Hepatic hemangioma is the most common benign tumor of the liver, with an incidence of 0.5% to 0.7% in the normal population, accounting for 84% of benign liver tumors. It can occur at any age, but is more common in women aged 30-70. The histological classification is sclerosing hemangioma, hemangioendothelioma, capillary hemangioma and cavernous hemangioma, with cavernous hemangioma being the most common. The growth rate is slow, and malignant changes rarely occur.
I. Clinical manifestations
1. Medical history: Most of them are found accidentally during clinical imaging examination and grow slowly. It may be related to multiple pregnancy and contraceptive drugs.
2, symptoms: often no conscious symptoms, >4cm may have epigastric distension or hidden pain, or a feeling of fullness, nausea, vomiting, etc.
3.Signs: epigastric pressure and tenderness or hepatic snapping pain, epigastric mass may be palpable in giant hemangioma, etc.
4.Kasabach-Merritt syndrome: coagulation factor depletion, thrombocytopenia and fibrin decline syndrome in giant hepatic hemangioma.
5.Rupture of hemangioma: often spontaneous or after trauma, manifested as intra-abdominal hemorrhage, which cannot stop by itself.
Second, auxiliary examination
1.Laboratory examination: no special, giant hemangioma may show thrombocytopenia and fibrinogen decline.
2.Imaging examination.
(1) Ultrasound examination: the accuracy rate is more than 80%, and it can detect hemangioma of more than 2cm, which appears as a hyperechoic area with uniform texture and clear boundary, and may be lobulated; if there is necrosis or thrombosis or calcification, it appears as echogenic unevenness or hypoechoic area.
(2) CT examination: the correct diagnosis rate is more than 90%, which shows a round or round-like hypoechoic shadow on plain scan; on enhanced scan, the peripheral edge of the artery is highly enhanced rapidly in the early stage, and the enhancement speed to the central area is slow, showing a typical “fast-in, slow-out” performance, which is in contrast to the “fast-in, fast-out” of primary liver cancer. This is in contrast to the “fast-in, fast-out” of primary hepatocellular carcinoma; the delayed stage becomes isointense.
(3) MRI: MRI has special diagnostic significance for this disease, which shows T1 low signal and T2WI characteristic “light bulb sign”-like high signal. The sensitivity is 1O0% for those with a diameter of 0.5cm or more, and the confirmation rate is 95%.
(4) Isotope 99mTc-RBC liver blood pool scan: It has high specificity and sensitivity, and is the best method to diagnose this disease. It can show the characteristic hemangioma image with significantly higher radioactivity than the surrounding liver tissue.
(5) Hepatic angiography: Hepatic arteriography is one of the most reliable diagnostic methods for hepatic hemangioma, which is characterized by the characteristic “early exit and late return” sign, i.e., the contrast agent enters the hepatic vessels rapidly and shows a very dense staining, such as “cotton ball” or “popcorn”. The “popcorn” or “fruit on the tree” sign is characteristic and lasts for a long time.
Third, the principle of treatment
Hemangioma grows slowly and rarely becomes malignant, so most of them do not need treatment and can be observed by regular follow-up, but in some cases, they must be actively treated.
1.Surgical treatment: It is the most thorough treatment method for hepatic hemangioma.
The indications for surgery include
(1) Large hepatic hemangioma (>5cm) with clear clinical symptoms; or >10cm.
(2) Hemangioma rupture and bleeding.
(3) Unclear diagnosis, and malignant lesions cannot be excluded.
(4) Excessive growth rate (>2cm/year).
(5) Kasabach-Merritt syndrome is present.
(6) Special location (near the 1st and 2nd hepatic hilum), which increases the risk of surgery for continued growth.
Surgical options available.
(1) Hepatectomy: irregular hepatectomy is mostly advocated, and regular hepatic lobectomy and segmental resection can also be chosen according to the location and size of the tumor.
(2) Hepatic hemangioma resection: High-pressure waterjet and ultrasonic knife (CUSA) can be used to separate, which reduces the scope of liver tissue resection and bleeding.
(3) Hemangioma ligation: easy to operate, little damage, good recent efficacy, but high recurrence rate (40%), rarely used alone.
(4) Hepatic artery ligation: it can temporarily reduce the size of the tumor, but it is difficult to maintain.
(5) In the past 2 years, we have performed more than 10 cases of laparoscopic hepatic hemangioma dissection, with good results, little intraoperative damage, little bleeding, maximum preservation of normal liver parenchyma, little damage to liver function, fast recovery, and discharge from hospital 3-5 days after surgery.
2.Non-surgical treatment.
Methods are.
(1) selective and super-selective hepatic artery cannulation (Sildinger’s cannulation method) imaging and sclerosis, embolization: with the advantages of small trauma, easy operation, small risk, etc., the efficacy is indeed the best choice in addition to surgery. It is suitable for cases that need treatment but have contraindications to surgery, fear of surgery and diffuse lesions that cannot be surgically removed. At present, the commonly used embolic agents and sclerosing agents include iodized oil, sodium cod liver oil acid, anhydrous ethanol, pinyamycin, gelatin microspheres, TH gum, etc.
(2) Percutaneous puncture intra-tumor sclerosing agent injection method: the puncture is accurately positioned by ultrasound and CT, and the appropriate amount of sclerosing agent (sodium cod liver oil, anhydrous ethanol, pinyamycin, bleomycin) is injected, which is suitable for smaller hemangiomas and for those who fail to be cannulated by Sildinger’s method.
(3) Percutaneous puncture “thermal destruction” treatment: Under the guidance of B-ultrasound or CT, accurate percutaneous puncture and implantation of destruction needles can be used for destruction treatment. At present, the most commonly used thermal destruction devices are radiofrequency, laser and microwave therapy instruments.
(4) Conformal radiotherapy: using three-dimensional positioning and computer imaging technology, using three-dimensional conformal radiotherapy is the new direction of tumor radiotherapy, and the recent reports are gradually increasing, and the long-term efficacy needs further observation.
(5) Other methods: electrochemical therapy, cryotherapy, Chinese herbal medicine, etc. can also be used.
IV. Regression and prognosis
Most hemangiomas do not require special treatment, and regular (3-6 months) ultrasound follow-up can be observed. Only about 30% of hepatic hemangiomas need treatment. Surgery is the first choice for radical treatment, but it has a certain mortality rate (<5%) and recurrence rate (10-40%); Sildinger's cannulation method of hepatic artery embolization and sclerotherapy is another effective treatment method with the advantages of less trauma, fewer complications, simple operation and easy acceptance, etc. It is reported that The rate of tumor disappearance at 1 year after treatment is 56%, and the recurrence rate can be as low as 10%.