Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant pedunculated hepatic hemangiomas, mostly seen in women, are considered a rare type of giant hepatic hemangioma, with challenging diagnosis. Unlike other types of liver hemangiomas, they can manifest different kinds of symptoms, and are prone to life-threatening manifestations like rupture or torsion. Hemangioma is the most common benign liver primary tumor. Hepatic hemangioma >4 cm (some studies suggest >10 cm) is referred to as a giant hemangioma. Although hepatic hemangioma does not manifest symptoms in most cases, a giant hepatic hemangioma can manifest different kinds of symptoms. Giant pedunculated hepatic hemangiomas are considered a rare type of giant hepatic hemangioma, with challenging diagnosis, as the thin pedicle could be hard to be detected on imaging. A 41-year-old woman was admitted to our hospital, with dull discomfort of the right upper quadrant and epigastric region and early satiety for the past 7 months, with the history of taking oral contraceptive (OCP) for 10 years. Ultrasound and computed tomography revealed a 130 × 124 × 76 mm solid mass, with central cystic lesion, located in the midline of the epigastric region, attaching to the inferior surface of the third segment of the left lobe of the liver. Due to the potential risk for torsion, and rupture of the hemangioma, the management of the patient proceeded to surgical excision. Pathological examination of the specimen confirmed the diagnosis of hepatic hemangioma. Giant pedunculated hepatic hemangioma is a rare benign tumor. It demonstrates higher incidence rate in women, as some hemangiomas have estrogen receptors, and estrogen can lead to endothelial cell proliferation and organization in vascular structure. Most hemangiomas do not express any symptoms; therefore, no treatment is needed except for the patients who manifest symptoms, or in giant pedunculated hemangiomas, as they are prone to rupture or torsion. In this review most cases were female, and most of them presented with abdominal pain, in most cases the tumor located in the left lobe of the liver. Almost all the reviewed cases underwent surgery. Giant hepatic hemangioma is a differential diagnosis of palpable mass, or other symptoms of the right upper quadrant, and epigastric region specially in women taking OCP. Imaging is needed to rule out these tumors, and most often, pedunculated hemangioma is harder to be defined on imaging. It requires surgery because of the risk of acute problems, such as torsion and rupture.

ObjectivesTo explore the clinical characteristics, postnatal treatment and prognosis of giant fetal hepatic hemangioma (GFHH).MethodRetrospective analysis was performed on children with giant fetal hepatic hemangioma (maximum tumor diameter > 40 mm) diagnosed by prenatal ultrasound and MRI from December 2016 to December 2020. These patients were observed and treated at the Children’s Hospital of Fudan University after birth. The clinical data were collected to analyze the clinical characteristics, treatment, and prognosis of GFHH using independent sample t tests or Fisher’s exact tests.ResultsTwenty-nine patients who were detected by routine ultrasound in the second and third trimester of pregnancy with giant fetal hepatic hemangiomas were included. The first prenatal ultrasound diagnosis of gestational age was 34.0 ± 4.3 weeks, ranging from 22 to 39 weeks. Of the patients, 28 had focal GFHHs and 1 had multifocal GFHHs. Surgery was performed, and the diagnosis was confirmed histopathologically in two patients. There were 8 cases with echocardiography-based evidence of pulmonary hypertension, 11 cases had a cardiothoracic ratio > 0.6, and 4 cases had hepatic arteriovenous fistula (AVF). The median follow-up time was 37 months (range: 14–70 months). During the follow-up, 12 patients received medical treatment with propranolol as the first-line therapy. The treatment group had a higher ratio of cardiothoracic ratio > 0.6 (P = 0.022) and lower albumin levels (P = 0.018). Four (14.8%) lesions showed postnatal growth before involuting. Complete response was observed in 13 (13/29) patients, and partial response was observed in 16 (16/29) patients.ConclusionsFetal giant hepatic hemangioma is mainly localized, and its clinical outcome conforms to RICH (rapidly involuting) and PICH (partially involuting), but some fetal giant hepatic hemangiomas will continue to grow after birth and then gradually decrease. For uncomplicated giant fetal hepatic hemangioma, postnatal follow-up is the main concern, while those with complications require aggressive medical treatment. Propranolol may have no effect on the volume change of GFHH.

IntroductionHepatic and splenic hemangiomas are common benign tumors that mainly affect female patients. Giant splenic hemangiomas are extremely rare, especially when correlated with multiple hepatic hemangiomas. Pathogenetic mechanisms between hemangiomas and oral contraceptives, as well as therapeutic approaches, are analyzed in this case report, in particular for the management of synchronous splenic and hepatic hemangiomas.Case presentationWe report here a 42-year-old woman with a giant splenic hemangioma, multiple hepatic hemangiomas and a history of oral estrogen intake for many years. At first it was difficult to determine the organ from which the giant hemangioma originated. Angiography proved extremely helpful in tracing its origin in the spleen. Hematomas in the giant hemangioma posed a significant threat of rupture and catastrophic hemorrhage. We left the small hepatic hemangiomas in place, and removed the spleen along with the giant splenic hemangioma.ConclusionDiagnostic pitfalls in the determination of the origin of this giant hemangioma, attribution of its origin to the spleen angiographically, the unusual co-existence of the giant splenic hemangioma with multiple hepatic ones, and the potential threat of rupture of the giant hemangioma are some of the highlights of this case report. Estrogen administration represents a pathogenic factor that has been associated with hemangiomas in solid organs of the abdominal cavity. The therapeutic dilemma between resection and embolization of giant hemangiomas is another point of discussion in this case report. Splenectomy for the giant splenic hemangioma eliminates the risk of rupture and malignant degeneration, whereas observation for the small hepatic ones (<4 cm) was the preferable therapeutic strategy in our patient.

Giant Hemangioma Causing Budd-Chiari Syndrome

Surgical Management of Giant Hepatic Hemangioma: Single Center’s Experience with 144 Patients

Rationale:Hepatic hemangioma is the third most common pediatric tumor, and it is rare in the neonatal period. This case study presents a rare case of hepatic hemangioma found in a neonate.Patient concerns:A girl who was 18 days of age with the emergence of jaundice and an abdominal mass was admitted for physical examination in the local department.Diagnoses:An ultrasound showed that the hepatic left lobe was about 9 cm × 7 cm × 7 cm in size. A CT scan indicated a giant hemangioma in the hepatic left lobe. MRI detected a lesion measuring about 92 mm × 71 mm × 68 mm.Interventions:The patient was treated with propranolol 3.5 mg PO bid (body weight 3.8 kg) after 1 week of admission for 4 weeks, but the mass did not appear to regress. Surgery was then performed successfully.Outcomes:The patient recovered well without recurrence beyond one year.Lessons:Imaging strategies and prenatal diagnosis are vital for the diagnosis of infantile hepatic hemangioma. Propranolol is effective in both cutaneous and hepatic multifocal and diffuse hemangioma. Adequate treatment time is necessary to cure the disease. The role of propranolol in massive hepatic hemangioma remains uncertain and needs further investigation.

Natural History of Patients Hospitalized for Management of Cirrhotic Ascites

This study was designed to explore the safety and efficacy of percutaneous microwave (MW) ablation as an alternative treatment for symptomatic giant hepatic hemangiomas. Patients (n = 7; 6 females, 1 male; mean age = 44 years) with symptomatic, giant hemangiomas (n = 8) were treated with ultrasound-guided percutaneous MW ablation and followed for a mean of 18 months. Patient pain was recorded both before and after the procedure according to the 10-point visual analog scale. All patients were treated using one or three gas-cooled 17-gauge antennas powered by a 2.4-GHz generator (Neuwave Medical, Madison, WI). Mean ablation time was 11.6 min. Four patients received hydrodissection to protect the abdominal wall, colon, or gallbladder (5 % dextrose in water, mean volume 900 mL). Immediate postablation biphasic CT of the abdomen was performed, and four of seven patients have undergone delayed follow-up imaging. All ablations were technically successful with no major or minor complications. Average pain score decreased from 4.6 to 0.9 (p < 0.05), and six of seven patients report resolution or improvement of symptoms at 18-month average follow-up (range 1-33 months). Immediately postablation, mean tumor diameter decreased 25 % (from 7.3 to 5.5 cm, p < 0.05) and volume decreased 62 % (from 301 to 113 cm(3), p < 0.05). In this series, percutaneous MW ablation was safe, well-tolerated, and effective in markedly shrinking large hepatic hemangiomas and improving symptoms in most patients.

Spontaneous internal hemorrhage from a hepatic hemangioma is rare. This casedescribes a 59-year-old woman who was hospitalized with recurrent cough andfever for 6 months. The doctor thought that she had pneumonia, but otherinfectious diseases could not be ruled out. Therefore, related tests wereperformed and strong antibiotics were used, but the symptom of fever waspersistent and recurred. Enhanced computed tomography (CT) findings showed aright hepatic giant hemangioma with hemorrhage, while tuberculosis, liverabscess, and immune disease were excluded by the physician. Because thepatient’s fever was associated with a large hepatic hemangioma, the patient wastransferred to surgery. During treatment, the amount of bleeding increased, soshe underwent a right hepatic hemangioma resection in the emergency department.Her postoperative fever symptoms subsequently resolved. Pathological examinationconfirmed hemorrhagic necrosis with infection in hepatic hemangioma. Follow-upshowed that the patient was afebrile.

Introduction: Haemangiomas are the most common benign tumours of the liver. Most of them are asymptomatic. Giant hepatic haemangioma is defined as size greater than 5 cm in diameter. The surgical treatment for giant hepatic haemangioma is not very well defined and reported. Here we analysed the treatment outcome of giant hepatic haemangiomas and redefined the nomenclature according to the size and proposing an algorithm for management of all hepatic haemangiomas. Material and Methods: Retrospective analyses of 6 giant hepatic haemangioma more than 10 cm in size treated by a single surgeon were included. The clinical characteristics, diagnosis, managements and outcomes were recorded. Review of literature was done for definitions, management strategies and outcome of giant haemangiomas and an algorithm was proposed. Results: Five patients were female and the mean age was 36.6 years (range 32 to 45). Pain abdomen was the most common symptoms (100%). Ultrasound abdomen was the initial diagnostic modality followed by contrast enhanced computed tomography. The mean size of haemangioma was 17.4cm (range 12cm to 32cm). Four patients had haemangioma in the left lobe and two had in the right lobe of liver. Formal hepatectomy was done in three patients and enucleation was done in three patients. The mean operating time was 3.66 hours (range 2.5 hours to 5 hours). The mean blood loss was 840ml (range 300ml to 1500ml). There was no surgical morbidity or mortality. On follow-up no haemangioma related complications are reported. Conclusions: Giant hepatic haemangioma is mostly symptomatic. Hepatectomy and enucleation can be done without significant morbidity and mortality. There is a need for redefining the nomenclature of giant hepatic haemangiomas according to the size.

Surgical management of giant hepatic hemangiomas : complications and review of the literature

Bipolar radiofrequency ablation for symptomatic giant (>10 cm) hepatic cavernous haemangiomas: Initial clinical experience

Patient: Female, 37-year-oldFinal Diagnosis: Kasabach-Merritt syndromeSymptoms: Abdomen distension • painMedication: —Clinical Procedure: —Specialty: Gastroenterology and HepatologyObjective:Rare diseaseBackground:Liver hemangiomas are the most common benign liver tumor. Giant hepatic hemangiomas are hemangiomas that are greater than 4 cm in diameter. While asymptomatic giant hepatic hemangioma patients can be monitored without intervention, patients that experience complications can be managed by trans-arterial embolization, radiofrequency ablation, surgical resection, or enucleation. Although there is no consensus on definite medical treatment or optimal timing of surgery, liver transplantation is rarely indicated. Among giant hepatic hemangioma patients who received liver transplantation, Kasabach-Merritt syndrome (KMS), a consumptive coagulopathy associated with hemangiomas, is one of the most common indications. We present a case of giant hepatic hemangioma complicated by Kasabach-Merritt syndrome, which was successfully treated by orthotopic liver transplantation.Case Report:The patient was a 39-year-old woman with a known history of multiple giant hepatic hemangiomas who presented with abdominal pain and distension. She had life-threatening intra-abdominal hemorrhages caused by benign endometriomas due to hepatic hemangiomas complicated by Kasabach-Merritt syndrome. Despite interventional radiology embolization of a bleeding uterine artery and aggressive resuscitation with fluid and blood products, the patient’s status continued to decline. Emergent orthotopic liver transplantation was applied with subsequent resolution of the consumptive coagulopathy. She remained well at 2-month follow-up, with normal liver enzyme levels and intact liver allograft function.Conclusions:Liver transplantation is indicated for selected patients with giant hepatic hemangioma complicated by KMS; despite the high surgical risk, outcomes seem favorable.

Liver haemangiomas are common, but their size very rarely exceeds 40cm. Most people with liver haemangiomas are asymptomatic, and diagnosis is usually made incidentally during imaging for other complaints. When a liver haemangioma is symptomatic or produces complications, surgical intervention may be warranted. Kasabach-Merritt syndrome is an uncommon complication reported in certain rare vascular tumours in children, with only a few cases reported in adults. The syndrome describes a consumptive coagulopathy initiated within a vascular tumour, mainly tufted angiomas and kaposiform haemangioendotheliomas and, less commonly, giant haemangiomas. The process can extend beyond the tumour and become disseminated in certain cases due to trauma or surgery. The definitive treatment for giant liver haemangiomas can include arterial embolisation, surgical excision, hepatectomy or even liver transplantation. We report the case of a 32-year-old woman with a 42 × 32 × 27cm (18,870ml) liver haemangioma associated with Kasabach-Merritt syndrome. The diagnosis was challenging, even with proper imaging, owing to the rarity of the condition. It was achieved with an exploratory laparotomy with biopsy.

Objective To evaluate the effect of bleomycin combined with iodinated oil on symptomatic giant hepatic haemangioma. Methods This study included 29 patients(37 lesions) with symptomatic giant hepatic haemangioma, they were treated with bleomycin combined with lipiodol. All of the patients were followed up for (7.7± 0.78) months. The clinical symptom and volume of the haemangiomas were observed. Results Among the 29 patients, the volume of the haemangioma was 10–1 543(456.34±63.45) cm3 before intervention and 6-980(224.52 ±56.01) cm3 after intervention. No fatality or morbidity related to the treatment was identified. Symptomatic improvement was observed in all patients, and significant volume reduction was achieved. Conclusions Minimally invasive embolisation of bleomycin combined with iodinated oil is an alternative and effective treatment for giant symptomatic hepatic haemangioma. Key words: Hepatic haemangioma; Embolisation; Iodinated oil; Bleomycin