Prenatal diagnosis and management of fetuses with liver hemangiomata

Prenatal Diagnosis and Prognosis of Abdominal Arteriovenous Fistulae: A Comprehensive Case Series and Systematic Review

This study had two main objectives. Firstly, we conducted a thorough literature review on the prenatal diagnosis of abdominal congenital arteriovenous fistulas (CAVFs) involving the abdominal aorta and hepatic arteries. Secondly, we aimed to provide detailed descriptions of eight additional cases diagnosed at our medical center and assess the outcome of this anomaly for informed counseling. We conducted a systematic search of online databases using specific keywords like "outcome", "ultrasound", "intrahepatic fistulae", and "fetal venous anomalies", focusing on studies published between 1998 and 2023. We selected 10 relevant articles and analyzed 13 cases. Additionally, we conducted a five-year prospective study in two referral centers, identifying eight CAVF cases with an incidence rate of 0.16%. Among the 21 cases evaluated, 11 resulted in live births, all of which received treatment. However, four cases (36.3%) had poor postnatal outcomes and neonatal demise due to heart failure. Prenatal signs of poor fetal hemodynamics, including cardiomegaly or hydrops, were observed in 52.3% of cases, regardless of outcome. Our findings highlight the rarity of this vascular malformation and emphasize the importance of effective treatment to avoid unfavorable outcomes. The long-term effectiveness of prenatal treatment or postnatal embolization remains uncertain, with liver transplantation being considered the most reliable treatment option.

Postnatal treatment and evolution patterns of giant fetal hepatic hemangioma: a case series of 29 patients

OBJECTIVES

To explore the clinical characteristics, postnatal treatment and prognosis of giant fetal hepatic hemangioma (GFHH).

METHOD

Retrospective analysis was performed on children with giant fetal hepatic hemangioma (maximum tumor diameter > 40 mm) diagnosed by prenatal ultrasound and MRI from December 2016 to December 2020. These patients were observed and treated at the Children's Hospital of Fudan University after birth. The clinical data were collected to analyze the clinical characteristics, treatment, and prognosis of GFHH using independent sample t tests or Fisher's exact tests.

RESULTS

Twenty-nine patients who were detected by routine ultrasound in the second and third trimester of pregnancy with giant fetal hepatic hemangiomas were included. The first prenatal ultrasound diagnosis of gestational age was 34.0 ± 4.3 weeks, ranging from 22 to 39 weeks. Of the patients, 28 had focal GFHHs and 1 had multifocal GFHHs. Surgery was performed, and the diagnosis was confirmed histopathologically in two patients. There were 8 cases with echocardiography-based evidence of pulmonary hypertension, 11 cases had a cardiothoracic ratio > 0.6, and 4 cases had hepatic arteriovenous fistula (AVF). The median follow-up time was 37 months (range: 14-70 months). During the follow-up, 12 patients received medical treatment with propranolol as the first-line therapy. The treatment group had a higher ratio of cardiothoracic ratio > 0.6 (P = 0.022) and lower albumin levels (P = 0.018). Four (14.8%) lesions showed postnatal growth before involuting. Complete response was observed in 13 (13/29) patients, and partial response was observed in 16 (16/29) patients.

CONCLUSIONS

Fetal giant hepatic hemangioma is mainly localized, and its clinical outcome conforms to RICH (rapidly involuting) and PICH (partially involuting), but some fetal giant hepatic hemangiomas will continue to grow after birth and then gradually decrease. For uncomplicated giant fetal hepatic hemangioma, postnatal follow-up is the main concern, while those with complications require aggressive medical treatment. Propranolol may have no effect on the volume change of GFHH.

Fetal giant liver hemangioma: Ultrasound, magnetic resonance imaging, three-dimensional reconstruction findings and perinatal outcomes of two cases

In this case report, we present two cases of fetal liver giant hemangioma assessed using ultrasound, magnetic resonance imaging and three-dimensional reconstructions with their respective postnatal outcomes.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Mortality predictive factors in congenital hepatic hemangioma: a case-control study

Congenital hepatic hemangiomas (CHHs) are benign vascular tumors whose clinical, histological, and genetic correlation has recently been described in patients with long-term survival, although no mortality risk factors have been identified to date. The aim of this study is to analyze predictors of mortality in patients with CHH. A retrospective single-center case-control study of consecutive CHH patients diagnosed in our institution between 1991 and 2021 was performed, who were classified into two groups according to their survival. Demographic, gestational, imaging, and laboratory data at diagnosis were collected and compared between both groups. A total of 29 patients were included (12 males; 17 females) of whom 5 died as a result of CHH evolution due to cardiac failure and coagulopathy, with a median age of 11 days until death. No differences in demographic or gestational data were reported. There were neither differences when comparing imaging tests, nor in location, number of affected liver segments, or CHH estimated volume. Upon laboratory data at diagnosis, deceased patients had a significant elevation of median liver enzymes [glutamic-oxaloacetic transaminase (359 u/L vs. 45 u/L; p < 0.01) and glutamic-pyruvic transaminase (313 u/L vs. 20 u/L; p < 0. 01)], as well as a decreased median platelet count (85,250/µL vs. 337,000/µL; p < 0.01), prothrombin activity (54% vs. 93%; p < 0.01), and fibrinogen (131 mg/dL vs. 284 mg/dL; p < 0.01), with no differences in blood count or biochemistry data.

CONCLUSIONS

CHH clinical behavior can be innocuous or life-threatening. Thrombocytopenia, coagulation disorders, and increased liver enzymes at diagnosis seem to be the main predictors of mortality.

WHAT IS KNOWN

• Congenital Hepatic Hemangiomas (CHHs) are benign vascular tumors whose clinical behavior can be innocuous or life-threatening.

WHAT IS NEW

• Thrombocytopenia, coagulation disorders and increased liver enzymes at diagnosis seem to be the main predictors of mortality in these patients.

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Infantile hepatic hemangioma misdiagnosed by prenatal ultrasonography: A case report

RATIONALE

The drastic differences in treatment and prognosis of infantile hepatic hemangioma (IHH) and hepatoblastoma (HBL) make accurate prenatal diagnosis imperative. The retrospective comparisons of ultrasonic features between fetal IHH and HBL have been reported before, but clinically, the differential diagnosis in utero is very difficult and can lead to prenatal misdiagnosis.

PATIENT CONCERNS

A 27-year-old woman at 30 gestational weeks underwent the routine prenatal examination. A heterogeneous solid mass of the fetus, with close relationship to the liver, was recognized by ultrasound.

DIAGNOSIS

A diagnosis of HBL was highly considered.

INTERVENTIONS

The fetus was aborted and the autopsy was performed.

OUTCOMES

The histological outcome was IHH.

LESSONS

The prognosis of fetal IHH and HBL is very different, so an accurate diagnosis prenatally is crucial and indispensable. The radiologist and clinician should differentiate between IHH and HBL, especially since the fetus can have serious complications.

Prenatal ultrasound and magnetic resonance evaluation and fetal outcome in high-risk fetal tumors: A retrospective single-center cohort study over 20 years

Introduction

Fetal tumors are rare and usually followed by poor outcome. We describe our single‐center experience with fetal tumors evaluated by ultrasound and magnetic resonance imaging (MRI). Our aims were to evaluate mortality and morbidity including long‐term outcome and to determine which ultrasound and MRI characteristics were helpful for pre‐ and perinatal management.

Material and methods

We conducted a retrospective analysis on prenatally diagnosed tumors between 1998 and 2018. Poor outcome included fetal or neonatal death and survival with serious illness. MRI addressed tumor morphology (sacrococcygeal teratomas), compromise of surrounding structures (head and neck tumors) and early depiction of brain alterations specific to tuberous sclerosis (rhabdomyomas).

Results

Of 68 pregnancies, 15 (22%) were terminated and eight children (8/53, 15%) died pre‐ or postnatally. Of the 45 survivors (45/68, 66%), 24 (24/45, 53%) were healthy, eight (8/45, 18%) had a minor illness and 13 (13/45, 29%) a serious illness. Diffusion‐ and T1‐weighted MRI reliably predicted tumor morphology in teratomas. To detect head and neck tumors critical to airway obstruction, MRI was superior to ultrasound in delivery planning. Rhabdomyomas were frequently associated with tuberous sclerosis, regardless of their number or size in ultrasound; MRI could depict specific brain alterations from the early third trimester onwards. For several rare tumors, MRI provided critical differential diagnoses that could not be clearly displayed in ultrasound.

Conclusions

The rate of survivors with serious long‐term illness among fetuses with prenatal diagnosis of a tumor was high. MRI is specifically helpful for risk stratification in fetal teratomas and delivery planning in head and neck tumors.

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

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

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

OBJECTIVES

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

RESULTS

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

CONCLUSIONS

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

Prenatally diagnosed congenital hemangioma with elevated middle cerebral artery peak systolic velocity mimicking the Kasabach-Merritt phenomenon: A case report

Congenital hemangioma is a rare vascular tumor that develops prenatally, and a large congenital hemangioma may be accompanied by the Kasabach-Merritt phenomenon. We present a case of prenatally diagnosed fetal congenital hemangioma through ultrasound and maternal anti-Jr(a) antibody alloimmunization with elevated middle cerebral artery peak systolic velocity. To investigate fetal anemia and hemostatic condition, we performed percutaneous umbilical blood sampling, which revealed no symptom of either Kasabach-Merritt phenomenon or sensitization to anti-Jr(a) antibody. Consequently, pregnancy could be continued without further intervention. After birth, congenital hemangioma was found on the infant's left thigh, and Kasabach-Merritt phenomenon was not shown. Percutaneous umbilical blood sampling could provide precise information prenatally in case of congenital hemangioma with maternal alloimmunization.

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

INTRODUCTION

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

CASE REPORT

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

CONCLUSION

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

Unexpected middle cerebral artery peak systolic velocity values in the normal fetal population. Are they a matter of concern?

Objective: The aim of this study was to investigate in the fetus the relationship between unexpected high middle cerebral artery peak systolic velocity (middle cerebral artery (MCA) peak systolic velocity (PSV)) values and hemoglobin (Hgb) levels in normal pregnancies without conditions leading to fetal anemia.Material and methods: This was a prospective study of 922 singleton low-risk pregnant women attending the maternity of La Fe Hospital between 35 and 41 weeks. Multiple pregnancies and pregnancies with growth restriction, smallness, macrosomia or conditions leading to fetal anemia were excluded. During each examination, a biometry and a Doppler examination of the umbilical artery pulsatility index (umbilical artery (UA) pulsatility index (PI)), MCA PI and MCA PSV were performed. MCA PSV was converted into multiples of median (MoM), and birth weight (BW) into centiles adjusting for gender. All pregnancies delivered in a 2-week interval since examination. In order to explain Hgb levels at birth, a correlation between MCA PSV MoM and Hgb was performed and Hgb levels of fetuses with normal MCA PSV and abnormal MCA PSV were compared, using 1.3 MoM as cut-off for mild anemia. Finally, a multivariate linear regression analysis was performed including MCA PSV MoM and several Doppler and clinical parameters.Results: The univariate analysis showed no correlation between the MCA PSV MoM and the umbilical artery Hgb (r² = 0.026, p = .1237) while a weak correlation was found with the umbilical vein Hgb (r² = 0.0053, p = .027). Also, fetuses with values of MCA PSV MoM <1.3 MoM did not differ in terms of artery and vein Hgb with those presenting values >1.3 MoM (p = .99 and p = .61, respectively). Finally, both prediction models explaining arterial and venous Hgb presented very weak predictive accuracies (R Squared: 0.0965 and R Squared: 0.106) indicating a low possibility to diagnose fetal anemia in otherwise normal fetuses based on clinical and sonographic data.Conclusion: In normal pregnancies that are not suffering from conditions leading to fetal anemia, unexpected high MCA PSV values do not necessarily reflect the presence of this condition. Active management in this circumstance might result in unjustified higher rates of labor induction and operative delivery.

Huge fetal hepatic Hemangioma: prenatal diagnosis on ultrasound and prognosis

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

A rare case of a neonatal hepatic tumor presenting as hydrops fetalis

Hepatic hemangioendothelioma is a rare and benign vascular tumor, usually asymptomatic at birth. However, it can present with severe cardio-respiratory symptoms and consumptive coagulopathy. Here we present a severe case of hepatic hemangioendothelioma presenting as hydrops fetalis, suggesting that it can have significant prenatal and postnatal morbidity.

Fine clinical differences between patients with multifocal and diffuse hepatic hemangiomas

BACKGROUND

It has been reported that multifocal and diffuse hepatic hemangiomas are true infantile hemangiomas for which a continuum probably exists. We determined the similarities and fine differences between the two types of hemangioma and identified the multifocal subgroup of type, which needs timely treatment.

MATERIAL AND METHODS

Twenty-four patients (4 males and 20 females; age 114±142days) with multifocal or diffuse hepatic hemangiomas who were treated between January 2000 and June 2015 were studied. For the multifocal type, patients were divided into countable (MC) and uncountable (MU) subgroups. The medical data were analyzed retrospectively.

RESULTS

The clinical presentations included hepatomegaly (n=11), dyspnea (n=7), heart failure (n=9), hypothyroidism (n=6), and anemia (n=1). There were 19 and 5 patients with multifocal and diffuse types, and 6 and 13 patients in the MC and MU groups, respectively. There were significant differences between the multifocal and diffuse types with respect to hepatomegaly, heart failure, dyspnea, and hypothyroidism. However, there was no difference between the MU group and the diffuse type except for hypothyroidism. Observation was commonly recommended for patients with the multifocal type, and their survival rate was clearly higher than for patients with the diffuse type. Both the MU and diffuse-type groups needed treatment, unlike MC patients. The complete remission rate was higher in the MC group than in the MU and diffuse-type groups. Patients with the diffuse type were more likely to die.

CONCLUSIONS

Patients with diffuse-type hepatic hemangioma are at high risk and need active treatment. The MU group for the multifocal type is unique and has high similarities to the diffuse type with respect to clinical presentation and treatment, which suggests that a continuum of the disease phenotypes exists.

LEVEL OF EVIDENCE

Case-control study, level III.

Congenital Hepatic Arteriovenous Malformation

Hepatic arteriovenous malformation (AVM) is a rare developmental vascular disorder characterized by direct arterial connection to a fistulous venous drainage system within the liver. The condition results in a high-flow, low-resistance shunt that can cause high-output cardiac failure and hydrops. Prenatal diagnosis is possible when sonography detects multiple engorged vascular channels in the fetal liver. Current treatment options include postnatal obliteration of the arterial feeder vessels by surgical ligation or percutaneous transcatheter embolization with detachable coils. The authors present a case of a prenatally diagnosed hepatic AVM complicated by fetal distress, high-output cardiac failure, and consumptive coagulopathy that had recanalization of feeder vessels noted two weeks after initial successful coil placement.

Spontaneous Subcapsular Hematoma of the Fetal Liver: A Case Report and Review of Literature

We report a case of a cystic abdominal mass on ultrasound which presented a diagnostic dilemma at 32 weeks gestation. A presumptive antenatal diagnosis of a subcapsular liver hematoma (SCH) was made based on the location and ultrasound appearance similar to SCH seen in pediatric and adult patients. Sequential evaluation of the mass showed an evolving ultrasound appearance which reinforced our initial impression of a subcapsular hematoma of the fetal liver. Postnatal ultrasound confirmed the resolving SCH as well as a previously undetected echo bright lesion characteristic of an infantile focal hemangioma directly adjacent to the resolving SCH. A review of the literature is provided.

Prenatal diagnosis of a liver cavernous hemangioma

Liver tumors seldom occur in the perinatal period. Hepatic hemangiomas are the most common tumors of the liver diagnosed during fetal and neonatal life. The diagnosis can be suspected antenatally by ultrasound and MR scan. The differential diagnosis is often challenging. While small hepatic hemangiomas are usually asymptomatic, large tumors can lead to complications such as high-output congestive heart failure, consumptive thrombocytopenic coagulopathy and hemorrhage after tumor rupture. We describe a case of hepatic hemangioma presenting as a solid abdominal mass with several cystic areas on an obstetric ultrasound and report on the contribition fetal MR imaging to the diagnosis.

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

BACKGROUND

The clinical presentation of foetal hepatic haemangioma (HH) is highly variable, from asymptomatic to life-threatening.

OBJECTIVE

The aim of this study was to describe foetal hepatic haemangioma and identify prognostic factors.

MATERIALS AND METHODS

Antenatal and postnatal imaging studies, clinical and biological records of infants with antenatally diagnosed HH (2001-2009) were reviewed.

RESULTS

Sixteen foetuses had one focal lesion, with a mean volume of 75 ml (5-240 ml). One had multifocal HH. Most presented as a focal well-delimited heterogeneous vascular mass. Four had associated cardiomegaly, five had cardiac failure. Eight of the nine foetuses with cardiac disorders were symptomatic at birth: cardiac failure with pulmonary hypertension (9), consumptive coagulopathy (8), compartmental syndrome (2). All received supportive medical treatment, four embolisation. Five of these died. The remaining eight had a normal cardiac status. Two became symptomatic after birth: one with a large porto-hepatic shunt and one with significant mass effect. Prenatal cardiac abnormality (univariate, P = 0.031), enlargement of more than one hepatic vein (P = 0.0351) and large volume (P = 0.0372) were associated with symptomatic disease.

CONCLUSION

Hepatic haemangioma associated with prenatal cardiac disorders, large volume and more than one enlarged hepatic vein have poorer outcome and require specific perinatal multidisciplinary management.

Congenital tumors: imaging when life just begins

Background

The technical developments of imaging methods over the last 2 decades are changing our knowledge of perinatal oncology. Fetal ultrasound is usually the first imaging method used and thus constitutes the reference prenatal study, but MRI seems to be an excellent complementary method for evaluating the fetus. The widespread use of both techniques has increased the diagnosis rates of congenital tumors. During pregnancy and after birth, an accurate knowledge of the possibilities and limits of the different imaging techniques available would improve the information obtainable, thus helping the medical team to make the most appropriate decisions about therapy and to inform the family about the prognosis.

Conclusion

In this review article, we describe the main congenital neoplasms, their prognosis and their imaging characteristics with the different pre- and postnatal imaging methods available.

Fetal and neonatal liver tumours

Liver tumours are rare in children and account for about 5% of all tumours in the fetus and newborn. The most frequently occurring are benign vascular tumours and mesenchymal hamartomas although malignancy in the form of hepatoblastoma is a possibility. While the diagnosis can be suspected antenatally (by ultrasound and MR scan), a precise diagnosis is often difficult due to the complexity of the tumours. Inutero development of such tumours may be associated with polyhydramnios, fetal hydrops and extreme cases the maternal mirror syndrome. Postnatal symptoms may include abdominal distension, cardiac failure, consumptive coagulopathy and bleeding due to tumour rupture, but is dependent on the nature of the actual tumour. Treatment options may include watchful waiting, surgical resection, hepatic artery embolisation/ligation and chemotherapy.

Conservative management in three cases of prenatally recognized splenic cyst using 2D, 3D, multi-slice and Doppler ultrasonography

The aetiology, differential diagnosis and management strategies of the foetal spleen affected with a cystic lesion are discussed. In the current literature, there are very few reports that relate to antenatally diagnosed splenic cyst. Our study presents 3 case reports that were first suspected due to anisoechogenic structures detected during routine ultrasonographic examination at the 27th, 31st and 34th weeks of gestation. All 3 cases were further characterized by the lack of pathological power Doppler findings inside and around the lesions, and were morphologically refined by prenatal 3D ultrasound imaging. All findings were reconfirmed postnatally. No complications such as cyst expansion, subcapsular bleeding or acute abdomen have developed, and all 3 cystic lesions have regressed spontaneously after birth.

Prenatal diagnosis of fetal hepatoblastoma: case report and review of the literature

Hepatoblastoma is the most common liver malignancy in childhood. The reported incidence is 11.2 cases per 1 million during the first year of life. Genetic predispositions include Beckwith-Wiedemann syndrome and familial polyposis. The prognosis depends on the extent of tumor spreading at the time of initial treatment, which typically includes chemotherapy and surgery. Imaging of hepatoblastoma has only rarely been reported prenatally. Here we report a recent case with a successful outcome and discuss issues of differential diagnosis and treatment.

Spectrum and outcome of prenatally diagnosed fetal tumors

OBJECTIVE

To describe the spectrum of prenatally diagnosed fetal tumors, and the course and fetal outcome in affected pregnancies.

METHODS

This was a retrospective study in two German tertiary referral centers of 84 fetuses with tumors diagnosed in the prenatal period. The tumors were classified according to their location and histology.

RESULTS

The most common site of origin was the heart (20/84, 23.8%), followed by the face and neck region (19/84, 22.6%) and the abdomen (16/84, 19%). Lymphangiomas (21/84, 25%) and rhabdomyomas (19/84, 22.6%) comprised half of the tumor histology. Less frequently, teratomas (14/84, 16.6%) and hemangiomas (12/84, 14.2%) were seen. Complications included arrhythmia in cases with rhabdomyoma (8/19, 42%) and signs of heart failure in cases with hemangioma (4/12, 33%) and teratoma (4/14, 28.6%). The overall survival rate was 75%. Cases with either a histological diagnosis of teratoma or tumor located in the brain had the worst prognosis.

CONCLUSION

The combination of sonographic features and their location allows reliable prediction of the histological type in the vast majority of fetal tumors. Malignancy, associated malformations and aneuploidy are observed infrequently. Knowledge of the presence of a fetal tumor facilitates close surveillance by a specialized team, which might lead to early recognition of problems and improve perinatal outcome.

Prenatal diagnosis and therapy of upper extremity vascular malformation causing high cardiac output and Kasabach-Merritt sequence: a report of two cases

We present two cases of upper extremity vascular malformation causing a high output state in the prenatal period. One fetus responded well to transplacental digitalis treatment. Both newborns had a Kasabach-Meritt sequence including anemia and thrombocytopenia. Postpartum treatment included successful interventional occlusion of the main feeding arteries and subsequent surgical removal of the tumor.

Congenital symptomatic intrahepatic arteriovenous fistulas in newborns: management of 2 cases with prenatal diagnosis

BACKGROUND

Fetal and neonatal hepatic arteriovenous fistulas are rare and associated with a high mortality rate; they can be prenatally detected by ultrasonography. Management of these malformations can be a challenge for pediatric surgeons.

METHODS

Two patients with a prenatal diagnosis of intrahepatic arteriovenous shunts were treated at our institution in the last 2 years. A hepatic complex arteriovenous malformation fed respectively by prominent branches of the hepatic artery and of the celiac trunk rising from dilated suprarenal aortae and draining into suprahepatic veins was detected. In the first case, an embolization was performed; in the second, the surgical resection of the vascular malformation was the treatment of choice.

RESULTS

The first patient died after embolization and before surgery for hemodynamic complications. The second patient, at a follow-up of 16 months, is alive and doing well.

CONCLUSION

Hepatic resection is the treatment of choice for localized intrahepatic arteriovenous malformation. Theoretically, embolization could be curative or reduce the size of a malformation, making consequent hepatic resection feasible. Results do not support this theory because of the high rate of complications recorded that brought in every case, ours included, to the death of the child.

Genetics of vascular anomalies: an update

Vascular anomalies arise from genetic, environmental, mechanical, and/or hormonal factors. Some are inherited in a Mendelian fashion whereas others result from abnormal chromosomal segregation during gametogenesis or appear sporadically during various stages of life. Understanding the molecular basis of vascular development and vascular anomalies provides potential tools for diagnosis and treatment of the diseases.

Prenatal diagnosis of liver and biliary tract disease

The diagnosis and detection of some forms of liver and bile duct disease have become possible since the adoption of routine fetal ultrasound scanning in the UK, and the remarkable advances in molecular biological techniques. Nevertheless, although antenatal detection may well have improved, it remains difficult to offer a specific diagnosis, much less a prognosis, in most cases. Cystic dilatation of the biliary tree is probably the most common finding. This may be due to cystic choledochal malformations or, occasionally but crucially, biliary atresia. Postnatal investigations (such as ultrasonography, magnetic resonance cholangiography and liver histology) must take the latter possibility into account, as early surgery is the key to a successful outcome following reconstructive biliary surgery. Antenatally diagnosed liver tumours are usually of vascular origin and have an unpredictable natural history. Some may cause fetal cardiac failure and are candidates for in-utero intervention, but in all likelihood, a large proportion will resolve without specific therapy.

Prenatal Diagnosis of Vascular Anomalies: Update and Review of the Literature

Optimal care for a subgroup of infants with complicated vascular anomalies requires prenatal diagnosis. Fetal vascular lesions are either vascular tumors or vascular malformations, both of which are often detected on routine ultrasound. Imaging, such as ultrasound and fetal MRI, can be used to examine lesions and provide the data for a differential diagnosis, which may impact the course of care both in utero and postnatally. Prenatal diagnosis provides the opportunity for antenatal intervention, parental counseling, and planning of the mode and location of delivery to optimize postnatal care. Prenatal diagnosis of vascular lesions also serves to alert the physician to the potential for associated syndromes and complications. Any indication of a vascular anomaly should be referred for further examination by an experienced multidisciplinary team of physicians to ensure the window in which evaluation, planning, and treatment can take place is not missed.