Hyalinized hemangioma of the liver

We report the case of a 65-yr-old woman with hyalinized hemangioma of the liver which, on radiological examination, resembled primary or metastatic carcinoma of the liver. She had undergone a partial colectomy for a sigmoid adenocarcinoma, followed by the diagnosis of a hepatic tumor with ultrasonic echogram 5 months later. The tumor was depicted as a low-density mass on plain computed tomography (CT), and an enhancement at the peripheral portion was noted by contrast CT. Hepatic angiography disclosed a faint pooling of contrast medium in segment 8. A subsementectomy of the liver was performed under the diagnosis of metastatic adenocarcinoma or hepatocellular carcinoma. Histologically, the tumor was composed of dense collagenous tissues with marked hyalinization and scattered sclerotic vessels. Elastic fibers were distributed concentrically around the vessels. Totally hyalinized sclerosis of hemangioma is uncommon, and can be erroneously diagnosed as carcinoma by radiologic examination. This unusual hemangioma is reported, with pertinent literature.

Extrarenal angiomyolipomas of the perinephric space

We describe 2 cases of extrarenal angiomyolipoma of the perinephric space. All other cases of extrarenal angiomyolipoma of the retroperitoneum are reviewed and the clinical relevance of this unusual pathological entity is discussed.

Pseudotumors of the umbilical cord and fetal membranes

Antenatally diagnosed pseudotumors, i.e. non-neoplastic tumors, of the umbilical cord and fetal membranes may when scanned by ultrasound have an appearance leading to misdiagnosis. In the present cases, a hematoma in the fetal membranes was interpreted as a chorioangioma, and a cystic mass inside the umbilical cord caused by degeneration of Wharton's jelly was regarded as an omphalomesenteric or allantoic cyst. The two cases are presented. Color Doppler evaluation seems advisable.

Benign lesions of the mandibular and maxillary region in children: characterization by CT and MRI

The CT criteria for classifying lesions of the mandibular and maxillary regions in adults as benign or malignant are well recognized: irregular soft tissue margins and bone destruction. We reviewed the charts of 12 pediatric patients from 3 institutions to evaluate these criteria in children. These masses were evaluated by CT and/or MRI based solely on well-recognized and published criteria. The patients' ages ranged from 4 mo to 18 yr. The histological diagnoses were ameloblastoma (4), hemangioma (2), lymphangioma, desmoplastic fibroma, hemangiopericytoma, neurofibroma, fibrous dysplasia, and juvenile angiofibroma. All but one case was surgically proven. Among the 12 cases, 5 had bone destruction and 5 showed irregular soft tissue margins. Three cases satisfied both criteria. With well-recognized CT criteria (in adult patients), characterization of these processes led to an incorrect diagnosis of a malignant lesion in 8 of the 12 cases preoperatively. Therefore, CT and MR imaging should only be a guide to the planning and extent of surgical resection. Without clearly defined distal spread of the mass, the classification of these masses in children should be made with caution.

Rare causes of elevated maternal serum alpha-fetoprotein. A report of three cases

Three rare conditions--amniotic band disruption sequence, placental chorioangioma and congenital nephrosis--were diagnosed in midtrimester because of elevated maternal serum alpha-fetoprotein. The diagnosis is important for genetic counseling and obstetric follow-up.

Pulmonary capillary hemangiomatosis: report of a case and review of the literature

We describe a case of pulmonary capillary hemangiomatosis in a 60-year-old woman with a 1-year history of progressive exertional dyspnea. Four years before admission a diagnosis of breast cancer was made, and she underwent mastectomy plus radiation therapy and treatment with oral antiestrogens. The chest X-ray showed bilateral interstitial infiltrates. Pulmonary function studies revealed a severe restrictive pattern. Abundant red blood cells were found in the bronchoalveolar lavage fluid. On the basis of open lung biopsy, interstitial fibrosis was diagnosed. Cardiac catheterization revealed pulmonary hypertension. Steroids were prescribed, but the patient's condition continued to deteriorate and she died approximately 3 years after presentation. The identification of proliferating and invasive capillaries, which are unique to pulmonary capillary hemangiomatosis, led to the correct diagnosis at autopsy.

[The significance of radioisotope methods in the diagnosis of liver hemangiomas]

A growing use of ultrasonography for the examination of abdominal organs has resulted in an easier detection of hemangioma-like focal benign changes in the liver. Such cases ask for further diagnosis. Apart from other methods, the diagnosis of hemangiomas is possible by in vivo technetium-labeled erythrocytes. The authors present the erythrocyte labeling technique and the scintigraphic method carried out in 44 patients. On the basis of the obtained results they conclude that scintigraphy can be successfully used for the diagnosis of hemangiomas, especially if the changes seen by ultrasonography are big enough for the scintigraphy. If they are below 20 mm only tomography (SPECT) with labeled erythrocytes is to be considered.

[Differential diagnosis of hemangiomas, malignant processes and cystic formations in the liver by scintigraphy]

The aim of the study was determination and verification of the diagnosis in patients with liver hemangiomas already detected by ultrasonography. Scintigraphy was performed in 92 patients after equilibration of marked erythrocytes with tin pyrophosphate (Sn-PYP) scintigraphy and a static scintigram of the liver (early and late after 2-3 h) were obtained. The clinical treatment of all patients involved classical scintigraphy of the liver with 99mTc colloid. After the treatment fragmentary accumulation of radioisotopes was detected on early scintigrams and were markedly evident on late ones in areas presenting vascular formations manifested as foca-coll zones on classical scintigram.

Distinguishing soft-tissue hemangiomas from vascular malformations using technetium-labeled red blood cell scintigraphy

Soft-tissue vascular lesions in children can be classified as either hemangiomas or vascular malformations. The distinction between the two has important prognostic and therapeutic implications. Over the past 8 years, we have evaluated 64 vascular lesions with the technetium-labeled red blood cell (Tc-RBC) scan. Twenty-eight lesions imaged as hemangiomas with intense focal uniform uptake. This diagnosis was confirmed in 27 lesions, or 96 percent. Thirty-six lesions imaged as vascular malformations with abnormal vessels or diffusely increased activity. This diagnosis was confirmed in 35 lesions, or 97 percent. Overall, the Tc-RBC scan was 97 percent accurate in distinguishing hemangiomas from vascular malformations. It is particularly useful when the clinical diagnosis of the lesion may not be evident. Not only can biopsy be avoided, but parents can be reassured at an earlier age and given accurate information regarding prognosis.

Ultrasonography and guided biopsy in the diagnosis of hepatocellular carcinoma

Ultrasonographic screening and follow-up of patients with chronic liver disease lead to the detection of a large number of small asymptomatic hepatocellular carcinomas, so that the changing appearance of this neoplasm during its natural history has now been recognized. Ultrasonography provides information on shape, echogenicity, growth pattern and vascular involvement of the neoplasm. Three different shapes may be identified, depending upon the size and the invasiveness of the neoplasm: nodular, massive and diffuse. The echogenicity is variable and the tumour mass may appear hypo, hyper or isoechoic in comparison with the surrounding liver tissue. A mixed pattern and/or a hypoechoic ring may also be visualized. A tendency to change from a low echo pattern to a low periphery and finally to a massive pattern with increasing echogenicity has been shown in Japanese patients. The infiltrative growth pattern may be grossly distinguished from the expansive one on the basis of the aspect of the tumour boundary. Vascular invasion is easily recognizable as a mass within a major portal branch or even in the portal trunk. Duplex and color Doppler ultrasonography enable further insights on the vascular alterations related to this neoplasm. Abnormal signals, typical of HCC, are characterized by high-peak with broadening of spectrum. Low impedance continuous signals are less characteristic. Finally, ultra-sound guidance allows puncture of intrahepatic nodules as small as 1cm. The sensitivity of this procedure in the diagnosis of focal liver lesions is very high, varying between 91% and 95% with a specificity of 92%-100%.

Sonography with intraarterial infusion of carbon dioxide microbubbles (sonographic angiography): value in differential diagnosis of hepatic tumors

Differential diagnosis of small liver tumors is important, but is not always possible, even with angiography. To solve this problem, we introduced sonographic angiography, which combines sonography and angiography. The vascular pattern of a variety of hepatic nodules was evaluated with sonographic angiography, and the results were compared with those of conventional angiography. Sonographic angiography (sonography performed during intraarterial infusion of carbon dioxide microbubbles) was performed in 184 patients with a total of 222 hepatic nodules: 139 hepatocellular carcinomas, nine adenomatous hyperplasias, seven regenerative nodules, 21 hemangiomas, 33 metastases, seven lymphomas, one granuloma, and five focal nodular hyperplasias. Sonographic angiography detected a hypervascular pattern with peripheral blood supply in cases of hepatocellular carcinoma (sensitivity, 90%; specificity, 89%). Typical vascular patterns of adenomatous hyperplasia, hemangioma, metastasis, and focal nodular hyperplasia on sonographic angiography were hypovascularity (sensitivity, 100%; specificity, 91%), spotty pooling (sensitivity, 100%; specificity, 100%), peripheral hypervascularity (sensitivity, 64%; specificity, 100%), respectively. The detectability of hypervascularity was greater with sonographic angiography than with conventional angiography in hepatocellular carcinoma, metastasis, and hemangioma. Our experience indicates that sonographic angiography depicts characteristic vascular features that reflect the vascular anatomy of specific types of hepatic tumors, and thus is useful in the differential diagnosis of these lesions.

Imaging strategies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI, and ultrasonography in 12 histologically proven cases

Twelve patients with the histologic diagnosis of soft-tissue hemangioma of the extremities (nine intramuscular, two subcutaneous, and one synovial) were evaluated in a retrospective study using plain film radiography (n = 12), angiography (n = 8), computed tomography (CT; n = 4), magnetic resonance imaging (MRI; n = 3), and ultrasonography (US; n = 2). In eight of nine intramuscular lesions, the plain film demonstration of phleboliths suggested the diagnosis, while the plain radiographs were normal in three. Angiograms showed the pathognomonic features of soft-tissue hemangioma in six patients. MRI was characteristic in all three patients: The lesion demonstrated intermediate signal intensity on T1-weighted spin echo images and extremely bright signal on T2-weighting. US showed a hypoechoic soft-tissue mass in one case and a mixed echo pattern in the other. In one case, a central echogenic focus with acoustic shadowing consistent with a calcified phlebolith was identified, and one lesion exhibited increased color flow and low resistance arterial Doppler signal. CT showed a nonspecific mass in one of four cases and a mass with phleboliths in three. If a deep hemangioma is suspected, we recommend initial imaging with plain radiography followed by MRI. US may be useful in confirming the presence of a mass in doubtful cases or if MRI is unavailable. CT offers no distinct advantage over the combined use of plain radiography and MRI. Although angiography demonstrated the pathognomonic features in all six deeply situated lesions, because of its invasiveness it should be reserved chiefly for those patients undergoing surgical resection.

Small hyperechoic renal tumors displaying no fat content on CT

We report two cases of small renal adenocarcinoma and one case of small angiomyolipoma, which were identified as hyperechoic tumors by ultrasonography. None of the three tumors displayed fat content on plain CT. Since CT cannot reliably identify the intratumoral structure of small hyperechoic renal tumors, we recommend intraoperative pathological examination when CT findings do not correspond with the results of ultrasonography.

Infiltrating angiolipoma in the foot

A case of infiltrating angiolipoma of the right lower extremity is reported. Angiolipomas are benign neoplasms of adipose tissue with a rich vascular component and are classified as either infiltrating or noninfiltrating. Noninfiltrating angiolipomas are seen in young individuals, present as painful, soft, subcutaneous nodules and are treated by enucleation. Infiltrating angiolipoma is a rare neoplasm with only 23 previously reported cases. These lesions are usually unencapsulated or rarely partially encapsulated and tend to infiltrate bony, neural, muscular, and fibrocollagenous tissue. Treatment of infiltrating angiolipomas is aimed at wide excision with radiotherapy indicated for cases of recurrence.

[Hepatic hemangiomas. The importance of the image]

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

[Solitary angiomyolipoma of the liver]

Today in the age of ultrasonography focal hepatic lesions are diagnosed more often, which are difficult to be classified. Metastases are leading numerically among the malignant tumors, hemangiomas among the benign. We report on a rare case of a hemangiomyolipoma of the liver and the diagnostic difficulties. The final diagnosis was made only after hemihepatectomy.

[Traumatic sinus pericranii. Case report]

The patient was involved in a traffic accident at the age of 1 and the left parieto-occipital scalp was contused without skull fracture. At the age of 5, an extracranial scalp mass was first noticed just beneath the multiple scalp scars. Angiography through the mass revealed that the extracranial mass cavity was connected to the superior sagittal sinus through the emissary veins. The mass located in the subgaleal, epiperiosteal space was totally resected and the connection with the intracranial sinus was closed with bone wax. Histologically, there were many capillaries and some large blood cavities with only one layered endothelium and connective tissue. Therefore, the mass was diagnosed as sinus pericranii and considered to be secondary to previous head trauma because: 1) The patient had a history of head trauma with considerably severe scalp injuries. 2) The extracranial blood sinus was located exactly beneath the traumatic scar. 3) There was no neoplastic tissue histologically. 4) No scalp mass was noticed before the traffic accident. 5) There was an elapsed time between the trauma and the growth of the mass. 6) No scalp nevus such as port-wine stain existed.

Lung scintigraphy in pulmonary capillary hemangiomatosis. A rare disorder causing primary pulmonary hypertension

The authors report the results of lung scintigraphy in two patients with primary pulmonary hypertension caused by pulmonary capillary hemangiomatosis, a rare disorder resulting from the proliferation of histologically normal capillaries in the lung. Perfusion studies revealed a nonhomogeneous pattern with some focal defects, similar to that seen with some other histologic types of primary pulmonary hypertension. The mechanisms underlying this perfusion pattern are unknown.

Hepatic hemangiomas: diagnosis with fusion of MR, CT, and Tc-99m-labeled red blood cell SPECT images

A method of image analysis was developed for correlation of hemangiomas detected at computed tomography (CT) and/or magnetic resonance (MR) imaging with increased blood pool activity evident at single photon emission CT (SPECT) performed after labeling of red blood cells with technetium-99m. Image analysis was performed in 20 patients with 35 known hepatic hemangiomas. After section thickness and pixel sizes of the different studies were matched, intrinsic landmarks were chosen to identify anatomically corresponding locations. Regions of interest (ROIs) drawn on the CT and/or MR images were translated, rotated, and reprojected to match the areas of interest on the corresponding SPECT images by means of a two-dimensional polynomial-based warping algorithm. Analysis of ROIs on 30 SPECT-MR and 20 SPECT-CT pairs of registered images provided absolute confirmation that 34 suspected hemangiomas identified on SPECT images correlated exactly with lesions seen on CT and/or MR images. Accuracy of fusion was within an average of 1.5 pixels +/- 0.8 (+/- 1 standard deviation). The technique enabled diagnostic confirmation of hemangiomas as small as 1.0 cm and proved useful for evaluating lesions located adjacent to intrahepatic vessels.

[Emission-computed tomography in the diagnosis of kidney tumors and cysts]

Emission computed tomography (ECT) was used to examine 48 patients with suspected renal lesions. Sectional images of renal cysts diagnosed in 14 of them were characterized by well-defined outlines surrounded by uniformly declining radiopharmaceutical accumulations. Renal tumors were detected in 25 patients. ECT pattern of the tumor had obscure borders suggesting the tumor invasion into the renal tissue. Accumulation of the radiopharmaceutical round the tumor was less pronounced than in functioning renal tissue. According to ECT findings, 8 subjects were free of urological pathology. It is concluded that ECT is a promising diagnostic tool in urology as it permits sectional visualization of renal neoplasms structure, is highly sensitive, informative and noninvasive. It can identify mass lesions of the kidneys and warrants exhaustive information on functional performance of the renal parenchyma.

Computed tomography attenuation measurements for the characterization of hepatic haemangiomas

The attenuation values of 21 hepatic haemangiomas in 19 patients were measured on non-enhanced computed tomographic (CT) scans and compared with the attenuation of adjacent liver and the inferior vena cava (IVC). The attenuation of hepatic haemangiomas was lower than that of the surrounding liver, but there was no correlation between these two measurements. There was a highly significant correlation between the attenuation of haemangiomas and blood in the vena cava (r = 0.905, p less than 0.001). All the haemangiomas had attenuations within 7 HU of caval blood. By comparison, in 34 hypodense hepatic lesions that did not show contrast-enhanced appearances characteristic of haemangioma, there was no significant correlation between the attenuation of the lesions and the IVC. Nineteen (56%) of these lesions had attenuations differing more than 7 HU from that of caval blood. The influence of this observation on the requirement for dynamic contrast-medium-enhanced and delayed post-contrast CT in the assessment of hepatic lesions is discussed.

[Computed tomography symptomatology of liver hemangiomas]

The paper is concerned with analysis of CT-symptomatology of 72 liver hemangiomas in 43 patients. The authors employed standard and dynamic computerized tomography. All hemangiomas were divided into 2 groups: under 6 cm and over 6 cm. Small hemangiomas were characterized by clear-cut contours and regular density. Zones of low density, regular in structure with clear-cut contours were revealed by CT in hemangiomas over 6 cm. Morphologically, this zone corresponded to a hyaline structure (a hyaline slot) making it possible to differentiate hemangiomas from necrotic tumors. In serious cases dynamic CT with visual evaluation and plotting of time-density graphs was recommended. Visually hemangioma had a picture of contrast medium accumulation, beginning from a focal periphery. Graphically the time of appearance of a contrast medium and the time of reaching a maximum for hemangiomas is delayed as compared to the same intervals of contrast medium accumulation in the liver parenchyma. It tells hemangioma graphs from graphs of other tumors, of which intervals coincide with those of liver parenchyma graphs.