Most hepatic hemangiomas are cavernous hemangiomas, a common benign tumor of the liver, which can occur at any age, but often appear in adults with symptoms, more in women. If the tumor is enlarged, or located under the liver envelope, it may lead to hemorrhage and life threatening.
The tumor can be found in any part of the liver, often located under the pericardium, and is mostly solitary (about 1% are multiple), with a diameter of less than cm, but can be as small as a few mm, or as large as cm, with a dark red or purple surface and a spongy surface. Microscopically, hemangioma is a network of empty spaces lined with flattened endothelial cells of different sizes, containing red blood cells and sometimes freshly mechanized thrombi.
Etiology of hepatic hemangiomas.
Hepatic hemangioma is the most common benign tumor in the liver, accounting for, % of benign hepatic tumors, common in elderly women, mostly spongy hemangioma, rarely capillary hemangioma and hemangioendothelioma, common in multiple pregnancies and oral contraceptive pills, lesions can be single or multiple, mostly seen in the posterior segment of the right lobe of liver
The tumor is clearly demarcated from the surrounding liver tissue and consists of blood-filled vascular cystic cavities with fibrous intervals and cystic walls lined with flattened endothelial cells.
Clinical manifestations of hepatic hemangioma.
Smaller lesions are asymptomatic and can be detected by ultrasound during physical examination. Larger lesions can cause epigastric discomfort or palpable masses, and giant hemangiomas can significantly enlarge the liver and obtain clinical performance. Repeated thrombosis causes tumor swelling, causing glisson′s envelope pulling and swelling pain, the masses vary in softness and hardness, with different degrees of compressibility, a few are hard and nodular, the masses rarely rupture spontaneously, liver function is generally normal, the rare syndrome of large hemangioma is consumption coagulation disorder, thrombocytopenia and hypofibrinemia.
Ancillary tests for hepatic hemangioma.
Ultrasound findings.
The lesion may show a homogeneous, strongly echogenic lesion with mostly well-defined borders, or strong echogenicity with irregular hypoechogenicity within the lesion, and dilated blood sinuses within the lesion
CT manifestations.
(1) Plain scan: hypodense areas in the liver with clear contours and homogeneous density or more hypodense areas within the lesion, representing thrombotic mechanization or fibrous segregation, and a few calcifications may be seen.
(2) Enhanced scan.
(1) Early lesion edges are significantly enhanced in a nodular or “island-like” fashion, with density similar to that of the adjacent abdominal aorta and significantly higher than that of the surrounding liver parenchyma, lasting for more than, minutes.
②As time lengthens, the amplitude of enhancement pushes closer to the center of the lesion, while the hypodense area of the lesion becomes relatively smaller.
③Delayed scan lesion is isointense or slightly dense (no change in lower density within the lesion on flat scan).
Enhancement scan is an important method to diagnose hepatic cavernous hemangioma with characteristic performance, and the correct diagnosis rate can be above, %. Generally, the typical performance appears in the early arterial phase, i.e., ~, seconds after injection, so the correct examination technique is emphasized, i.e., rapid, mass injection of contrast agent, rapid scan, and timely delayed scan, otherwise, misdiagnosis or omission is easily caused by not seeing characteristic performance.
Isotope, mCT hepatic blood pool scan and hepatic angiography can help in the close diagnosis of hepatic hemangioma, which shows no tumor staining, clear sharp margins, and long hemangioma development time.
MRI: T, the image shows low signal intensity, T2 relaxation time is prolonged and shows high signal intensity tissue.
Differential diagnosis of hepatic hemangioma.
The main tissues of spongiform hemangioma are distinguished from malignant tumors in the liver.
Hepatocellular carcinoma: usually with a history of hepatitis, hepatic sclerosis, AFP may be positive, and venous enhancement scan helps to differentiate.
Hepatic metastases: Some intrahepatic metastases may show marginal enhancement on enhancement scans, similar to the early manifestations of hemangioma, but hypointense on delayed scans may help to differentiate.
Hepatic abscesses: Generally, the boundary around the lesion is unclear and blurred, and a low-density halo is seen around the abscess, typically with peri-lesion enhancement and the presence of gas within the lesion.
The need for surgery depends on the growth rate and clinical symptoms of the tumor, not on the absolute size of the tumor. Most patients who have been diagnosed without symptoms can be reviewed regularly on an outpatient basis without special treatment. There are many treatment methods for hepatic hemangioma, including surgery, interventional therapy, sclerotherapy and laparoscopic hemangioma resection, etc. Although the surgical program has certain risks, it is the most direct and thorough means to treat the underlying hepatic hemangioma. For symptomatic giant hepatic hemangioma that cannot be surgically removed, in situ liver transplantation can also be considered. Currently, for drug treatment of hepatic hemangioma, the efficacy is poor.