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

Benign and malignant focal liver lesions displaying rim arterial phase hyperenhancement on CT and MRI

Rim arterial phase hyperenhancement is an imaging feature commonly encountered on contrast-enhanced CT and MRI in focal liver lesions. Rim arterial phase hyperenhancement is a subtype of arterial phase hyperenhancement mainly present at the periphery of lesions on the arterial phase. It is caused by a relative arterialization of the periphery compared with the center of the lesion and needs to be differentiated from other patterns of peripheral enhancement, including the peripheral discontinuous nodular enhancement and the corona enhancement. Rim arterial phase hyperenhancement may be a typical or an atypical imaging presentation of many benign and malignant focal liver lesions, challenging the radiologists during imaging interpretation. Benign focal liver lesions that may show rim arterial phase hyperenhancement may have a vascular, infectious, or inflammatory origin. Malignant focal liver lesions displaying rim arterial phase hyperenhancement may have a vascular, hepatocellular, biliary, lymphoid, or secondary origin. The differences in imaging characteristics on contrast-enhanced CT may be subtle, and a multiparametric approach on MRI may be helpful to narrow the list of differentials. This article aims to review the broad spectrum of focal liver lesions that may show rim arterial phase hyperenhancement, using an approach based on the benign and malignant nature of lesions and their histologic origin. CRITICAL RELEVANCE STATEMENT: Rim arterial phase hyperenhancement may be an imaging feature encountered in benign and malignant focal liver lesions and the diagnostic algorithm approach provided in this educational review may guide toward the final diagnosis. KEY POINTS: Several focal liver lesions may demonstrate rim arterial phase hyperenhancement. Rim arterial phase hyperenhancement may occur in vascular, inflammatory, and neoplastic lesions. Rim arterial phase hyperenhancement may challenge radiologists during image interpretation.

Case report: Sclerosed hemangioma of the liver: A diagnostic challenge

Hemangiomas are the most common noncystic benign hepatic tumors and are usually incidentally discovered during routine radiological examinations. The diagnosis of hepatic hemangiomas with a typical presentation is generally easy with plain and cross-sectional imaging; however, it can be complicated when hemangiomas undergo histological changes such as fibrosis. Sclerosed hepatic hemangioma (SHH) is the extreme presentation of this fibrotic process. These atypical lesions can be misdiagnosed as primary hepatic malignancies or metastasis. Their diagnosis is established by histological examination. We report the case of a patient with an SHH, which was misdiagnosed as an intrahepatic cholangiocarcinoma. This article's aim is to draw attention to this infrequent pathology and underline the features of this benign tumor that could suggest its diagnosis prior to surgery to avoid unnecessary hepatic resections.

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.

When Benign Behaves Badly: Atypical Hemangiomas on Contrast-Enhanced Ultrasonography

ABSTRACT

Hemangioma is the most common benign liver tumor and is frequently encountered as an incidental finding on imaging. The classic enhancement pattern of hemangioma is diagnostic on contrast-enhanced ultrasound (CEUS), and it follows the same pattern of enhancement on computed tomography and magnetic resonance imaging. However, there is a subset of hemangiomas that demonstrate atypical enhancement patterns on CEUS. The ability to recognize the different enhancement patterns and discern when additional imaging or biopsy may be necessary is essential to accurately interpret an atypical hemangioma on CEUS. This article reviews various enhancement patterns of hemangioma on CEUS to avoid pitfalls in characterization of focal liver lesions on CEUS.

Hepatic sclerosing haemangioma showing restricted diffusion: A case report with histopathologic correlation

Hepatic sclerosing haemangiomas are rare benign tumours that are often difficult to distinguish from malignant tumours because these tumours do not show the typical imaging features of cavernous haemangiomas. We report a case of a sclerosing haemangioma that showed restricted diffusion and was difficult to differentiate from a malignancy.

A 60-year-old female was referred to our hospital for evaluation of a hepatic mass that was incidentally diagnosed after a CT scan for right lower quadrant abdominal pain.

Contrast-enhanced dynamic CT showed hepatic capsular retraction, with a small peripheral enhancement of the mass. The lesion appeared homogeneously hypointense on T1-weighted images, heterogeneously hyperintense on T2-weighted images, hyperintense on diffusion-weighted images, and hypointense on apparent diffusion coefficient (ADC) map. The lesion was suspected to be a cholangiocellular carcinoma and was surgically resected, but a final diagnosis of hepatic sclerosing haemangioma was made.

Hepatic sclerosing/sclerosed haemangiomas are usually considered to show an increased ADC, which is useful for distinguishing them from malignant tumours. However, in this particular case, most of the lesion contained many obliterated or narrowed vascular channels, which might have acted as septa restricting the diffusion of water molecules in the intervening fibrous and/or hyalinized tissue. Hepatic sclerosing haemangiomas in the process of becoming completely fibrotic may show restricted diffusion, similar to malignant tumours.

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.

Gadoxetic acid-enhanced MRI for differentiating hepatic sclerosing hemangioma from malignant tumor

BACKGROUND

To investigate the imaging features of gadoxetic acid-enhanced magnetic resonance imaging (MRI) to differentiate hepatic sclerosing hemangioma from malignant tumors.

METHODS

This retrospective case-control study included 18 patients with sclerosing hemangioma and 54 patients with common hepatic malignant tumor, including hepatocellular carcinoma, metastatic adenocarcinoma, and cholangiocarcinoma, who were examined using gadoxetic acid-enhanced liver MRI from January 2008 to June 2019. Imaging features including signal intensity, tumor margins, enhancement pattern, and presence or absence of diffusion restriction were analyzed. Significant MRI features for predicting sclerosing hemangioma were identified using multivariable logistic regression analysis. Diagnostic performances of each imaging feature and combinations of significant imaging features were summarized.

RESULTS

In the multivariable analysis, irregular margins (odds ratio [OR], 10.12; 95 % confidence interval [CI], 1.27-80.94; p = 0.029), centripetal or internal nodular enhancement in the transitional phase (OR, 13.58; 95 % CI, 1.48-124.82; p = 0.021), and absence of diffusion restriction (OR, 39.20; 95 % CI, 4.82-318.49; p = 0.001) were significant imaging features for the diagnosis of sclerosing hemangioma. Presence of at least two significant imaging features had a sensitivity, specificity, and accuracy of 88.9 %, 96.3 %, and 94.4 %, respectively, for diagnosing sclerosing hemangioma.

CONCLUSION

Combinations of two or more of the significant imaging features (irregular margins, centripetal or internal nodular enhancement in the transitional phase, and absence of diffusion restriction) were effective for differentiating hepatic sclerosing hemangioma from malignant tumors using gadoxetic acid-enhanced MRI.

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.

Hepatic sclerosing hemangioma mimics hepatic malignancies: a case report and multidisciplinary approach

Background

Hepatic sclerosing hemangiomas (HSH) are rare benign vascular tumors that mimic radiologically hepatic malignancies. HSH is characterized by extensive fibrosis and hyalinosis as a result of degeneration and thrombosis. Pre-operative diagnosis is very difficult and most of the cases undergo surgical resections.

Case presentation

A 65 years old, hepatitis C virus-infected female presented by an accidentally discovered hepatic focal lesion. Magnetic resonance imaging (MRI) showed a T2 hyperintense mass displaying peripheral enhancement in porto-venous phase. The patient had a simultaneous typical hepatic hemangioma and multiple vertebral bodies’ hemangiomata. Tissue-guided biopsy revealed a densely sclerotic stroma containing vascular spaces with occasional obliteration of the lumen. Immunohistochemical staining was performed for Pan CK, CD34, SMA, VEGF, and c-Kit which confirmed the vascular nature of neoplasm and the involuting phase of hemangioma development. The patient was reassured and recommended for a regular radiological follow-up to reassess the lesion size.

Conclusion

The definitive preoperative diagnosis of HSH is still problematic. However, the awareness of surgeons by this entity, peripheral enhancement in porto-venous phase on dynamic MRI, the presence of simultaneous typical hepatic hemangioma in the absence of cancer history could raise suspicion for HSH. Liver biopsy is still the gold standard in approaching the accurate diagnosis.

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.