378 hemangiomas (95.5%), while 17 hemangiomas (4.5%) were incompletely ablated, showing subtle enhancement at the peripheral rim. The major complication rate was 2.0% (7/357). The median follow-up period was 67 months (range, 12-124 months). Of the 224 patients with hemangioma-related symptoms, 216 demonstrated complete disappearance of symptoms (96.4%), while 8 were ameliorated (3.6%). Ablated lesion shrinkage was progressive, and 11.4% of hemangiomas almost completely disappeared over time (P < 0.01).

CONCLUSION

With a reasonable ablation strategy and comprehensive treatment measurements, thermal ablation could be a safe, feasible, and effective treatment option for hepatic hemangioma.

A Retrospective Analysis of Clinical Characteristics, Treatment Modalities and Outcome of the Patients With Infantile Hepatic Hemangiomas: Single-center Experience From Turkey

OBJECTIVE

Hepatic hemangiomas (HH) are the most common vascular tumors of the liver. It is important to distinguish hemangiomas from malignant liver tumors.

MATERIALS AND METHODS

The patients 0 to 1 years old, were diagnosed with HH and followed up in the oncology outpatient clinic between 2009 and 2020 were included in the study.

RESULTS

A total of 127 patients with the diagnosis of HH were included in the study. Of the patients, 99 (78%) had focal, 20 (15.7%) had multifocal, and 8 (6.3%) had diffuse HHs. Surgery was performed and the diagnosis was confirmed histopathologically in 6 patients (4.7%). During the follow-up, 16 (12.5%) patients received medical treatment. Thirteen (10.2%) were treated with propranolol, 2 (1.5%) with corticosteroids, and 1 (0.8%) with propranolol and corticosteroids. Complete response was obtained in 9 (9/16) patients and partial response was obtained in 6 (6/16) patients with medical treatment.

CONCLUSION

Although HH is a benign tumor, it is important to make its differential diagnosis with malignant tumors of the liver. Over the years, the need for histopathologic examination for diagnosis has decreased. The success rate of propranolol is high, and the need for other treatment options with a high side-effect profile has decreased significantly since 2008.

Feasibility of laparoscopic enucleation for hemangioma in special hepatic segments

Background and aim

This study aims to evaluate the safety and efficacy of laparoscopic enucleation for liver hemangioma in special hepatic segments.

Methods

We retrospectively reviewed 58 patients who underwent laparoscopic surgery for hepatic hemangioma at a single center from January 2016 to January 2022. Segments I, IVa, VII, and VIII are defined as special hepatic segments, attributing to the bad visualization and adjacent to important vessels such as hepatic veins and inferior vena cava that lead to a high risk in laparoscopic surgery. Patients were categorized into a special location group (SLG) and a normal location group (NLG) according to the location of hemangioma. General data, intraoperative and postoperative outcomes, and postoperative complications of the two groups were compared and analyzed.

Results

There were no significant differences in age (p = 0.288), gender (p = 0.331), body mass index (p = 0.168), the maximum diameter of hemangioma (p = 0.330), ASA risk grading (p = 0.615), and comorbidities (p > 0.05) between the two groups. The operation time (p < 0.001), intraoperative blood loss (p < 0.001), and intraoperative blood transfusion rate (p = 0.047) were significantly higher in the SLG. The rate of conversion to laparotomy was higher in the SLG, but there was no significant difference (p = 0.089). In addition, the exhaust time (p = 0.03) and postoperative hospital stay (p < 0.01) were significantly shorter in the NLG. The postoperative complications were comparable between the two groups, and there were no perioperative deaths.

Conclusion

Laparoscopic enucleation of hemangioma in special hepatic segments is difficult and has a critical risk of massive bleeding during surgery. Meanwhile, it is also safe, feasible, and effective.

Benign liver tumours: understanding molecular physiology to adapt clinical management

Improvements in understanding the pathophysiology of the different benign liver nodules have refined their nosological classification. New criteria have been identified using imaging, histology and molecular analyses for a precise diagnosis of these tumours. Improvement in the classification of liver tumours provides a more accurate prediction of disease progression and has modified patient management. Haemangioma and focal nodular hyperplasia, the most common benign liver tumours that develop in the absence of chronic liver disease, are usually easy to diagnose on imaging and do not require specific treatment. However, hepatocellular adenomas and cirrhotic macronodules can be difficult to discriminate from hepatocellular carcinoma. The molecular subtyping of hepatocellular adenomas in five major subgroups defined by HNF1A inactivation, β-catenin mutation in exon 3 or exon 7/8, and activation of inflammatory or Hedgehog pathways helps to identify the tumours at risk of malignant transformation or bleeding. New clinical, biological and molecular tools have gradually been included in diagnostic and treatment algorithms to classify benign liver tumours and improve patient management. This Review aims to explain the main pathogenic mechanisms of benign liver tumours and how this knowledge could influence clinical practice.

Transarterial chemoembolization as the primary treatment for a super-giant hepatic hemangioma

Hepatic hemangiomas are common benign liver tumors. While the majority are small and require no treatment, giant hemangiomas are characterized as measuring greater than 4-6 cm in size and may require intervention. Surgical resection and enucleation have been described historically as the treatment for giant hemangiomas requiring intervention. Additionally, limited data exists about the treatment of hemangiomas measuring greater than 20 cm, particularly in regards to transarterial chemoembolization. We present a case of a super-giant hemangioma measuring greater than 20 cm treated with transarterial chemoembolization alone.

Liver transplantation for giant hemangioma of the liver: A case report and review of the literature

Large benign hepatic masses as a rare indication for liver transplantation have been reported less frequently. These liver transplantations are complex, with high intraoperative bleeding, high perioperative complication rates, and high mortality rates due to difficulties in visualization, especially when they have undergone various percutaneous operations or open surgery, resulting in severe perihepatic adhesions. Here is a case report of a patient admitted to our hospital who underwent liver transplantation after suffering from a giant hemangioma in liver transplantation for 10 years and who had received multiple interventional treatments ineffective in the past.

A Comprehensive Review of Hepatic Hemangioma Management

BACKGROUND

Hepatic hemangiomas (HHs) are benign liver lesions often discovered incidentally on imaging for various unrelated pathologies. We herein review the etiology, classification, diagnostic imaging, and management of HHs.

METHODS

A comprehensive systematic review was performed utilizing MEDLINE/PubMed and Web of Science databases, with the end of search date being March 1, 2022, regarding HH diagnosis, imaging, and management.

RESULTS

HHs can be broadly classified as capillary hemangiomas or cavernous hemangiomas. While the exact pathophysiology related to the development of HHs remains largely unknown, hormone exposure has been postulated to cause HH growth. HHs appear homogenously hyperechoic on US with distinct margins and posterior acoustic enhancement. While cavernous hemangiomas appear as well-defined hypodense lesions on pre-contrast CT images with the same density as the vasculature, one of the most reliable imaging features for diagnosing cavernous hemangiomas is high signal intensity on T2 weighted images. While most HHs are asymptomatic, some patients can present with pain or compressive symptoms with bleeding/rupture being very rare. Kasabach-Merritt syndrome is a rare but life-threatening condition associated with thrombocytopenia and microangiopathic hemolytic anemia. When HHs are symptomatic or in the setting of Kasabach Merritt syndrome, surgery is indicated. Enucleation is an attractive surgical option for HH as it spares normal liver tissue. Most patients experience symptom relief following surgical resection.

CONCLUSION

HHs are very common benign liver lesions. High-quality imaging is imperative to distinguish HHs from other liver lesions. Surgery is generally reserved for patients who present with symptoms such as pain, obstruction, or rarely Kasabach-Merritt syndrome. Surgery can involve either formal resection or, in most instances, simple enucleation. Patients generally have good outcomes following surgery with resolution of their symptoms.

Comparison of Hepatectomy and Hemangiomas Stripping on Patients with Giant Hepatic Hemangiomas

Objective. To compare the value of a hepatectomy and hemangioma stripping on patients with giant hepatic hemangiomas. Methods. Seventy-four patients with giant hepatic hemangiomas were retrospectively analyzed from data collected from their hepatobiliary surgeries performed from June 2010 to June 2015 at the People’s Hospital of Ningxia and the general hospital affiliated with Ningxia Medical University. The patients were divided into a hepatectomy group (37 patients) and a hemangioma-stripping group (37 patients). Conditions of each group were compared before and after surgery and comprised of surgery duration, intraoperative blood loss, blood transfusion, duration of hepatic blood occlusion, and hospital stay. Any complications after surgery, such as pleural effusions, bile leakage, and abdominal hemorrhage, were also observed. Results. In the hemangioma-stripping group, the surgery time was 2.38 ± 0.93 h, intraoperative blood loss was 889.19 ± 756.37, blood transfusion amount was 723.78 ± 801.14, the duration of hepatic blood occlusion 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. In the hepatectomy group, surgery time was 3.26 ± 1.16 h, intraoperative blood loss was 1551.35 ± 1755.88 mL blood transfusion amount was 1693.24 ± 2117.72 mL, duration of hepatic blood occlusion was 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. The difference between the groups was statistically significant (P < 0.05). The pleural effusion incident rate in the former group was lower than that of the latter group, and the difference was statistically significant. Conclusions. Hemangiomas stripping is an effective method by which to cure hepatic hemangioma, with the advantages being a relatively easy surgery with less patient trauma, rapid recovery, and fewer complications. This method should be used more often in clinical settings.

Case Report: Spontaneous Rupture of Hepatic Hemangioma

Background

Hepatic hemangioma (HH) is a congenital vasal malformation that seemed like the most probable benign liver neoplasm, composed of masses of blood vessels, which are anomalous in arrangement and size. In most cases, HH is asymptomatic, and patients have an excellent prognosis. According to research, the location and size of the mass are correlated with the symptoms and complications. Reports of spontaneous rupture of HH have been less reported in the literature. In this emergency condition, dynamic contrast-enhanced CT scanning, especially triple-phase computed tomography (CT) with delayed imaging, is preferred.

Case Presentation

Here, we presented two middle-aged female patients with spontaneous rupture of HH in our hospital. Following an accurate diagnosis of enhanced CT and emergency surgery, patients recovered well and were discharged from the hospital.

Conclusion

Appropriate imaging studies, especially enhanced CT, and emergency surgery are indispensable for patients with spontaneous rupture of HH. As a surgeon, we need to pay attention to the asymptomatic patient with HH.

Digital Staging of Hepatic Hemangiomas Reveals Spatial Heterogeneity in Endothelial Cell Composition and Vascular Senescence

Hepatic hemangioma (HH) is the most common benign primary liver tumor; however, despite its high prevalence, a stage-specific classification of this tumor is currently missing. For a spatial stage-specific classification, a tissue microarray (TMA) consisting of 98 HHs and 80 hemangioma margins and 78 distant liver tissues was digitally analyzed for the expression of 16 functional and vascular niche-specific markers. For cross-correlation of histopathology and functional characteristics, computed tomography/MRI imaging data of 28 patients were analyzed. Functional and morphological analyses revealed a high level of intra- and interpatient heterogeneity, and morphological heterogeneity was observed with regard to cellularity, vascular diameter, and endothelial cell subtype composition. While regressed hemangiomas were characterized by low blood vessel density, low beta-catenin levels, and a microvascular phenotype, non-regressed HHs showed a pronounced cellular and architectural heterogeneity. Functionally, cellular senescence–associated p16 expression identified an HH subgroup with high vascular density and increased lymphatic endothelial cell content. Histological HH regions may be grouped into spatially defined morphological compartments that may reflect the current region-specific disease stage. The stage-specific classification of HHs with signs of regression and vascular senescence may allow a better disease course–based and cell state–based subtyping of these benign vascular lesions.

Giant Hepatic Hemangioma Causing Prolonged Fever and Indicated for Resection

Hepatic hemangiomas are benign liver tumors, and most of them progress asymptomatically. We report a case of hepatic hemangioma considered the cause of fever. A 53-year-old woman had a fever of 40°C for about 3 months without infection. Hepatic hemangiomas with internal bleeding of 10 cm in size on liver S8/7 and S3/2 were observed. These were resected laparoscopically for diagnostic treatment. She was afebrile after the operation. The pathological diagnosis was hematoma inside cavernous hemangioma. It should be noted that a bleeding hepatic hemangioma may cause fever of unknown origin and be indicated for resection.

Management of hepatic haemangioma in pregnancy

Hepatic cavernous haemangioma is a benign tumour of vascular origin found within the liver. Often incidentally diagnosed, the management of these vascular masses is frequently determined by the size of the mass and symptoms associated with its compression of adjacent structures. Tumours >10 cm are known as giant haemangiomas and are associated with increased risks of compression symptoms, coagulopathies and haemorrhage. Known to express hormone receptors for oestrogen, intervention for these masses remains controversial in the setting of pregnancy where concerns for tumour growth and life-threatening complications are increased. Here we present the case of a woman in her 30s recently diagnosed with a giant haemangioma who is found to be pregnant, their management and a review of the literature.

Interventional treatments for hepatic hemangioma: A state-of-the-art review

Hepatic hemangiomas (HHs) are the most common benign tumors of the liver. These tumors are mainly asymptomatic and do not require treatment. Nevertheless, there are some special cases that require therapeutic intervention, and surgery and intervention are currently the primary treatment modalities. Despite significant advances in the development of minimally invasive techniques and their popularization, interventional treatment of HH is still the preferred choice. In the present review, we discuss the pathological properties, type of blood supply, and treatment indications for HH and assess the status and progress of the existing interventional treatments.

A Nomogram Model for Predicting the Response to Transcatheter Arterial Embolization in Patients With Symptomatic Hepatic Hemangioma

Background: Transcatheter arterial embolization (TAE) is regarded as an effective treatment for patients with symptomatic hepatic hemangioma. However, few studies have evaluated the efficacy of TAE alone for treating hepatic hemangioma. The aim of this study was to identify the factors that influence the response to TAE and formulate a quantitative nomogram to optimize the individualized management of hepatic hemangioma.

Methods: We retrospectively studied 276 patients treated with TAE for hepatic hemangioma at our center from January 2011 to December 2019. The full cohort was randomly divided into training and validation cohorts. After assessing the potential predictive factors for the efficacy of TAE in the training cohort, a nomogram model was established and evaluated by discrimination and calibration.

Results: During follow-up, the symptom relief rate was 100%. The tumor blood supply (p < 0.001), tumor number (p = 0.004), and tumor size (p = 0.006) were identified as significant predictors of the failure of tumor shrinkage in response to TAE. The nomogram model showed favorable discrimination and calibration, with a C-index of 0.775 (95% CI, 0.705–0.845) in the training cohort, which was further confirmed in the validation cohort (C-index 0.768; 95% CI, 0.680–0.856). The side effects of TAE were relatively minor and included mainly abdominal pain, nausea, vomiting, fever, and the presence of elevated hepatic transaminases.

Conclusion: TAE is a safe and effective treatment for symptomatic hepatic hemangioma. The established nomogram performed well for the estimation of the effect of TAE in patients with hepatic hemangioma and can facilitate the selection of patients who would benefit most from the treatment.

Safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation of giant hepatic hemangioma: a matched case-control study and literature review

BACKGROUND

To report the safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation (LIRC) compared with laparoscopic hepatectomy (LH) in treating giant hepatic hemangioma.

METHODS

From 2017 to 2020, 19 consecutive patients with giant hepatic hemangioma (≥ 10 cm) received LIRC in one center. We selected a subgroup of 103 patients treated by LH in other four centers who well matched the 19 consecutive patients treated with LIRC, in a 1:1 fashion based on the tumor location, tumor size, and body mass index. Furthermore, the differences in technical success, operative time, operative blood loss, change of laboratory indexes, hospital stays, complication and clinical responds are compared between the two groups.

RESULTS

Technical success was achieved in all 38 patients. Patients in the LIRC group had a relative shorter operative time (P < 0.001) and less operative blood loss (P = 0.003). The serum levels of C-reactive protein (CRP), total bilirubin (TBil), alanine aminotransferase (ALT), and aspartate transaminase (AST) were elevated significantly (P < 0.05) 1 day after the resection and returned to normal within 7 days in both groups; however, relatively lower serum levels of those indexes were observed in the LIRC group (P < 0.05). The total complication rate was relatively lower in the LIRC group compared with the LH group (P = 0.029). Patients in the LIRC group had shorter hospital stays than those in the LH group (P = 0.010). The clinical response was similar in the two groups.

CONCLUSIONS

LIRC is safe and effective for treating giant hepatic hemangioma.

The Two-Step Treatment for Giant Hepatic Hemangiomas

The aim of the present study is to analyze the feasibility and the impact of a two-step approach in the treatment of giant hemangiomas (GH) i.e., exceeding 10 cm in maximum diameter, consisting of transarterial embolization (TAE) followed by laparoscopic liver resection (LLR). Ten patients with 11 GH were treated with TAE and subsequent LLR between 2017 and 2020 (Group A). A matched cohort of 10 patients with GH treated with upfront LLR between 2014 and 2017 was identified for comparison (Group B). Data were analyzed regarding intraoperative and postoperative outcomes, including successful completion of LLR, morbidity, and mortality. Successful microparticle embolization of the GH-feeding arteries was performed in all patients in group A. In three cases a liquid embolic agent (Squid-18) was also injected to obtain complete embolization. No complications were observed after TAE. Successful surgery was performed after a mean time interval of 2.2 days from TAE without any case of conversion to laparotomy. Statistically significant differences between group A and group B were found in intraoperative blood loss (250 ± 200 vs. 400 ± 300 mL, p = 0.039), operative time (245 ± 60 vs. 420 ± 60 min, p = 0.027), and length of stay (5 ± 1 vs. 8 ± 2 days, p = 0.046). Our data suggest that two-step TAE + LLR might be a safe and effective option for surgical treatment of GH >10 cm.

Giant Hepatic Hemangioma Regressed Significantly Without Surgical Management: A Case Report and Literature Review

Hepatic hemangioma (HH) is a congenital vascular anomaly comprising networks of abnormal blood and/or lymphatic vessels with endothelial cell proliferation. Their pathophysiology is not fully understood, and no specific drug is available to treat them. Conservative management, which limits observation, is preferred for most patients. A HH larger than 4 cm is considered a giant HH that may be treated using surgery ranging from embolization to hepatic resection or liver transplantation. Here, we describe a case with multiple and giant HHs that regressed significantly after treatment with azithromycin (AZM). A systematic literature review of HH and the effects of AZM on angiogenesis was then conducted.

Liver Resection for Giant Hepatic Cavernous Hemangioma

Liver hemangiomas are common. Giant liver hemangiomas are rare and symptomatic patients require treatment. Surgery is the curative procedure. Other options such as intra-arterial embolization may be used to decrease the volume and bleeding of these lesions. Three cases of giant liver hemangioma were treated with liver resection, one with left lateral hepatectomy and two with right lateral hepatectomy. All patients had made an uneventful recovery with no recurrence at 3-year follow-up. Most hemangiomas are small, asymptomatic, and do not require any treatment. Liver resection is a safe and effective treatment for giant hemangiomas.

Differentiation of Hepatocellular Carcinoma from Hepatic Hemangioma and Focal Nodular Hyperplasia using Computed Tomographic Spectral Imaging

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy. This study was designed to investigate the value of computed tomography (CT) spectral imaging in differentiating HCC from hepatic hemangioma (HH) and focal nodular hyperplasia (FNH).

METHODS

This was a retrospective study of 51 patients who underwent spectral multiple-phase CT at 40-140 keV during the arterial phase (AP) and portal venous phase (PP). Slopes of the spectral curves, iodine density, water density derived from iodine- and water-based material decomposition images, iodine uptake ratio (IUR), normalized iodine concentration, and the ratio of iodine concentration in liver lesions between AP and PP were measured or calculated.

RESULTS

As energy level decreased, the CT values of HCC (n=31), HH (n=17), and FNH (n=7) increased in both AP and PP. There were significant differences in IUR in the AP, IUR in the PP, normalized iodine concentration in the AP, slope in the AP, and slope in the PP among HCC, HH, and FNH. The CT values in AP, IUR in the AP and PP, normalized iodine concentration in the AP, slope in the AP and PP had high sensitivity and specificity in differentiating HH and HCC from FNH. Quantitative CT spectral data had higher sensitivity and specificity than conventional qualitative CT image analysis during the combined phases.

CONCLUSIONS

Mean CT values at low energy (40-90 keV) and quantitative analysis of CT spectral data (IUR in the AP) could be helpful in the differentiation of HCC, HH, and FNH.

[Radiation therapy of hepatic haemangiomas: Review from a case report]

Haemangioma is the most frequent benign hepatic tumour. Haemangioma is generally asymptomatic but it can sometimes cause disabling symptoms depending on its size and location. Surgery and interventional radiology are the cornerstone of the treatment in this situation. Radiation therapy, already used with good efficacy and safety to treat hepatic malignant lesions as hepatocarcinoma and metastases, is a relevant option in case of contraindication to surgery because of multiple or very large lesions. In this context, we report the case of a patient presenting with multiple symptomatic hepatic haemangiomas, successfully treated by radiation therapy in our department. These good results justified a review of the literature to report series of patients treated in this indication and to describe the main treatment regimens used.

Spontaneous internal hemorrhage of a giant hepatic hemangioma with infection: a case report and literature review

Spontaneous internal hemorrhage from a hepatic hemangioma is rare. This case describes a 59-year-old woman who was hospitalized with recurrent cough and fever for 6 months. The doctor thought that she had pneumonia, but other infectious diseases could not be ruled out. Therefore, related tests were performed and strong antibiotics were used, but the symptom of fever was persistent and recurred. Enhanced computed tomography (CT) findings showed a right hepatic giant hemangioma with hemorrhage, while tuberculosis, liver abscess, and immune disease were excluded by the physician. Because the patient’s fever was associated with a large hepatic hemangioma, the patient was transferred to surgery. During treatment, the amount of bleeding increased, so she underwent a right hepatic hemangioma resection in the emergency department. Her postoperative fever symptoms subsequently resolved. Pathological examination confirmed hemorrhagic necrosis with infection in hepatic hemangioma. Follow-up showed that the patient was afebrile.

Two hepatic cavernous hemangiomas mimicking colorectal liver metastasis: A rare case report

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Hepatic cavernous hemangioma is a common benign lesion of the liver.

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Commonly seen in women and most of the patients are asymptomatic.

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The radiological features can resemble those of hepatic malignancies, which make the preoperative definitive diagnosis difficult.

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Surgical resection is necessary to confirm the diagnosis.

Introduction

1 Hepatic cavernous hemangioma (HCH) is a common benign lesion of the liver. The radiological features of HCH can resemble those of hepatic malignancies such as metastatic liver cancer, which make the preoperative definitive diagnosis difficult.

Presentation of case

We report the case of a 77-year-old woman who presented with a 2-month history of abdominal pain and per rectum fresh bleeding. The initial diagnosis at the referral hospital, based on computed tomography (CT) scan of the chest, abdomen, and pelvis, was sigmoid colon cancer with liver metastasis. Further evaluation at our hospital, the patient underwent colonoscopy and biopsy. Histopathological examination of the biopsy revealed an invasive moderately differentiated adenocarcinoma. The patient underwent laparoscopic sigmoidectomy and left hepatectomy. The histopathological examination of the sigmoid colon mass revealed an invasive moderately to poorly differentiated adenocarcinoma. One out of twenty lymph nodes is positive for metastatic carcinoma. The pathological stage is pT3, pN1a, pM0. The histopathological examination of the left hepatic lobe revealed two hyalinized cavernous hemangiomas with no malignancy is seen. The postoperative recovery was uneventful, and the patient was discharged home with regular follow-up in our outpatient clinic.

Discussion

HCH is congenital vascular malformation and is the most common benign hepatic tumors. Fine-needle biopsy during diagnostic laparoscopy for undiagnosed multiple liver tumor can differentiate atypical HCH from colorectal metastasis but can potentially lead to rupture or seeding of cancer cells.

Conclusion

Surgical resection is necessary to determine if the mass is malignant in some atypical HCH mimicking liver metastasis to confirm the diagnosis with histopathologic examination.

Surgical Management of Giant Hepatic Haemangioma - Need for Redefining the Nomenclature According to the Size

INTRODUCTION

Haemangiomas are the most common benign tumours of the liver. Most of them are asymptomatic. Giant hepatic haemangioma is defined as size greater than 5 cm in diameter. The surgical treatment for giant hepatic haemangioma is not very well defined and reported. Here we analysed the treatment outcome of giant hepatic haemangiomas and redefined the nomenclature according to the size and proposing an algorithm for management of all hepatic haemangiomas.

MATERIAL AND METHODS

Retrospective analyses of 6 giant hepatic haemangioma more than 10 cm in size treated by a single surgeon were included. The clinical characteristics, diagnosis, managements and outcomes were recorded. Review of literature was done for definitions, management strategies and outcome of giant haemangiomas and an algorithm was proposed.

RESULTS

Five patients were female and the mean age was 36.6 years (range 32 to 45). Pain abdomen was the most common symptoms (100%). Ultrasound abdomen was the initial diagnostic modality followed by contrast enhanced computed tomography. The mean size of haemangioma was 17.4cm (range 12cm to 32cm). Four patients had haemangioma in the left lobe and two had in the right lobe of liver. Formal hepatectomy was done in three patients and enucleation was done in three patients. The mean operating time was 3.66 hours (range 2.5 hours to 5 hours). The mean blood loss was 840ml (range 300ml to 1500ml). There was no surgical morbidity or mortality. On follow-up no haemangioma related complications are reported.

CONCLUSIONS

Giant hepatic haemangioma is mostly symptomatic. Hepatectomy and enucleation can be done without significant morbidity and mortality. There is a need for redefining the nomenclature of giant hepatic haemangiomas according to the size.

Spontaneous intracapsular hemorrhage of a giant hepatic cavernous hemangioma: a rare case report and literature review

Background

Hepatic cavernous hemangioma is the most common type of benign liver tumor. Although ruptures and hemorrhages of hepatic hemangioma are rare complications, they are associated with high mortality. Most practitioners only pay more attention to abdominal hemorrhages caused by the rupture of hepatic hemangiomas. However, spontaneous intracapsular hemorrhages can often be neglected and poorly understood.

Case presentation

A 65-year-old man was referred to our institution with right upper quadrant pain, which had occurred suddenly and without a history of recent trauma. The blood test results were normal. Magnetic resonance imaging (MRI) of the abdomen showed a cystic mass in the right liver lobe. Considering the possibility of hepatic cystadenoma with hemorrhage, the patient underwent a right hepatic lobectomy. The pathological findings unexpectedly revealed intratumoral hemorrhage of hepatic hemangioma. The patient recovered well and was discharged eight days after surgery.

Conclusions

Intracapsular hemorrhage of hepatic cavernous hemangioma is challenging to diagnose and has a high potential risk of rupture. MRI is beneficial for diagnosing subacute internal hemorrhage cases, and it is recommended to undergo surgery for patients with a definitive diagnosis.

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.

Deep learning for differentiation of benign and malignant solid liver lesions on ultrasonography

PURPOSE

The ability to reliably distinguish benign from malignant solid liver lesions on ultrasonography can increase access, decrease costs, and help to better triage patients for biopsy. In this study, we used deep learning to differentiate benign from malignant focal solid liver lesions based on their ultrasound appearance.

METHODS

Among the 596 patients who met the inclusion criteria, there were 911 images of individual liver lesions, of which 535 were malignant and 376 were benign. Our training set contained 660 lesions augmented dynamically during training for a total of 330,000 images; our test set contained 79 images. A neural network with ResNet50 architecture was fine-tuned using pre-trained weights on ImageNet. Non-cystic liver lesions with definite diagnosis by histopathology or MRI were included. Accuracy of the final model was compared with expert interpretation. Two separate datasets were used in training and evaluation, one with all lesions and one with lesions deemed to be of uncertain diagnosis based on the Code Abdomen rating system.

RESULTS

Our model trained on the complete set of all lesions achieved a test accuracy of 0.84 (95% CI 0.74-0.90) compared to expert 1 with a test accuracy of 0.80 (95% CI 0.70-0.87) and expert 2 with a test accuracy of 0.73 (95% CI 0.63-0.82). Our model trained on the uncertain set of lesions achieved a test accuracy of 0.79 (95% CI 0.69-0.87) compared to expert 1 with a test accuracy of 0.70 (95% CI 0.59-0.78) and expert 2 with a test accuracy of 0.66 (95% CI 0.55-0.75). On the uncertain dataset, compared to all experts averaged, the model had higher test accuracy (0.79 vs. 0.68, p = 0.025).

CONCLUSION

Deep learning algorithms proposed in the current study improve differentiation of benign from malignant ultrasound-captured solid liver lesions and perform comparably to expert radiologists. Deep learning tools can potentially be used to improve the accuracy and efficiency of clinical workflows.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

BACKGROUND

Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established.

METHODS

All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality.

RESULTS

A total of 64 patients, including 41 who underwent AR, 22 who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4 cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p = 0.028) and duration of surgery >4.5 h (RR: 2.3, p = 0.025).

CONCLUSION

Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

Giant Liver Hemangioma Mimicking a Hydronephrotic Kidney on 99mTc-DTPA Scintigraphy

We report a case of a 56-year-old woman who underwent Tc-DTPA renal scintigraphy for the evaluation of a right pelviureteric junction calculi, which incidentally showed radiotracer uptake in a giant liver hemangioma. The initial scintigraphic images showed a large lobulated lesion with peripheral uptake of radiotracer at the right abdominal region, resembling a large hydronephrotic kidney. However, the pattern of progression of the radiotracer, coupled with the clinical history and available corresponding radiologic images, confirmed the uptake to be that of a giant liver hemangioma.

Pyrexia of Unknown Origin: An Atypical Presentation of Hepatic Hemangioma

Pyrexia of unknown origin (PUO) has been a diagnostic challenge for decades. Hepatic hemangioma (HH) is not a common differential diagnosis of PUO. It is the most common benign hepatic tumor, commonly asymptomatic and incidentally detected, or can present with vague abdominal pain. PUO is a rare presenting feature. We describe a case of 38-year-old lady presenting with PUO. With no other identifiable source of fever despite exhaustive investigations, a giant hemangioma in right lobe of liver detected on abdominal ultrasonography was deemed to be the cause of PUO. The patient had sudden decrease in hemoglobin while undergoing workup, which on imaging showed a bleeding hemangioma and right hepatectomy was performed. Patient had an uneventful recovery and her PUO also resolved after surgery. HH should be considered a rare diagnosis of exclusion for PUO after a standard algorithmic approach does not reveal any other cause.

Natural history of hepatic hemangiomas as a guide for surgical indication

Background

Generally, hemangiomas are asymptomatic and most lesions are incidentally diagnosed on abdominal ultrasonography. The indications for surgery are still debated mainly due to limited data about the natural history of hepatic hemangiomas. The aim of this study is to investigate the natural history of hepatic hemangiomas, the effects of age and sex on their growth, and their tendency to increase in size or causing symptoms or complications as a guide for surgical indication. In this current study, combined retrospective and prospective analysis was conducted on 186 Egyptian adult patients having 244 hepatic hemangiomas who attended to the outpatient clinics. Follow-up was performed to observe the accurate site, size, number, rate of growth of the lesions, and their tendency to cause symptoms or complications.

Results

Ninety-one percent of patients were asymptomatic and 9% were symptomatic. During follow-up, 48% of patients showed an increase in tumor diameter, 22% decreased, and 30% were stable. The growth rate at 18–45-year group showed an increasing trend that was higher in females; it was 3.3 ± 2 mm/year for males and 3.9 ± 1.8 mm/year for females. At ˃ 45 year group, the female patients showed a decreasing trend (− 2.1 ± 1.1 mm/year) while in males showed an increasing trend that was slower than in 18–45-year group (2.6 ± 1.7 mm/year).

Conclusion

Growth pattern of liver hemangiomas is affected by age and sex. The majority of hemangiomas are asymptomatic and complications are rare. Hemangioma size alone is not an indication for surgery in asymptomatic patients. Surgical indications are limited to patients with severe symptoms, complications, or suspicious lesions. Most hemangiomas can be managed conservatively even giant hemangiomas.

Giant intrahepatic venous malformation with localized intravascular coagulopathy. Follow-up and treatment during pregnancy

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

Effectiveness of Transarterial Embolization in Treatment of Symptomatic Hepatic Hemangiomas: Systematic Review and Meta-analysis

PURPOSE

To evaluate the current evidence for the effectiveness of transarterial embolization (TAE) in treatment of symptomatic hepatic hemangiomas.

MATERIALS AND METHODS

A systematic literature review was conducted in PubMed, CINAHL and Scopus databases to identify studies of hepatic hemangiomas treated with transarterial embolization. Main outcome was defined as the mean difference between pre- and post-TAE hemangioma diameters. Treatment agents were categorized as Lipiodol based [bleomycin (L + BE), pingyangmycin (L + PYG) or ethanol (L + ethanol)] and non-Lipiodol based (polyvinyl-alcohol-only). Conventional random-effect meta-analysis technique was applied to analyze data.

RESULTS

Of 3080 initially inspected publications, 21 studies were included in the meta-analysis comprising of 1450 patients with total of 1871 hemangiomas (36.2% male, mean age: 46.3 ± 3.6 years). One hundred and twenty-six, 1666, 41 and 38 lesions were treated with L + BE, L + PYG, L + ethanol and PVA, respectively. Median follow-up time after embolization was 12 months. Lipiodol-based treatments showed significant effect in reducing hemangioma size after TAE compared to PVA (P < 0.001). Pooled diameter reduction (cm) (95% confidence interval) was - 4.37( - 5.32, - 3.42), - 4.70( - 5.70, - 3.71), - 0.93( - 2.02, 0.16) for overall TAE treatment, Lipiodol-based and non-Lipiodol-based treatments, respectively. Main complications included post-embolization syndrome and transient liver enzyme elevation (pooled incidence for Lipiodol-based and non-Lipiodol-based techniques: 36% and 33%; and 37% and 0, respectively). No fatal complications were reported. Symptomatic improvement was reported in 63.3%-100% of the cases with majority of studies (15/21) reporting improvement in all cases (pooled response rate: 98%).

CONCLUSIONS

Transarterial embolization with bleomycin, pingyangmycin or ethanol in combination with Lipiodol is safe and associated with reduced size of hemangiomas resulting in symptoms alleviation.

Orthotopic liver transplantation for Management of a Giant Liver Hemangioma: a case report and review of literature

Background

Hepatic hemangioma (HH) is the most common benign tumor of the liver. In special conditions such as rapidly growing tumors, persistent pain, hemorrhage and when pressure effect on adjacent organs exist treatment is indicated. Surgical management is the most common treatment for HH.

Case presentation

A 38-year-old male patient was diagnosed with HH for 7 years. The initial presentation of the mass was progressive abdominal distention causing early satiety, gastro-esophageal reflux disease, vomiting, dysphagia and weight loss. Later, the patient developed bilateral lower extremity edema. Imaging with computed tomography (CT scan) showed a large mass measuring 32.4*26*3.1 cm which was considered unresectable. The patient underwent a deceased donor liver transplantation. The excised mass was 9 kg. After nine days of hospitalization the patient was discharged in good condition. Three months later, the patient was admitted due to fever and cytomegalovirus infection for which he received intravenous ganciclovir and was discharged. In the latest follow-up the patient had no liver or kidney dysfunction eight months after the transplantation.

Conclusion

With appropriate patient selection, liver transplantation can be considered as a treatment option for patients with huge HHs which are life-threatening and surgically unresectable.

Surgical indication and strategy for liver hemangioma in the caudate lobe: a multi-institutional retrospective analysis with 137 patients

Objective

To investigate the surgical indication and tactics for liver hemangioma in the caudate lobe

Methods

From January 1994 to July 2019, 137 patients, including 51 males and 86 females with the average age of 49.2 years old were diagnosed with liver hemangioma in caudate lobe and received treatment at five tertiary referral hospitals. Clinical features, correlations between tumor size and clinical manifestations, treatments, and prognosis were analyzed.

Results

Of the 137 patients identified, 40 (29.20%) patients were asymptomatic, whereas other 94 patients had clinical symptoms mainly presented as upper abdominal discomfort, epigastric distention, upper abdominal dull pain, nausea, and vomiting. Fifteen (93.75%), 18 (39.13%), and 7 (10.45%) patients presented no clinical symptoms among those tumor size was less than 3 cm (D ≤ 3 cm, n = 16), 3 cm < D ≤ 6 cm (n = 46), and 6 cm < D ≤ 9 cm (n = 67), respectively, while all 8 patients with tumor larger than 9 cm were symptomatic. Tumor diameter was obviously associated with the presence of clinical symptoms. In follow-up period, 7 patients in the conservative group (n = 39) received surgery because of tumor growth or symptom appearance. Totally 105 patients received operation including partial resection or isolated complete resection of caudate lobe and caudate lobe resection combined with liver segment resection, right liver resection, or left liver resection. All operations went smoothly, and no severe complications appeared.

Conclusion

Tumor diameter was obviously associated with the presence of clinical symptoms in patients with hemangioma in caudate lobe. Surgical therapy is not recommended for asymptomatic patients and available for patient who has symptoms. Effective surgical strategies should be put into use to reduce operative bleeding.

Benign Hepatic Tumors: From Incidental Imaging Finding to Clinical Management

Benign hepatic tumors (BHTs) are commonly detected as incidental finding mainly due to the frequent utilization of imaging modalities, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Rigorous clinical evaluation, with a particular focus on chronic liver disease (CLD) or risk factors for CLD, medication history, physical examination for signs of CLD, blood tests, and a review of past liver radiology constitute the initial steps in the evaluation of a new liver lesion. Further, contrast-enhanced imaging using US, CT and MRI, can be used depending on the clinical scenario and their availability. The contrast-enhanced MRI provides detailed tissue assessment while avoiding exposure to radiations, although it is scarcely available and expensive. While the liver tissue-specific protocols ensure precise diagnosis, a biopsy is recommended in selected or doubtful cases. Further, most BHTs, such as hemangiomas, are harmless and do not require special management or follow-up, the hepatic adenomas and large or atypical cases of focal nodular hyperplasia are clinically relevant and require management/follow-up. In such cases, it is favorable to have a multidisciplinary team approach, which includes hepatologist, radiologist, hepatobiliary surgeon, and pathologist. This review aims to elaborate the current understanding of BHTs, and provide a practical guidance for primary care and practitioners of family and internal medicine for the disease evaluation and management.

Robotic, laparoscopic or open hemihepatectomy for giant liver haemangiomas over 10 cm in diameter

Background

To evaluate the clinical efficacy of robotic, laparoscopic, and open hemihepatectomy for giant liver haemangiomas.

Methods

From April 2011 to April 2017, consecutive patients who underwent hemihepatectomy for giant liver haemangiomas were included in this study. According to the type of operation, these patients were divided into the robotic hemihepatectomy (RH) group, the laparoscopic hemihepatectomy (LH) group, and the open hemihepatectomy (OH) group. The perioperative and short-term postoperative outcomes were compared among the three groups. The study was reported following the STROCSS criteria.

Results

There were no significant differences in age, sex, tumour location, body surface area (BSA), future liver remnant volume (FLR), standard liver volume (SLV), liver haemangioma volume, FLR/SLV, resected normal liver volume/resected volume, hepatic disease, rates of blood transfusion, liver function after 24 h of surgery, operative morbidity and mortality among the three groups. Compared with patients in the RH group (n = 19) and the LH group (n = 13), patients in the OH group (n = 25) had a significantly longer postoperative hospital stay (P < 0.05), time to oral intake (P < 0.05), and time to get-out-of-bed (P < 0.05); a higher VAS score after 24 h of surgery (P < 0.05); and a shorter operative time (P < 0.05). There were no significant differences in these postoperative outcomes (P>0.05) between the RH group and the LH group. When the setup time in the RH group was excluded, the operative time in the RH group was significantly shorter than that in the LH group (P<0.05). There was no significant difference in the operative time between the RH group and the OH group (P>0.05). The amount of intraoperative blood loss in the RH group was the lowest among the three groups (P<0.05), and the amount of intraoperative blood loss in the LH group was less than that in the OH group (P<0.05).

Conclusion

Robotic and laparoscopic hemihepatectomies were associated with less intraoperative blood loss,better postoperative recovery and lower pain score. Compared with laparoscopic hemihepatectomy, robotic hemihepatectomy was associated with significantly less intraoperative blood loss and a shorter operative time.

Current concepts in ablative procedures for primary benign liver lesions: a step forward to minimize the invasiveness of treatment when deemed necessary

With increased use of medical imaging, the incidental detection of benign solid liver tumors has become more frequent. Facing with benign disease, the indications for surgery are still object of discussion in light of the stable natural course of most lesions and obvious drawbacks of any surgical intervention; therefore, in most situations, a conservative approach is recommended, and surgery is mainly reserved for those cases with persistent or worsening symptoms, or who are at risk for complications as malignant transformation. The advent of ablative techniques has widened the range of treatment options available to these patients, presenting as a valid alternative to resection in terms of safety and efficacy in selected cases, particularly in patients who are considered poor surgical candidates and with smaller lesions. This review outlines the role of percutaneous ablative methods for benign solid liver tumors that are encountered in adults, providing a per histology analysis of the existing evidence. The up-to-date strategies for management of the most common benign solid tumors are recapitulated.