Colour Doppler sonography of hepatic haemangiomas with arterioportal shunts

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.

Incidental Liver Findings on Cross-sectional Imaging

Hepatic incidental findings often are seen on cross-sectional imaging examinations of the chest, spine, pelvis, or other nondedicated hepatic imaging. Radiologists are tasked with appropriately triaging, which requires further evaluation, even in the setting of an otherwise limited evaluation. This article reviews common benign entities encountered on ultrasound, computed tomography, or magnetic resonance imaging, along with their characteristic imaging features. Imaging features that are suspicious for malignancy or suggest the need for further evaluation also are discussed. Two algorithms are proposed to guide radiologists in their recommendations based on patient risk factors, focal hepatic abnormality size, and available imaging features.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach-Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.

RESULTS

Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach-Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.

CONCLUSION

The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.

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.

Hepatic hemangioma: What internists need to know

Hepatic hemangioma (HH) is the most common benign liver tumor and it is usually found incidentally during radiological studies. This tumor arises from a vascular malformation; however, the pathophysiology has not been clearly elucidated. Symptoms usually correlate with the size and location of the tumor. Less commonly the presence of a large HH may cause life-threatening conditions. The diagnosis can be established by the identification of HH hallmarks in several imaging studies. In patients that present with abdominal symptoms other etiologies should be excluded first before attributing HH as the cause. In asymptomatic patient’s treatment is not required and follow up is usually reserved for HH of more than 5 cm. Symptomatic patients can be managed surgically or with other non-surgical modalities such as transcatheter arterial embolization or radiofrequency ablation. Enucleation surgery has shown to have fewer complications as compared to hepatectomy or other surgical techniques. Progression of the tumor is seen in less than 40%. Hormone stimulation may play a role in HH growth; however, there are no contraindications for hormonal therapy in patients with HH due to the lack of concrete evidence. When clinicians encounter this condition, they should discern between observation and surgical or non-surgical management based on the clinical presentation.

Hepatic hemangioma with arterioportal shunt: Prevalence and lesion characteristics based on DSA, CT and MR imaging

PURPOSE

To evaluate the prevalence and lesion characteristics of hepatic hemangioma (HH) with arterioportal shunt (APS) based on digital subtraction angiography (DSA), computed tomography (CT) and magnetic resonance (MR) imaging.

METHOD

Ninety-eight consecutive patients with 189 HHs who underwent DSA, CT and/or MR imaging of the liver between January 2014 and December 2017 were included. The diagnosis of APS was established by DSA. APS was categorized as peripheral and central shunt based on imaging findings. The incidence and appearance of APS on DSA were compared with those on CT/MR images. Eleven possible lesion characteristics associated with APS were compared between HHs with and those without APS. Multiple logistic regression modeling was used to identify the independent lesion characteristics associated with APS.

RESULTS

APS was diagnosed in 103 (103/189, 54.5%) HHs on DSA, of which 96 lesions appeared as peripheral APS and 7 appeared as central. In contrast, APS was detected only in 57 HHs (57/103, 55.34%) on CT/MR imaging, of which 50 (50/96, 52.08%) appeared as peripheral APS while 7 (7/7, 100%) appeared as central. Lesion size (P <  .001), enhancement rapidity (P =  .031), and vascularization degree (P <  .001) were found to be significant independent imaging characteristics associated with APS.

CONCLUSIONS

APS can occur in HH with high frequency. DSA was superior to CT/MR imaging in detection of APS, particularly for the peripheral APS. Lesion size, enhancement rapidity and vascularization degree were associated with the presence of APS.

Interventional Treatment for Giant Hepatic Hemangioma Accompanied by Arterio-portal Shunt with Ascites

A 73-year-old woman with massive ascites associated with a giant hepatic mass accompanied by arterio-portal (AP) shunt was admitted to our hospital. Based on contrast-enhanced computed tomography (CT) and angiography findings, hepatic hemangioma with AP shunt and ascites due to portal hypertension was diagnosed. Transcatheter arterial embolization (TAE) by N-butyl-2-cyanoacrylate (NBCA) was performed without complications. The patient's ascites disappeared, and her liver function test results improved after the treatment. The patient has maintained a steady state for two years. This case indicates that TAE with NBCA is a safe and effective treatment for hepatic hemangioma accompanied by AP shunt.

Superb microvascular imaging technology for ultrasound examinations: Initial experiences for hepatic tumors

PURPOSE

To explore whether superb microvascular imaging (SMI) technology could be helpful for the evaluation of hepatic tumors.

MATERIALS AND METHODS

Our institutional review board approved this study, and informed consent was obtained from all of the patients. Twenty-three patients with 29 hepatic tumors were enrolled in our study. The tumors consisted of hemangiomas (n=15), focal nodular hyperplasias (FNHs) (n=7), and hepatocellular carcinomas (n=7). All lesions were pathologically (n=2) or radiologically (n=27) confirmed. The mean tumor diameter was 1.9cm (range, 0.9cm to 5.0cm). Using SMI technology, all lesions were scanned and categorized into subgroups according to the flow pattern on the SMI.

RESULTS

The hemangiomas exhibited nodular rim patterns (33%) and spotty dot-like patterns (20%), and both of these findings were very specific for the diagnosis of hemangioma. The FNHs exhibited spoke-wheel patterns (43%) and radiating vessel patterns (29%) that were very specific findings for the diagnosis of FNH. The other tumors did not exhibit any specific patterns on SMI.

CONCLUSION

Evaluations of the inner vascularities of hepatic tumors with the SMI technique were feasible, and the SMI features were significantly different between the different types of hepatic tumors. These differences could aid the diagnoses of hepatic tumors with US.

Focal liver lesions found incidentally

Incidentally found focal liver lesions are a common finding and a reason for referral to hepatobiliary service. They are often discovered in patients with history of liver cirrhosis, colorectal cancer, incidentally during work up for abdominal pain or in a trauma setting. Specific points should considered during history taking such as risk factors of liver cirrhosis; hepatitis, alcohol consumption, substance exposure or use of oral contraceptive pills and metabolic syndromes. Full blood count, liver function test and tumor markers can act as a guide to minimize the differential diagnosis and to categorize the degree of liver disease. Imaging should start with B-mode ultrasound. If available, contrast enhanced ultrasound is a feasible, safe, cost effective option and increases the ability to reach a diagnosis. Contrast enhanced computed tomography should be considered next. It is more accurate in diagnosis and better to study anatomy for possible operation. Contrast enhanced magnetic resonance is the gold standard with the highest sensitivity. If doubt still remains, the options are biopsy or surgical excision.

Quality of life can be improved by surgical management of giant hepatic haemangioma with enucleation as the preferred option

OBJECTIVES

Surgical resection represents the main curative treatment for giant hepatic haemangioma (GHH). The aim of this study was to compare the respective outcomes of hepatic enucleation (HE) and hepatic resection (HR) for GHH.

METHODS

Giant hepatic haemangioma was defined as haemangioma of 5-15 cm in size. A prospectively maintained database consisting of a series of consecutive patients who underwent HE or HR of GHH from January 2004 to December 2013 was analysed.

RESULTS

Hepatic enucleation was performed in 386 (52.9%) patients and HR in 344 (47.1%) of a final cohort of 730 patients. The median size of GHH was similar in the HR and HE groups (9.8 and 10.6 cm, respectively; P = 0.752). The HE group had a shorter median operative time (150 min versus 240 min; P = 0.034), shorter median hospital stay (5.7 days versus 8.6 days; P < 0.001), lower median blood loss (400 ml versus 860 ml; P < 0.001), and fewer complications (17.6% versus 28.2%; P < 0.001) than the HR group. Quality of life scores in both the HR and HE groups significantly improved compared with preoperative levels and were similar to those found in healthy Chinese individuals following surgery, confirming the efficacy of both treatments.

CONCLUSIONS

Hepatic enucleation was associated with favourable operative outcomes compared with HR and is a safe and effective alternative to partial hepatectomy for GHH.

Biliary collateral veins and associated biliary abnormalities of portal hypertensive biliopathy in patients with cavernous transformation of portal vein

PURPOSE

The purpose was to investigate magnetic resonance imaging (MRI) features of biliary collateral veins and associated biliary abnormalities of portal hypertensive biliopathy (PHB).

MATERIALS AND METHODS

Thirty-six patients including 18 patients with abnormal biliary changes and 18 patients as control group were involved in this study. MRI features of biliary collateral veins were analyzed.

RESULTS

Stenosis with dilated proximal bile ducts occurred in 33.3% of patients, 27.8% of patients had irregular ductal walls, 22.2% of patients had thickened ductal walls, 16.7% of patients had angulated ductal walls, and 44.4% of patients had thickened gallbladder walls.

CONCLUSIONS

Biliary collateral veins and associated biliary abnormalities of PHB can be detected by MRI.

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

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

Clinical impact of ultrasound-related techniques on the diagnosis of focal liver lesions

Since its introduction in clinical practice, ultrasound technology has greatly impacted patient management, particularly in the case of liver diseases, where hepatologists usually perform ultrasound examinations. Clinicians are increasingly aware of the great potential of ultrasound waves and of the recent innovations that exploit the mechanical properties of ultrasound waves. Thus, at present, not only B-mode ultrasound but also contrast-enhanced ultrasound and, more recently, elastosonography are used worldwide in various settings. This review aims to describe why clinicians should be aware of ultrasound-based techniques, how they should use these techniques for assessing focal liver lesions, and how these techniques impact patient management. We will review the clinical potential of ultrasound-related techniques, starting from lesion detection, moving to characterization, and concluding with their utility in guiding treatments and analyzing their effects.