Proposal of size-based surgical indication criteria for liver hemangioma based on a nationwide survey in Japan.

Abstract

265 Background: Although hepatic hemangioma is one of the most frequent benign tumors in the liver, surgical indication for this neoplasm remains unclear. The objective of the present study was to conduct a nation-wide survey on resected cases of liver hemangioma and propose evidence-based surgical indication criteria for this disease (Research project of Japanese Society of Hepato-Biliary-Pancreatic Surgery). Methods: Of a total of 510 patients undergoing surgical resection for liver hemangioma in 118 Japanese centers between 1998 and 2012, abdominal symptoms, coagulopathy, diagnostic accuracy and surgical outcomes were analyzed according to the tumor status. Results: The patients were classified into 4 groups based on the tumor size; Group A) ≤ 5cm (n = 122, 24%), B) 5-10cm (n = 164, 32%), C) 10-15cm (n = 124, 24%), and D) > 15cm (n = 100, 20%) Hemangioma in Group A was most frequently diagnosed as a malignant tumor (43.5%) due to absence of typical imaging findings as cavernous hemangioma and with highest incidence of positive of HBV (15.7%). Diagnostic accuracy was 98.4% in Groups B-D. In Group B, 71% of patients presented no abdominal symptoms or Kasabach-Merritt syndrome. Symptoms associated with hemangioma increased in proportion as the size increased, and the incidence of abdominal distension, tumor rupture, and Kasabach-Merritt syndrome were 55%, 2.0%, and 26%, respectively, in Group D. The incidence of liver failure after hepatectomy was higher in Group D than in Groups A-C (3.0% vs. 0.5%, p = 0.02). There was only one operative death (0.2%) in Group D. Conclusions: In patients with = /< 5cm hemangioma, surgical resection is indicated when malignant tumor can not be ruled out. However, surgical indications for 5-10cm asymptomatic hemangiomas should be limited because preoperative diagnosis of benign disease is trustworthy in this subgroup. Tumor size > 10cm would be candidate for surgery when accompanied with abdominal symptom or coagulopathy, and hepatectomy for tumors > 15cm should be performed in high volume centers by experienced hepatic surgeons to avoid serious morbidity or mortality.