Hepatic Sclerosed Hemangioma: a case report and review of the literature

Mask-aware transformer with structure invariant loss for CT translation

Multi-phase enhanced computed tomography (MPECT) translation from plain CT can help doctors to detect the liver lesion and prevent patients from the allergy during MPECT examination. Existing CT translation methods directly learn an end-to-end mapping from plain CT to MPECT, ignoring the crucial clinical domain knowledge. As clinicians subtract the plain CT from MPECT images as subtraction image to highlight the contrast-enhanced regions and further to facilitate liver disease diagnosis in the clinical diagnosis, we aim to exploit this domain knowledge for automatic CT translation. To this end, we propose a Mask-Aware Transformer (MAFormer) with structure invariant loss for CT translation, which presents the first effort to exploit this domain knowledge for CT translation. Specifically, the proposed MAFormer introduces a mask estimator to predict the subtraction image from the plain CT image. To integrate the subtraction image into the network, the MAFormer devises a Mask-Aware Transformer based Normalization (MATNorm) as normalization layer to highlight the contrast-enhanced regions and capture the long-range dependencies among these regions. Moreover, aiming to preserve the biological structure of CT slices, a structure invariant loss is designed to extract the structural information and minimize the structural similarity between the plain and synthetic CT images to ensure the structure invariant. Extensive experiments have proven the effectiveness of the proposed method and its superiority to the state-of-the-art CT translation methods. Source code is to be released.

Hepatic Cavernous Hemangioma Mimicking Malignancy on 18 F-FDG PET/CT Imaging

ABSTRACT

A 65-year-old woman was referred to our hospital because of a liver lesion revealed by ultrasound and CT in an outside institution. 18 F-FDG PET/CT images revealed an FDG-avid lesion in the left lateral lobe of the liver. Malignancy cannot be excluded. A subsequent resection was performed to remove the lesion. Postoperative pathology was hepatic cavernous hemangioma. This case suggests that PET/CT findings of FDG-avid hepatic cavernous hemangioma could mimic malignancy.

Multiple sclerosing hemangiomas mimicking hepatocellular carcinoma: A case report

Hepatocellular carcinoma is a prevalent malignant tumor affecting the liver, and surgical resection and liver transplantation are the primary treatment options for early-stage HCC patients. However, the presence of benign hepatic tumors with similar imaging characteristics to HCC poses challenges in diagnosing and treating the disease, often resulting in misdiagnosis and inappropriate treatment. This case report presents a 52-year-old female patient who exhibited space-occupying liver lesions on abdominal CT and MRI scans. Based on pathological sections from other hospitals, liver malignancy was highly suspected, and hepatocellular tumor was diagnosed preoperatively. But the tumor markers of the patient were all within the normal range. After evaluating the overall condition of the patient, we finally chose the diagnosis and treatment of dissection and partial hepatectomy. Surprisingly, the final diagnosis of postoperative pathology was sclerosing hemangioma. The patient recovered well and was discharged 2 weeks later. Hepatic sclerosing hemangioma is an extremely rare disease that can be easily mistaken for malignant liver tumors due to absence of typical imaging presentations. The diagnosis also needs to be differentiated from other benign tumors, such as liver adenoma and liver abscess, according to the medical history, symptoms, and auxiliary examinations. Therefore, special attention should be given to the diagnosis and treatment of sclerosing hemangioma.

Added Value of Ultrasound-Based Multimodal Imaging to Diagnose Hepatic Sclerosed Hemangioma before Biopsy and Resection

Imaging methods have the overwhelming advantage of being non-invasive in the diagnosis of hepatic lesions and, thanks to technical developments in the field of ultrasound (US), radiation exposure can also be avoided in many clinical situations. In particular, contrast-enhanced US (CEUS) outperforms other radiological methods in regard to real-time images, repeatability, and prompt reporting and demonstrates relatively few contraindications and adverse reactions. In this study, we reported in detail a rare benign tumor: hepatic sclerosed hemangioma (HSH). We described US-based multimodal imaging (B-flow imaging, US elastography, and Sonazoid CEUS) features of this HSH case. Furthermore, by summarizing the recently published literature on the imaging diagnosis of HSH, we offered readers comprehensive knowledge of conventional imaging methods (CT, MRI) and CEUS in the diagnosis of HSH and preliminarily discussed their mechanism of pathology-based diagnosis. Our multimodal imaging approach may provide a diagnostic strategy for HSH, thus avoiding unnecessary biopsy or resection.

Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part I - Cystic lesions

Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the first part of the guideline, concerning the characterization of focal hepatic lesions detected by ultrasound, and the diagnosis and clinical management of simple and parasitic hepatic cysts, and of polycystic liver disease.

Imaging mimickers of cholangiocarcinoma: a pictorial review

Cholangiocarcinoma (CCA) is the second most common primary hepatobiliary malignancy and presents as three separate morphological subtypes; namely mass-forming, periductal-infiltrating, and intraductal-growing patterns. Each of these subtypes have distinct imaging characteristics, as well as a variety of benign and malignant mimics, making accurate diagnosis of CCA on imaging challenging. Whilst histopathological examination is required to arrive at a definitive diagnosis, it is still important for radiologists to be cognizant of these entities and provide reasonable differential diagnoses, as these potentially have a large impact on patient management. This pictorial essay illustrates the three morphological subtypes of CCA, as well as some important mimics for each subtype, that are encountered in clinical practice.

Hepatic sclerosed hemangioma and sclerosing cavernous hemangioma: a radiological study

Purpose

To investigate and compare the CT and MRI features of hepatic sclerosed hemangioma (HSH) and sclerosing cavernous hemangioma (SCH).

Materials and methods

Twelve HSH cases and 36 SCH cases were included, the imaging findings on CT (9 HSH and 34 SCH) and MRI (8 HSH and 10 SCH) were analyzed. Qualitative image analysis included the location, size, shape, capsular retraction, density, calcification, signal intensity on T₁-weighted image (T₁WI) and T₂-weighted image (T₂WI), presence of diffusion restriction, apparent diffusion coefficient (ADC) map, transient hepatic attenuation difference around the lesion, and the dynamic enhancement patterns.

Results

The presence of liver cirrhosis in patients with HSH (3/12) was higher than SCH (1/36) (P = 0.043). The morphology appearance before enhancement showed no significant difference between HSH and SCH. Moreover, SCH had a stronger trend of centripetal enhancement patterns of cavernous hemangiomas (83.3%) compared to HSH (25%) (P < 0.001). Due to more frequent atypical enhancement features, containing rim-like enhancement, no enhancement, and peripheral heterogeneous enhancement, the misdiagnosis rate of HSH (75%) was significantly higher than that of SCH (16.7%) (P < 0.001). Furthermore, the ADC values of HSH and SCH were both higher than that of the surrounding liver parenchyma (P = 0.009, P = 0.002); however, there was no significant difference in ADC values between themselves (P = 0.613).

Conclusion

SCH showed the same trend of centripetal enhancement characteristics as typical hemangioma, while HSH exhibited atypical enhancement features due to complete sclerosis. Higher ADC values might contribute to the identification of atypical HSH and SCH from malignancies.

Cholangiocarcinoma - Part 2, Tumoral and Nontumoral Mimics and Imaging Features Helpful in Differentiation

Each of the 3 morphological subtypes of cholangiocarcinoma has a different set of imaging differentials. Emulators of mass-forming cholangiocarcinoma include other primary and secondary hepatic malignancies, benign tumors and tumor-like mimics such as abscess, hemangioma and confluent hepatic fibrosis. Benign inflammatory biliary strictures constitute the major differential of periductal-infiltrative type and intraductal calculi are the main consideration for intraductal-growth type. CT and MRI are the standard imaging tools for characterization of cholangiocarcinoma and differentiating it from close mimics. Here we will describe the various tumoral and non-tumoral mimics of cholangiocarcinoma and discuss specific imaging features useful in differentiation.

Hepatic Sclerosing Hemangioma Mimicking Malignancy: A Case and Literature Review

BACKGROUND

Sclerosing hemangiomas of the liver are rare, benign tumors with degenerative changes. These degenerative changes, however, often obscure the true, benign nature of the tumor and give them features indistinguishable from other malignant processes, thus making the diagnosis difficult.

CASE PRESENTATION

A 70-year-old male without any previously diagnosed liver disease or malignant process presented with incidental right hepatic mass in ultrasonography and weight loss. Physical exam was unremarkable. The labs were significant for mild pancytopenia, elevated total bilirubin and slightly decreased transferrin. Follow-up triple phase-contrast CT scan of the abdomen revealed a lobulated, poorly demarcated lesion measuring 4.8 x 4.5 cm, located in segment V of the liver with encasement of the left portal branch. The overall picture was indeterminate but highly suspicious for malignancy. A decision was made to perform a CT-guided biopsy which revealed sclerosing hemangioma of the liver.

CONCLUSION

It is challenging to differentiate sclerosing hepatic hemangioma from atypical hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors utilizing only imaging modalities. The diagnostic workup should include biopsy of the atypical liver lesion which unveils the final diagnosis and avoid subjecting the patient to an extensive, and invasive surgical resection.

A hepatic sclerosed hemangioma with drastic changes in contrast-enhanced ultrasonography

Hepatic sclerosed hemangioma is a rare benign liver tumor that originated from hepatic cavernous hemangioma; however, the process of its formation has been unclear. We herein present the patient of a histologically proven hepatic sclerosed hemangioma that showed drastic changes in diagnostic images in a short period. A 56-year-old man was referred to our hospital for the treatment of suspicious hepatocellular carcinoma with hepatitis C, approximately 2 cm in diameter in liver segment 8. Initially, the tumor manifested as early entire enhancement with mildly delayed washout in contrast-enhanced ultrasonography; however, it manifested as continuous peripheral enhancement with the central non-enhanced area after 1 month in various diagnostic images. He completely quit drinking and smoking 1 month preoperatively. No special symptoms and signs were found to suggest tumor ischemia. Anatomical resection of segment 8 was completed. Histological examination confirmed the final diagnosis of common type hepatic sclerosed hemangioma, derived from atypically enhancing cavernous hemangioma. No signs of impaired blood flow were observed in both diagnostic images and histological examination. Sclerosing changes in hepatic cavernous hemangioma may be completed in a relatively short time with no apparent reason.

Benign Neoplasms, Mass-Like Infections, and Pseudotumors That Mimic Hepatic Malignancy at MRI

A variety of conditions may mimic hepatic malignancy at MRI. These include benign hepatic tumors and tumor-like entities such as focal nodular hyperplasia-like lesions, hepatocellular adenoma, hepatic infections, inflammatory pseudotumor, vascular entities, and in the cirrhotic liver, confluent fibrosis, and hypertrophic pseudomass. These conditions demonstrate MRI features that overlap with hepatic malignancy, and can be challenging for radiologists to diagnose accurately. In this review we discuss the MRI manifestations of various conditions that mimic hepatic malignancy, and highlight features that may allow distinction from malignancy. Level of Evidence 5 Technical Efficacy Stage 3.

Imaging and Management of Liver Cancer

Imaging of primary hepatic neoplasms in patients at risk for hepatocellular carcinoma (HCC) and in patients with otherwise normal livers relies on proper multiphase image acquisition technique, with emphasis on a high-quality, late arterial phase, using either CT or MRI for accurate image interpretation. The introduction of liver imaging reporting and data system in 2011, with subsequent multiple updates, the most recent in 2018, has provided standardization of image interpretation, reporting and management recommendations for liver observations in patients at risk for HCC. This review article will emphasize key points of imaging primary liver tumors with emphasis on liver imaging reporting and data system, including strengths of this system. We will also review imaging of less common primary liver tumors such as cholangiocarcinoma and angiosarcomas. Imaging pitfall associated with primary liver malignancies will be demonstrated as well as ways to mitigate them. Finally, imaging and reporting of findings following locoregional treatment of HCC will be reviewed.

A hepatic sclerosing hemangioma emerged in the postoperative course of multiple gastric carcinoid tumors masquerading as metachronous liver metastasis

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The authors present an unusual case of newly appearing hepatic sclerosing hemangioma newly emerged in the postoperative course after the resection of multiple gastric carcinoid tumors.

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Hepatic sclerosing hemangioma is often misdiagnosed as malignant lesion for its resemblance on the imaging studies.

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Although preoperative diagnosis is still difficult, hepatic sclerosing hemangioma must be included into the differential diagnosis of hepatic tumors.

Introduction

Hepatic sclerosing hemangiomas are rare tumors whose appearance on imaging is similar to that of malignant tumors. The resulting difficulties in preoperative diagnosis frequently lead to surgical resection in order to accurately identify the tumor.

Case presentation

A 68-year-old man was diagnosed with multiple gastric carcinoid tumors (T1N1M0, pStage IIIB) after total gastrectomy with D2 lymph node dissection. Enhanced computed tomography of the abdomen 2 years after the initial surgery revealed a novel solid lesion with ring enhancement measuring 22 × 15 mm at S5 of the liver. Metachronous liver metastasis from multiple gastric carcinoid tumors was suspected, and partial hepatectomy of S5 was successfully performed. Histopathological diagnosis was sclerosing hemangioma with no malignant findings.

Discussion

Ours is the first reported case of a newly appearing sclerosing hemangioma excised and diagnosed histopathologically. Hepatic sclerosing hemangiomas are rarely observed, but they are often resected under a preoperative diagnosis of malignant lesion due to the similarity on imaging studies.

Conclusion

Surgeons must consider that a hepatic tumor may be a sclerosing hemangioma, particularly when the lesion appears to be ring enhanced.

Hepatic Sclerosing Hemangioma with Predominance of the Sclerosed Area Mimicking a Biliary Cystadenocarcinoma

We report here an extremely rare case of hepatic sclerosing hemangioma mimicking a biliary cystadenocarcinoma. A previously healthy 39-year-old woman was referred to our hospital because of a large tumor in the liver. Abdominal computed tomography revealed early peripheral ring enhancement in the arterial phase and slight internal heterogeneous enhancement in the delayed phase. Magnetic resonance imaging revealed a tumor with low intensity in the T1-weighted image and very high intensity in the fat-saturated T2-weighted image. The patient underwent hepatectomy for a possible malignant liver tumor. Grossly, the tumor appeared as a white, solid, and cystic mass (weighted 1.1 kg and measured 170×100×80 mm) that was elastic, soft, and homogeneous with a yellowish area. Histological examination showed that the tumor mostly consisted of fibrotic areas with hyalinization. The typical histology of cavernous hemangioma was confirmed in part, and the tumor was diagnosed as a sclerosing hemangioma with predominancy of the sclerosed area. A review of 20 cases reported previously revealed that only 2 (10%) patients were diagnosed as having sclerosing hemangioma preoperatively.

Uncommon evolutions and complications of common benign liver lesions

Frequently encountered on abdominal imaging studies, the majority of common benign liver lesions are asymptomatic, confidently diagnosed by imaging, and do not require further workup, follow-up, or treatment. The increasing use of multimodality liver imaging, has allowed the recognition of uncommon evolutions of common benign liver lesions such as size changes, fibrotic regression, and content and vascularization changes, and their complications such as rupture, hemorrhage, thrombosis, extrinsic compression, and malignancy. The purpose of this pictorial review is to describe and illustrate the incidence and diagnostic features of these uncommon evolutions and complications on cross-sectional imaging, mainly on computed tomography and magnetic resonance imaging, with emphasis on those imaging clues which are helpful in the differential diagnosis or indicate the need for treatment.

Multiple hepatic sclerosing hemangiomas: a case report and review of the literature

Background

Hepatic sclerosing hemangioma, a very rare benign tumor, is characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. Such atypical hemangiomas can be diagnosed incorrectly as primary or metastatic malignancies based on imaging characteristics. We present herein a rare case of giant and multiple hepatic sclerosing hemangiomas that are difficult to differentiate from hepatic malignancies and review the relevant literature.

Case presentation

The patient was a 48-year-old male who was found to have multiple hepatic tumors and a giant tumor (67 × 53 mm) superior to the inferior vena cave by an abdominal ultrasonography during a routine medical examination. The patient was referred to our hospital for further evaluations and diagnosis of the multiple hepatic tumors. Dynamic CT showed low-density tumors in the delayed phase suggestive of membrane-covered lesions. EOB-MRI demonstrated a mass with low-signal intensity mass on T1-weighted images and areas of high-signal intensity on T2-weighted images and a hypointense mass in the hepatobiliary phase, which showed high intensity on DWI-based ADC map. FDG-PET showed no accumulation of [¹⁸F]-FDG. A provisional diagnosis of multiple scirrhous hepatocellular carcinomas was made on the basis of these imaging studies, and caudate lobectomy of the liver and partial hepatectomy of S2 and S6 were performed. Histopathological examination showed that the tumors were composed of various sized irregularly dilated vessels with some blood thrombi, inflammatory cell infiltration, fibrous and hyalinized sclerotic or myxomatous stroma, resulting in a diagnosis of multiple hepatic sclerosing hemangiomas.

Conclusions

Differentiation of multiple sclerosing hemangiomas from other hepatic malignant tumors, such as intrahepatic cholangiocarcinoma, metastatic liver cancer, and scirrhous hepatocellular carcinoma characterized by abundant fibrous stroma, is difficult because the radiological findings are very similar. Inclusion of hepatic sclerosing hemangioma in the differential diagnosis of multiple liver tumors could enable optimal management; this possibility is important to consider before planning invasive therapies.

Preoperative diagnosis of the sclerosed hemangioma of the liver using multimodality imaging findings: A case report

A sclerosed hemangioma of the liver is a rare benign lesion characterized by fibrosis and hyalinization of a hepatic cavernous hemangioma as a result of degeneration. This condition has been difficult to correctly diagnose with imaging. Our patient was a 57-year-old man whose computed tomography (CT) scan showed a mass of 45 mm in diameter in the lateral segment. On dynamic contrast-enhanced CT, the lesion was found to comprise peripheral, gradual, and heterogeneous enhanced areas with a central nonenhanced area; malignancy was suspected. On magnetic resonance imaging, the peripheral area showed slight hperintensity on T2-weighted image, and showed a similar intensity on T1- and diffusion-weighted images as compared to the background liver and gradual enhancement, and the presence of abundant fibrous tissue was suspected. Conversely, the central area showed remarkable hyperintensity on T2-weighted images and no enhancement, and degeneration or hyalinization was suspected. The mass showed no uptake of fluorine-18 fludeoxyglucose (FDG). Some imaging findings suspected a benign tumor, and sclerosed hemangioma with abundant fibrosis and hyalinization was pathologically confirmed. Herein, we report a case of sclerosed hemangioma focusing on possible preoperative diagnosis using a combination of multimodality imaging findings—diffusion-weighted imaging and FDG-positron emission tomography imaging.

cDNA Microarray Analysis and Influx Transporter OATP1B1 in Liver Cells After Exposure to Gadoxetate Disodium, a Gadolinium-based Contrast Agent in MRI Liver Imaging

BACKGROUND/AIM

Gadoxetate disodium (Primovist or Eovist) is extensively used as a hepatospecific contrast agent during magnetic resonance imaging (MRI) examinations. However, there is no information determining whether gadoxetate disodium has a cytotoxic impact and/or affects relative gene expression on liver cells. In the current study, we investigated the effects of gadoxetate disodium on cytotoxicity and the levels of gene expression in human normal Chang Liver cells.

MATERIALS AND METHODS

The cytotoxic effect was detected via methyl thiazolyl tetrazolium (MTT) assay and 4',6-diamidino-2-phenylindole (DAPI) staining. mRNA expression was monitored by cDNA microarray and quantitative PCR (qPCR) analysis. The protein levels were determined by western blotting.

RESULTS

Gadoxetate disodium at 5 and 10 mM failed to induce any cell cytotoxicity and morphological changes in Chang Liver cells. Our data demonstrated that gadoxetate disodium significantly enhanced the expression of 29 genes and suppressed that of 27. The SLCO1C1 (solute carrier organic anion transporter family member 1C1) mRNA expression was also increased by 2.62-fold (p-value=0.0006) in gadoxetate disodium-treated cells. Furthermore, we also checked and found that gadoxetate disodium up-regulated organic anion transporter polypeptide 1B1 (OATP1B1) protein level and increased OATP uptake transporter gene SLCO1C1 mRNA expression.

CONCLUSION

Our results provide evidence regarding that gadoxetate disodium might be no cytotoxic effects on liver cells.

Hepatic sclerosed hemangioma with special attention to diffusion-weighted magnetic resonance imaging

BACKGROUND

A hepatic sclerosed hemangioma (HSH) is a very rare benign liver tumor. The correct preoperative diagnosis of HSH is very difficult because its features of imaging are similar to those of intrahepatic cholangiocarcinoma or colorectal liver metastasis.

CASE PRESENTATION

We experienced five patients who were diagnosed histologically with HSH. The preoperative diagnoses were HSH in two patients, cavernous hemangioma in one, intrahepatic cholangiocarcinoma in one, and colorectal liver metastasis in one. All patients were treated with hepatectomy (one laparoscopic and four laparotomies), and the diagnosis was completed by histological investigation of the resected specimen. In particular, we investigated the apparent diffusion coefficient (ADC) mean value using diffusion-weighted sequences of magnetic resonance imaging (DW-MRI). The average of the ADC mean (ADC_mean) value of HSH was 1.94 × 10^-3 mm²/s (range 1.73-2.10 × 10^-3 mm²/s), which was higher than the value of common malignant liver tumors. Interestingly, the ADC_mean values were almost the same between the degenerate (1.90 ± 0.17 × 10^-3 mm²/s) and the non-degenerate areas (1.95 ± 0.26 × 10^-3 mm²/s) in HSH.

CONCLUSIONS

The ADC_mean value seemed to be quite useful to preoperatively distinguish HSH from other malignant liver tumors.

Primary benign liver lesions

Benign focal liver lesions can origin from all kind of liver cells: hepatocytes, mesenchymal and cholangiocellular line. Their features at imaging may sometimes pose difficulties in differential diagnosis with malignant primary and secondary lesions. In particular, the use of MDCT and MRI with extracellular and hepatobiliary Contrast Agents may non invasively help in correct interpretation and definition of hepatocellular or mesenchymal and inflammatory nature, allowing to choose the best treatment option. The peculiarities of main benign liver lesions at US, CT and MRI are described, with special attention to differential diagnosis and diagnostic clues.

Peritumoral Hyperplasia in Hepatic Sclerosed Hemangioma

Peritumoral hyperplasia (PTH) is a hyperplastic lesion located around hypervascular tumors. Hepatic sclerosed hemangioma is a very rare form of hemangioma with sclerotic changes and is distinct from sclerosing hemangioma. We present a patient with non-alcoholic steatohepatitis-induced cirrhosis who presented with a hypervascular tumor. The tumor showed atypical findings of hemangioma and was treated with surgical resection because hepatic malignancy could not be ruled out. Histopathologic examination revealed the tumor was a sclerosed hemangioma with PTH. Lesions with carcinogenic potential were found in the PTH lesion. Sclerosed hemangioma should be observed and managed carefully.