Patients often ask medical questions about hepatic hemangioma, and the following is a brief summary of the relevant literature and years of practical experience.
Hepatic hemangiomas are mostly cavernous hemangiomas, which are benign tumors and are usually found during physical examination. CT or MR-enhanced scans, nuclear scans, and hepatic arteriograms can make a definite diagnosis. The condition is more common in middle-aged women, and the incidence is six times higher in women than in men. Because the disease is asymptomatic and presents only as an intrahepatic occupying lesion, it requires a specialist to differentiate it from hepatocellular carcinoma.
The traditional view is that if the maximum diameter of the tumor is less than 5 cm, the patient may not feel it and may not need treatment. However, if the tumor is larger than 5 cm, or if the tumor is distended and painful in the liver area, or if the tumor grows rapidly in a short period of time and is in danger of rupture and bleeding near the edge of the liver, it should be treated actively. Traditional treatment is surgical resection, which has the advantage of complete treatment, but has the disadvantage of high trauma, high cost and long hospital stay. New technologies are based on transvascular interventional embolization, tumor drug injection, physical ablation, etc. These technologies are minimally invasive and efficient, and outpatient treatment or hospitalization can be done in 2-3 days. Interventional treatment can completely bring the tumor under control, shrinking, not growing, and just being symptom-free, and complete removal can usually be unnecessary. There are no drugs that can eliminate hemangiomas, including herbal medicine.
Possible complications of hepatic hemangioma include
① Rupture of hepatic hemangioma, which may cause symptoms of acute abdomen or internal bleeding.
②Thrombocytopenia and hypofibrinogenemia, which are often caused by impaired coagulation mechanisms in a few patients.
(iii) Liver enlargement, which can be caused by the growth of hemangioma.
④Hepatic cysts, which can be complicated by liver cysts in about 10% of patients.
Tips.
1, hepatic hemangioma is benign lesion, there is still no curative drug for hepatic hemangioma, so patients with hemangioma <5cm, do not need to seek medical advice everywhere, regular follow-up can be. If the tumor is >5cm and there are self-conscious symptoms, patients should go to the interventional department of hospital for treatment.
2.Dietary precautions
(1) Diet should be light, rich in nutritious products, more vitamin and magnesium-rich food, avoid greasy and thick, spicy and irritating, spicy food, such as chili, seafood, barbecue, strong wine and spicy fried food, less food such as beef, lamb, pork, dog meat and other febrile food.
(2) Diet should include more vegetables and fruits to keep the ambassador open and prevent constipation, because frequent constipation can aggravate the symptoms of abdominal distension and belching, and forceful defecation in severe constipation can risk the rupture of huge tumor.
(3) You should not eat too much, seven or eight minutes full is appropriate, usually pay attention to keep your mood relaxed, do not get angry and do not have too heavy psychological burden, and do some low intensity exercises to enhance your resistance.
3.The difference between liver cancer and hepatic hemangioma
Ultrasound can detect liver tumor, but it is almost impossible to distinguish between liver cancer or hepatic hemangioma. The resolution of enhanced CT or MR scan is about 92%, that is to say, there are still about 8% of hemangiomas that cannot be distinguished, which has to draw people’s attention.
4.How to determine whether the diagnosis of hepatic hemangioma is misdiagnosed?
(1) The diagnosis must be confirmed by enhanced CT, and if the CT still confirms the diagnosis of hemangioma, then the following diagnosis can be made.
(2) If the patient also has cirrhosis, hepatitis B and AFP positive, then it is more likely to be hepatocellular carcinoma and must be closely monitored.
(3) Most hepatocellular carcinomas grow rapidly and can grow exponentially or even several times within a month, even the very few slow growers can grow more than 30% within a month, while hepatic hemangiomas grow slowly and most of them do not grow in size within a year. Therefore, after a patient is diagnosed with hepatic hemangioma, he should still be actively reviewed within one year, and the review can be arranged as follows (ultrasound can be used for the review).
①The first review should be done after 30 days, and there should be no change in the hemangioma; if there is any one of cirrhosis, hepatitis B or AFP positivity, the review should be done once in 20 days; three times in a row before the review is done according to the method.
②The second review should be conducted 60 days after the first review, and the hemangioma should still be unchanged.
If the hemangioma remains unchanged, it should be rechecked once a year thereafter.
(General patients can read up to this point, but if time and energy allow, you can continue to refer to the following expertise if you are interested)
Mechanism of occurrence
The disease is more common in middle-aged women, and its incidence is six times higher in women than in men. Because the disease has no obvious symptoms and presents only as an intrahepatic occupying lesion, clinical attention should be paid to differentiate it from hepatocellular carcinoma.
The pathogenesis of hepatic hemangioma is still unclear, and there are two different understandings. One is that it is a vascular malformation, and its growth is due to the expansion of blood sinusoids under the action of blood flow. The blood sinusoids have intact endothelial cells with abundant elastic fibers underneath, fibroblasts and smooth muscle cells in the middle membrane layer, and collagen fibers in the mesenchyme are abundant and widely distributed, resulting in unclear boundaries between the inner, middle and outer membrane layers and disorderly arrangement of elastic fibers. Secondly, hepatic hemangioma is considered to be a true tumor, and its growth is due to the formation of new vascular tissue. Hormones have an important role in the formation of neointima. It is speculated that steroids act on the emblematic structures of the vessel wall, part of the spongy vessels, and the possible mechanism is that steroids such as prednisone inhibit collagen biosynthesis in the vessel wall; on the other hand, steroids have the effect of stimulating or promoting angiogenesis. It has been reported that sex hormones can contribute to the proliferation, migration and even formation of capillary-like structures in vascular endothelial cells. Similarly clinical studies have confirmed the association of female hormones with the growth of hepatic hemangiomas. A long-term follow-up survey showed that 12.7% of female patients with hepatic hemangioma had an increase in tumor size during the follow-up period, but only 6.3% had a significant increase, while 22.7% of those treated with hormones had an increase in hepatic hemangioma diameter twice as large as the control group. All of the above indicate that the growth and recurrence of hepatic hemangioma are closely related to sex hormones, exogenous such as oral contraceptive drugs and endogenous such as pregnancy, i.e. pregnancy or oral contraceptive pills can accelerate tumor growth or recur after cure. It has also been reported that the positive rate of VEGF expression in hepatic hemangioma is as high as 78%, and the higher the VEGF expression, the more vigorous the proliferation of vascular endothelial cells, thus hepatic hemangioma should be regarded as a neoplastic organism. However, the real mechanism of hormone in the occurrence and development of hepatic hemangioma is not yet understood, which needs to be studied in depth to provide theoretical basis for clinical drug treatment of hepatic hemangioma
Classification
(1) Spongy hemangioma: The section is honeycomb, filled with blood, and microscopic examination shows cystic sinusoids of different sizes, filled with red blood cells and sometimes thrombus formation, and there are fibrous tissue septa between the sinusoids. The thrombus in the fibrous septum and sinusoids can be seen as calcified or venous stones.
(2) Sclerosing hemangioma with closed lumen and more degenerative changes in the fibrous septum.
(3) Vascular endothelial cell tumor, in which the endothelial cells are actively proliferating and prone to malignant transformation.
(4) Hepatic capillary hemangioma with narrow vascular lumen and more fibrous septal tissue.
Clinical manifestations.
1.Small hemangiomas are mostly asymptomatic, and larger hemangiomas may have distension and pain in the liver area.
2.Small hemangioma is asymptomatic, while larger hemangioma may have palpable mass in the right upper abdomen and large liver.
3.Large liver, mass and compression symptoms due to the enlargement of tumor are mostly asymptomatic in early stage.
Diagnosis.
Diagnosis is mainly based on ultrasound, CT, nuclear scan and hepatic arteriography to confirm the diagnosis. Smaller hemangiomas with no symptoms do not need to be treated, but can be observed dynamically, and partial hepatectomy can be chosen for those with compression symptoms. Most hemangiomas are solitary and less than 4 cm in diameter. Hepatic hemangiomas are often found incidentally during ultrasound examinations and are variable in size, shape and number and are often congenital in nature. If the hepatic hemangioma is stationary and does not develop, it is usually not life-threatening without any conscious symptoms. Hepatic hemangioma may contain fibrous tissue and mechanized thrombus, which may cause swelling of tumor and distension of liver peritoneum due to repeated thrombosis.
Complications of hepatic hemangioma
1.Rupture of hepatic hemangioma: It may cause acute abdomen or internal bleeding symptoms.
2. Thrombocytopenia and hypofibrinogenemia: A few patients often suffer from this condition due to impaired coagulation mechanism.
3.Liver enlargement: When hemangioma grows up, it will cause liver enlargement.
4.Hepatic cysts: About 10% of patients can be complicated by liver cysts.
Diagnostic basis
Imaging examination (such as ultrasound, CT and MRI) is the main way to diagnose hepatic hemangioma at present.
1.X-ray plain film: the examination has little significance. Only giant hepatic hemangioma will show elevation of right diaphragm and change of gas compression in digestive tract, and it is non-specific. The possibility of hepatic hemangioma will be considered when the tumor appears calcification.
2.B ultrasound: It shows a well-defined hypoechoic occupancy with a less pronounced posterior echogenic enhancement effect. B-mode ultrasound can detect hepatic hemangiomas >2 cm in diameter. The typical presentation is a well-defined hypoechoic lesion with less pronounced posterior echogenic enhancement. However, most small hemangiomas are strongly echogenic (up to 5 cm in diameter) and show mixed internal high and low echogenicity with irregular borders and variable shapes, due to intra-tumor fibrous changes, thrombosis or necrosis. Sometimes hepatocellular carcinoma may also have similar images, so other imaging tests are needed to differentiate them.
3.CT: Under CT scan, hepatic hemangioma appears as round or ovoid low-density foci, which can be multiple or single. Most of them have uniform density and clear borders, and the density of hemangioma in fatty liver is higher. When the intra-tumor mechanization is more, it shows stellate or fissure-like hypodensity, and sometimes the intra-tumor may show indefinite calcification. CT-enhanced imaging is very helpful for the characterization of hepatic hemangioma, especially for the differentiation from hepatocellular carcinoma, which mostly shows oval hypodense shadow on plain scan image and no differentiation between the two CT values (P>0,05), so enhanced examination is essential. According to the special changes of blood in hepatic hemangioma, “two fast and one slow” CT enhancement scan technique is necessary for the diagnosis of hepatic hemangioma. The CT enhancement of hepatic hemangioma is characterized as follows: the edge of the early lesion shows high-density enhancement consistent with the abdominal aorta of the same layer; the enhanced area shows progressive centripetal expansion; the delayed (>5 min) scan shows isointense filling of the lesion, and then the lesion returns to the low density in the flat scan after another 1 h delay. Some scholars refer to this symptom as “fast-in, slow-out” performance of hepatic angioma. In contrast, CT enhancement of hepatocellular carcinoma shows the unique CT sign of “fast in and fast out”, that is, the whole lesion reaches a uniform or inhomogeneous high density in the early stage (arterial stage), and then rapidly decreases and approaches the density of the liver parenchyma, and the CT value of the liver parenchyma starts to decrease and approaches the density of the lesion that continues to decrease in 2-3 min, thus appearing twice. The contrast is then rapidly discharged and returns to the hypointense shadow on plain scan. Liver metastases, on the other hand, tend to occur in middle-aged and elderly patients with a history of primary disease. At the early stage of CT enhancement. Its edges or the whole lesion appears to be significantly enhanced. However, in the hepatic portal phase, the contrast agent is basically discharged, and some may have the “bull’s eye” sign, and the lesion is hypointense on delayed scan, rarely appearing isointense filling, which can be distinguished from hepatic hemangioma
4.MRI: MRI has special diagnostic significance for this disease and will not miss small lesions. t1 weak signal, t2 high intensity signal, is an important indication to distinguish hepatocellular carcinoma. t2WI shows characteristic “bulb sign” like high signal, such as intravenous gadolinium chalate. Surgical resection can be considered for patients with a diameter of 5 cm on enhancement scan. However, the indications can be relaxed for lesions in specific areas (hilar, square, caudate lobe). The surgical resection technique of hepatic hemangioma has been improved in recent years by applying the waterjet separator – waterjet – provided by ERBE, Germany. Compared with traditional surgery, waterjet surgery is an improvement in terms of blood loss, blood transfusion, operation time and postoperative hospitalization days, which is worth advocating
Indications for treatment
The indications for treatment of hepatic hemangioma are controversial. In 1970, Adam referred to tumors >4 cm in diameter as giant hepatic hemangioma and used this as an indication for surgery. Some authors have suggested that if the diameter of hemangioma is >5 cm, surgery should be performed regardless of the presence of clear clinical symptoms, but the requirements for the size of hemangioma vary from 8 cm, >l0 cm to the largest >15 cm. Some authors have cited the risk of rupture and bleeding of hepatic hemangioma as an important reason for surgical treatment. In recent years, with further understanding of the natural growth pattern of hepatic hemangioma, the indications for treatment of hepatic hemangioma have changed, and the number of cases of conservative observation without treatment has gradually increased. We believe that tumor size and concern about rupture and bleeding are not criteria for the need of surgical treatment of hepatic hemangioma. spontaneous rupture of hepatic hemangioma is rare, with only a few dozen cases reported worldwide so far, and the risk of liver surgery is much higher. jarnagin reported 1803 liver surgery mortality cases in consecutive l0 years from 1991 to 2001, 4% in the first 5 years and 1,3% in the last 2 years. There are more or less complications or discomfort after liver surgery, and Fioole et al. recently reported a mean follow-up of 55 months, with 14, 3% of patients with benign liver disease having varying degrees of discomfort after surgery. Therefore, we believe that treatment indications should be determined by a comprehensive analysis of the advantages and disadvantages depending on the patient’s age, growth rate, tumor size, and degree of symptoms, in order to avoid over-intervention and expansion of surgical indications; at the same time, it is important to avoid excessive tumor growth, which increases the difficulty and risk of surgical resection or loss of surgical treatment.
We believe that the surgical indications for hepatic hemangioma should be strictly controlled. Specifically, they include.
(1) Very clear symptoms (excluding other diseases that may cause similar symptoms).
(2) rupture of the tumor or the presence of a high-flow arteriovenous fistula and coagulation dysfunction (Kasabach-Merrit syndrome)
(3) Other liver tumors cannot be ruled out.
(4) Angiosarcoma diameter >10cm.
However, when the diameter of the tumor is 5 cm to 10 cm and the following conditions are combined, it is considered as a relative indication for surgery, and treatment should be considered when the patient’s study, work and life are seriously affected by the psychological stress caused by the presence of the disease.
(1) Adjacent to the first and second hepatic hilar.
(2) Tumor growth rate >2 cm in diameter per year.
(3) Tumor protruding from the edge of the liver, especially located below the rib arch.
(4) Combined with other surgical disorders such as gallbladder stones. For hemangiomas located in the central or caudal lobe of the liver, surgical treatment may require the removal of large pieces of liver tissue, and the complications and mortality rates of surgery are not yet acceptable to patients. Therefore, we do not advocate aggressive surgery, but rather close follow-up and strict control of surgical indications.
Treatment methods
Surgical methods
(1) Hepatic hemangioma resection or lobectomy.
(2) Hepatic artery ligation.
(3) Intraoperative cryotherapy.
Non-surgical treatment
(1) Radiotherapy.
(2) Hepatic arteriography and tumor artery embolization, which are minimally invasive treatment techniques commonly used in recent years.
Principles of medication.
Generally no drug therapy is used. For surgical treatment, antibiotics are used in addition to basic drugs to prevent wound infection.
Evaluation of efficacy.
1.Cure: CT and color ultrasound show that the mass disappears, the symptoms disappear and the incision heals without complications.
2.Improved: CT and color ultrasound showed that the swelling became smaller and the symptoms were reduced.
3, not healed: no change, or further enlargement of the mass.
Tips.
Hepatic hemangioma is a benign lesion, and there is still no effective drug for hepatic hemangioma, so if the hemangioma is less than 5cm, there is no need to seek medical help, and regular follow-up can be done. If the tumor is >5cm and there are self-conscious symptoms, you should go to the hospital and follow the medical advice.
Dietary precautions
(1) The diet of liver hemangioma should be light and rich in nutrients, with vitamin and magnesium-rich foods, and avoid oily and thick, spicy and stimulating foods, such as chili, seafood, barbecue, strong wine and spicy fried foods, and less febrile foods such as beef, lamb, pork and dog meat.
(2) The diet of liver hemangioma should include more vegetables and fruits, keep the ambassador open and prevent constipation, because frequent constipation can aggravate abdominal distension, belching and other symptoms, and forceful defecation in severe constipation may cause the risk of rupture of huge tumor.
(3) Liver hemangioma should not eat too much, seven or eight minutes full is appropriate, usually pay attention to keep a relaxed mood, do not be angry, do not have too heavy psychological burden, smooth the mood, can do some low-intensity exercise to enhance their resistance.
The difference between liver cancer and liver hemangioma
Ultrasound can detect liver tumor, but it is almost impossible to distinguish between liver cancer or hepatic hemangioma. Enhancing the resolution of CT is about 92%, which means that there are still about 8% of hemangiomas that cannot be distinguished, which compels people to pay attention to it.
How to determine whether a diagnosis of hepatic hemangioma is misdiagnosed after it is confirmed?
(1) The diagnosis must be confirmed by enhanced CT, and if the CT still confirms the diagnosis of hemangioma, then the following diagnosis can be made.
(2) If the patient also has cirrhosis, hepatitis B and AFP positive, then it is more likely to be hepatocellular carcinoma and must be closely monitored.
(3) Most hepatocellular carcinomas grow rapidly and can grow exponentially or even several times within a month, even the very few slow growers can grow more than 30% within a month, while hepatic hemangiomas grow slowly and most of them do not grow in size within a year. Therefore, after a patient is diagnosed with hepatic hemangioma, he should still be actively reviewed within one year, and the review can be arranged as follows (ultrasound can be used for the review).
①The first review should be done after 30 days, and there should be no change in the hemangioma; if there is any one of cirrhosis, hepatitis B or AFP positivity, the review should be done once in 20 days; three times in a row before the review is done according to the method.
②The second review should be conducted 60 days after the first review, and the hemangioma should still be unchanged.
If the hemangioma is still unchanged, it should be rechecked once a year in the future.