CHL is the most common benign tumor of the liver and accounts for the majority of benign tumors of the liver. With the popularization of ultrasound, CT, MRI and other diagnostic imaging devices in hospitals at all levels, these cases are becoming common. Because it belongs to the category of liver tumors, it is often easily confused with liver cancer, and patients are very anxious for treatment of CHL.
Most patients with CHL have no conscious symptoms, and those <3 cm are detected by ultrasound, CT, MRI and other imaging examinations; those >5 cm have symptoms such as discomfort in the liver area, loss of appetite and indigestion due to the size of the tumor. CHL rupture bleeding, accompanied by severe pain, is very similar to hepatocellular carcinoma rupture bleeding, which may lead to misdiagnosis. The differential diagnosis between clinical CHL and primary liver cancer is not difficult, and because of the risk of bleeding, liver biopsy is contraindicated in CHL located on the surface of the liver, therefore, liver ultrasonography, enhanced CT, and MRI are indispensable methods to diagnose hepatic cavernous hemangioma.
The clinical management of hepatic hemangioma often depends on the size, location, growth rate and the degree of clinical progression of CHL. Patients with CHL with tumors <3 cm and no conscious symptoms can be treated without any treatment, but the following situations must be treated.
1, CHL qualitative diagnosis is unclear or suspicious of malignant change;
2.CHL with rapid increase in size within a short period of time;
3, CHL > 3 cm in diameter, especially if it protrudes from the surface of the liver and is prone to ulceration and bleeding;
4.Patients with symptoms of compression of adjacent organs;
5.CHL > 5 cm in diameter should be considered for treatment regardless of the presence or absence of symptoms, location, or progressive enlargement;
6, CHL has been ruptured within the tumor necrosis bleeding, sudden increase in volume with severe pain;
7, CHL with progressive anemia or coagulation changes, or heart failure caused by arteriovenous fistula;
8.Childhood CHL.
For the treatment of CHL, in addition to the traditional surgical resection, there are also various imaging interventions such as hepatic artery embolization, local ablation and local sclerosis.
I. Hepatic artery embolization is the classic method of vascular intervention for CHL
After the right femoral artery is successfully punctured by Seldinger technique under X-ray fluoroscopy, the catheter is inserted into the blood supplying artery of the lesion, and the appropriate amount of embolic agent is injected to block the tumor blood vessels and cause ischemic necrosis of the tumor, thus achieving the treatment purpose. The commonly used embolic agents include iodized oil, sodium cod liver oil, anhydrous ethanol, pinyamycin, gelatin sponge, urea, cyanoacrylate tip adhesive (TH glue), silk particles and stainless steel ring, as well as new sclerosing agent polyglactin.
However, the efficacy of single embolization is not long-lasting and the tumor is prone to recurrence because the tissue structure of CHL is different from that of hepatocellular carcinoma, which is mainly composed of aberrant blood sinuses lined with endothelial cells and is not a substantial tumor. In addition, the blood supply of CHL is complicated, most of them are hepatic artery supply, but some of them have portal vein supply, or some of them form arteriovenous fistula. Hepatic artery embolism can cause abnormal deposition and possible fibrosis of the liver and lungs. Therefore, preoperative CT scan of the liver must be done to evaluate the tumor blood supply in detail.
Percutaneous hepatic injection sclerotherapy
Percutaneous hepatic puncture injection sclerotherapy is an interventional therapy guided by B ultrasound or CT. Sclerosing agents include sodium cod liver oil, anhydrous alcohol, colloidal 32P, pinyamycin, bleomycin, polyglaucine, etc.
This method of treatment is simple, inexpensive and rapid, but the diffusion range is limited, and its efficacy is related to the distribution range and uniformity of the sclerosing agent in the tumor and the injection dose. Moreover, whether cod liver oil sodium, anhydrous alcohol, pinyamycin or bleomycin as sclerosing agent, can produce more serious adverse reactions, for cases with huge tumor, the effect of a single treatment is not significant, and the excessive amount may produce serious side effects, increasing the patient’s pain.
C. Ultrasonic interventional percutaneous liver perforation local ablation CHL therapy
This is one of the most popular interventional ablation treatment methods in recent years. Under the guidance of ultrasound intervention, microwave needles are inserted into the tumor lesion through the skin and liver, generating high temperature locally and transmitting to the adjacent tissues to form a spherical ablation zone, causing in situ coagulation and necrosis of tumor tissues. This method has been used to treat primary liver cancer with definite results. It can be administered via percutaneous, laparoscopic and open routes, especially percutaneous thermal ablation has the advantages of minimally invasive, simple, effective, practical and repeatable.
In China, this technique has been applied to the treatment of CHL with good results. For CHL with a diameter of 3 cm, the treatment can be completed at one time, and more than 3 cm can be superimposed at multiple points to form a wide range of coagulation necrosis area, so as to achieve the treatment purpose, and microwave ablation itself has a good hemostatic effect. At the same time, we have improved the method of microwave ablation for the treatment of large hepatic hemangioma, and also achieved very good results. Its effectiveness and safety are clearly shown to be superior. Moreover, it is a minimally invasive treatment with short hospitalization time and much lower cost than surgical resection.
Percutaneous inter-tissue radioactive particle implantation therapy
Also known as intracorporeal knife. The biological basis of radioactive particle implantation therapy is the direct and indirect biological effects induced by ionizing radiation, which can cause cell necrosis and apoptosis, and directly cause tissue destruction. The vascular endothelium is one of the most sensitive tissues in the body to radiation killing effects, and the basic component of hemangioma is a blood sinusoid lined with a large number of abnormal endothelial cells, which has a greater vulnerability to ionizing radiation.
The key to nuclear irradiation therapy is to ensure that the target tissue is irradiated with sufficient dose. The use of multi-point interventional injection technique can not only destroy the peri-tumor trophoblastic vessels, but also enable the good dispersion of nuclide in the tumor, so as to cause the denaturation of the vessel wall and thrombosis of the hemangioma. Due to the side effects of radioactivity, the indications, efficacy and side effects of this method for the treatment of CHL need to be further observed.
At present, the treatment of hepatic cavernous hemangioma advocates the selection of reasonable treatment methods according to the size, location, pathological changes and systemic conditions of the tumor. Due to the inlet and outlet flow and vascular anatomy of CHL, hepatic artery interventional embolization is not complete and often has recurrence and more complications, so it needs to be performed by experienced interventionalists after careful evaluation.
For symptomatic giant hepatic hemangiomas that cannot be surgically removed, with the development of modern imaging-mediated technology and the affirmation of the efficacy of interventional ablation, simple and effective treatments such as local injection sclerosis or local ablation are recommended. In particular, local interventional ablation treatment does not require liver incision, less intraoperative bleeding and no need to block the blood flow in and out of the liver, so it will not cause liver ischemia and reperfusion injury; as only the tumor foci are treated, the normal liver tissue can be preserved to the maximum extent, which is suitable for the treatment of CHL with liver disease background; under ultrasound intervention, the puncture can easily hit the tumor target and directly destroy or melt the tumor tissue with high accuracy; there is real-time tracking of image observation, The treatment is minimally invasive under local anesthesia, and the recovery is fast and more acceptable to patients. Since CHL is a benign tumor, it does not require complete clearance of the tumor, and interventional treatment can achieve in situ inactivation of the tumor, which has obvious superiority compared with other treatment methods and will become the future direction of CHL treatment.