Giant hepatic hemangioma

Case contributed by Matt A. Morgan

Presentation

Right upper quadrant pain. No history of hepatitis. Abnormal finding on ultrasound at another institution.

Patient Data

Age: 55 years
Gender: Female

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

mri

There is a relatively well-marginated mass in the right lobe of the liver measuring 11.3 x 6.9 x 14.3 cm.

  • majority of the lesion is moderately T2 hyperintense, with central irregular regions that are even more T2 hyperintense
  • T1 hypointense
  • no loss of signal on the out-of-phase sequence
  • no ascites or perihepatic fluid
  • no evidence of cirrhosis or portal hypertension
  • displays mass effect on adjacent vessels
mri

Dynamic sequence with 8 mL of Gadavist.

  • peripheral nodular discontinuous enhancement
  • progressive filling in on the later phases

Case Discussion

Giant hepatic hemangiomas (or "giant hepatic slow flow venous malformations") were defined to be hemangiomas >4 cm 3. Although they can develop a heterogeneous appearance with a central "scar", their enhancement pattern (peripheral nodular discontinuous enhancement on CT or MRI) leaves little doubt what the diagnosis is.

Management of these lesions is not always as straightforward as diagnosis, however. The opinion put forth by some suggests following these lesions with imaging if they are asymptomatic, even despite a small risk of catastrophic rupture. There is no standard follow-up protocol, and some suggest less rather than more imaging follow-up.

Absolute surgical indications for treatment of a hepatic hemangioma are rupture with hemoperitoneum, intratumoral hemorrhage, rapid growth, or consumption coagulopathy (Kasabach-Merritt syndrome). Depending on its location, persistent abdominal pain, obstructive jaundice, or portal hypertension may result, and "large" hemangiomas (>5 cm?) may be at risk for hemorrhage with trauma. These represent relative surgical indications.

In one meta-analysis, 16/19 haemorhaged hemangiomas (84.2%) were giant hemangiomas with a mean diameter of 14.8 cm (range 6–25 cm) 4, so size appears to be correlated with risk of bleeding.

Another controversy is which surgical approach should be undertaken. When surgery is indicated, enucleation with temporary inflow occlusion (Pringle maneuver) is recommended b some as the treatment of choice, with fewer postoperative complications and less blood loss when compared with anatomic resection. The presence of a pseudocapsule created by the compression of the surrounding parenchyma allows this "shelling out" of the hemangioma 5. Some surgeons, however, recommend anatomic resection, especially for left lobe giant hemangiomas 6.

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