Hepatic hemangioendothelioma. Angiographic appearance and apparent prednisone responsiveness

Neonatal tumours in Malaysia: a call for heightened awareness

PURPOSE

Neonatal neoplasms are rare tumours notorious for their atypical presentation and unpredictable behaviour. Their optimal treatment remains uncertain, a dilemma compounded by the deleterious effects of adjuvant chemo- or radiotherapy during this vulnerable period of growth. This paper examined the relatively high incidence of these tumours and its impact on paediatric surgery in Malaysia.

METHODS

Neonatal tumours treated at the Department of Paediatric Surgery, Kuala Lumpur Hospital over an 8-year period were retrospectively analysed. Besides data pertaining to patient demographics, distribution of tumour types and survival rates, morbidity from disease as well as treatment was emphasised in particular.

RESULTS

The 28 neonatal tumours, majority of which were sacrococcygeal teratoma, constituted 7% of all tumours treated by the unit. Surgical excision remained the mainstay of treatment. Mortality and morbidity from disease and treatment were not insignificant, at 7 and 29%, respectively.

CONCLUSION

The outcome of neonatal tumours treated in Malaysia appeared to be influenced by indigenous factors unique to the local healthcare setting. Several solutions were expounded, chief among these are strategies of improved and earlier detection, in addition to the centralisation of expertise for this group of tumours.

Elevated plasma vascular endothelial growth factor levels in 2 patients with hemangioendothelioma

Two patients with hemangioendothelioma and elevated plasma vascular endothelial growth factor (VEGF) levels are presented. A reduction in the plasma VEGF level after therapeutic intervention correlated with a successful clinical response. Conversely, a stable plasma VEGF level correlated with therapeutic failure.

Interventional treatment of infantile hepatic hemangioendothelioma

BACKGROUND/PURPOSE

Hemangioendothelioma is the most frequent liver tumor in infancy. Untreated symptomatic patients with heart failure have a high mortality rate. Symptomatic forms may request nonoperative treatment, because surgery is burdened with high risks in patients with heart failure. The authors report their experience with interventional coil occlusion of infantile hepatic hemangioendothelioma (IHE).

METHODS

Four patients (age range, 2 to 146 days; mean, 53 days) suffering from IHE associated with heart failure were treated by endovascular coil occlusion of arterial feeders. Catheter intervention was performed via an arterial (n = 2) or venous (n = 2) approach.

RESULTS

Signs of heart failure resolved within 2 to 8 days after occlusion in 3 patients. Tumor regression could be observed sonographically within 4 weeks postinterventionally. In 3 children, tumor size was reduced from a mean of 544 mL (65 to 1,350) to a mean of 4 mL (2 to 6); Mean systolic peak velocity in the hepatic artery was decreased from 170 cm/s (140 to 200) before occlusion to 45 cm/s (36 to 70) during follow-up. In the fourth patient, endovascular intervention could not control a rapidly progressing hemangioendotheliomatosis, and finally a liver transplantation had to be performed.

CONCLUSIONS

Interventional occlusion of feeding arteries in symptomatic IHE is a safe and effective alternative to early open surgery. The efficacy of endovascular intervention in multifocal tumors seems questionable.

Monosegmental living-donor liver transplantation for infantile hepatic hemangioendothelioma

Infantile hepatic hemangioendothelioma (IHHE) is a rare vascular tumor that presents before the age of 6 months. The patients with IHHE suffer from high-output congestive heart failure caused by major arteriovenous fisutulas in the liver, which leads to respiratory compromise and results in a high mortality rate despite medical treatments. A case of 4-month-old baby with liver failure caused by IHHE is reported. The baby received an urgent liver transplantation from a living donor. A monosegmental graft was used to mitigate graft-to- recipient size mismatching. The surgical procedure of monosegmental living donor liver transplantation also is discussed.

Hemangioma of the liver in children: proliferating vascular tumor or congenital vascular malformation?

BACKGROUND

Hepatic vascular tumors (HVT) are the most common benign liver tumors present in infancy and childhood commonly associated with high output cardiac failure. Pediatric HVT usually are divided into infantile hemangioendothelioma (IHE), cavernous hemangioma (HC), and arteriovenous malformations (AVM). The aim of this study was to analyze clinical and histologic features of pediatric HVT in relation to treatment strategies.

PROCEDURE

During last 12 years, 17 children have been treated because of HVT. The diagnosis of HVT was established in all on the basis of clinical and imaging data. A retrospective analysis of clinical records and histopathology divided 17 into: Group 1, neonates; and Group 2, infants and older children.

RESULTS

Radiologic imaging revealed the vascular nature of the tumors in all patients. All nine from Group 1 were symptomatic from AVMs and seven were operated upon. Only one of eight children from Group 2 presented symptoms of AVM requiring surgery; four of five in this group had surgery because of the risk of malignancy. Within Group 1, a mixture of proliferating IHE with microscopic features of AVM was found in most. In three neonates with HVT immunologic and clinical features of cytomegalovirus (CMV) hepatitis were noted. In two Group 2 patients, pure HC was present and in another, the diagnosis of angiosarcoma was established after biopsy of a peritoneal metastasis.

CONCLUSIONS

HVT in children demonstrate internal morphologic heterogeneity and an age-related behavior of the disease. We also confirm the proliferative nature of all hemangioendotheliomas (HEs) in children. Further studies on the tumorigenesis of these lesions are needed.

[Use of interferon in a case of hepatic hemangioma]

Hepatic hemangioendothelioma can have a fatal outcome. After failure of classic therapies, and when surgery or arterial embolization are not possible, those benign tumours may benefit from interferon alpha treatment.

CASE REPORT

We report a case of a 14-month-old infant who presented with hepatic hemangiomatosis and cardiac failure. The disease can neither be controlled by steroids nor by radiotherapy associated with digitalo-diuretic treatment. Due to the important vascular volume of the tumour, neither surgical care nor arterial embolization were possible. Thus this infant was treated for ten months by interferon alpha. The evolution was favourable: cardiac failure, calcifications and volume of the angiomatosis were regressive.

CONCLUSION

Interferon alpha treatment helps to control cardiac failure and the course of hepatic hemangioma in childhood.

Hepatic hemangioendothelioma: clinical experience and management strategy

PURPOSE

This study sought to define management strategies based on clinical experience in treating infantile hepatic hemangioendothelioma.

METHODS

A retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was performed.

RESULTS

Thirteen patients (median age, 14 days) with hemangioendothelioma were identified. Congestive heart failure (P<.03) and abdominal mass (P<.081) were predictive of 5-month mortality rates. Ultrasonography and computerized axial tomography were the diagnostic modalities most commonly used. Treatment strategies consisted of medical management (steroids and alpha-interferon) and interventional modalities (hepatic artery ligation or embolization, resectional surgery, or orthotopic liver transplantation). Patients who underwent resectional surgery, with or without orthotopic liver transplantation, had a lower 5-month mortality rate (P<.02) and a greater 2-year survival rate (P<.003) than did those who underwent hepatic artery ligation or embolization. Early morbidity and mortality tended to be a consequence of the primary lesion, whereas late morbidity and mortality were reflective of the treatment modality used.

CONCLUSIONS

In cases of failed medical management, resectional therapy should be used when possible. If partial hepatectomy is not technically achievable, hepatic artery embolization should be used either as definitive therapy or as a temporizing measure until orthotopic liver transplantation is possible.

Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms

This second part of our review about vascular proliferations summarizes the clinicopathologic features of the cutaneous vascular hyperplasias and benign neoplasms. Hyperplasias comprise a heterogeneous group of vascular proliferations that eventually show a tendency to regression. Angiolymphoid hyperplasia with eosinophilia is included within the group of hyperplasias because of its historical denomination and its reactive nature, probably as a consequence of an arteriovenous shunt, although usually the lesions do not regress. Pyogenic granuloma, bacillary angiomatosis, intravascular papillary endothelial hyperplasia, and pseudo-Kaposi's sarcoma qualify as vascular hyperplasias because they regress when the stimulus that initiated them is removed. Benign neoplasms form a large group of hemangiomas with distinctive clinicopathologic characteristics, although some of them are of recent description and may produce diagnostic difficulties. We classified cutaneous benign vascular neoplasms according to their cell lineage of differentiation, for example, endothelial, glomus cell, and pericytic differentiation. Subsequent categories are established according to the size of the involved vessels (capillaries, venules and arterioles, or veins and arteries) or the nature of the proliferating vessels (blood or lymphatic vessels). Capillary and cavernous hemangiomas have been the terms classically used to name the most common variants of benign vascular neoplasms (i.e., infantile hemangiomas), but they are not the most appropriate denominations for these lesions. First, these names are not contrasting terms. Furthermore, most of the socalled "cavernous" hemangiomas are not hemangiomas (neoplasms) at all, but venous malformations. The most important conceptual issue is that, at any point in time, a particular hemangioma has its own histopathologic pattern throughout the depth of the lesion. For these reasons, we classified hemangiomas into superficial and deep categories. Some of the lesions reviewed have been recently described in the literature, and they may histopathologically mimic lesions of Kaposi's sarcoma; these include targetoid hemosiderotic hemangioma, microvenular hemangioma, tufted hemangioma, glomeruloid hemangioma, kaposiform hemangioendothelioma, spindle-cell hemangioendothelioma, and benign lymphangioendothelioma. In each of these lesions, we update and emphasize those clinical and histopathologic features that are helpful for differential diagnosis with lesions of authentic Kaposi's sarcoma in any of its three stages of development (patch, plaque, or nodule).

Hepatic haemangioendothelioma presenting with early heart failure in a newborn: treatment with hepatic artery embolization and interferon

We report our management of a newborn presenting in utero with congestive heart failure secondary to a giant hepatic haemangioendothelioma. Control of heart failure was achieved by transcatheter hepatic artery embolization, and rapid regression of the tumor was observed after a course of alpha 1 interferon. The combination of hepatic artery embolization and interferon may be a useful approach in the management of this rare, potentially fatal condition.

MR imaging of hepatic hemangiomas of infancy and changes seen with interferon alpha-2a treatment

The purpose of this study was to describe the appearance on magnetic resonance (MR) imaging of hepatic hemangioma, and how the appearance changes in infants who have received interferon alpha-2a (IFN) treatment. We retrospectively studied 16 MR examinations in seven infants (mean age 3.2 months; range 5 days to 13 months) who were symptomatic with hepatic hemangiomas. Five of these seven patients had MR examinations both before and after treatment with IFN. In six of the seven patients, the hepatic hemangiomas were multicentric; they were usually discrete, well-defined nodules, best seen on T2-weighted images as high intensity lesions. One patient had a large solitary heterogeneous lesion. They all exhibited fast flow (seen as flow voids on spin-echo images and high signal intensity structures on gradient-recalled echo images) and enlarged hepatic arteries and veins. There was enlargement of the proximal abdominal aorta with distal tapering. Treatment was followed by accelerated regression of the hemangiomas in size and number and variable shrinkage of the enlarged vessels. As the tumor nodules regressed, they were replaced by normal-appearing hepatic parenchyma; neither fat nor fibrosis was detected by MR imaging.

Imaging diagnosis and follow-up of infantile hepatic haemangioendothelioma: a case report

A 4-week-old male infant was admitted to the hospital with acute gastrointestinal bleeding and marked coagulopathy secondary to vitamin K malabsorption in the presence of cholestasis. Physical examination revealed hepatomegaly and cutaneous haemangiomas. Ultrasonography, CT, and MRI demonstrated a multifocal vascular process and allowed the diagnosis of infantile hepatic haemangioendothelioma to be made without the use of more invasive diagnostic procedures. To avoid high-output congestive heart failure, the patient was treated with oral corticosteroids. After 5 months, rapid involution of the vascular malformations ensued. At age 2 years, a magnetic resonance scan confirmed complete resolution of the hepatic haemangioendothelioma.

Benign liver tumors in children: a 25-year experience

The most common benign liver tumors are hemangiomas and hamartomas, both of mesenchymal origin. Mortality for patients with these tumors has traditionally been substantial despite benign histology. Between 1965 and 1989, 22 patients were treated for a benign liver tumor. This represents 42% of all primary neoplasms of the liver observed during this period. Incidental findings of liver tumors at autopsy were excluded from this series. There were 9 boys and 13 girls with a mean age at presentation of 2.3 years (range, birth to 14 years). Sixteen had hemangiomas and presented earlier in life (mean age, 4.4 months). In this subgroup, high-output cardiac failure was present in 58% of the newborns. Seven hemangiomas were resected, four were observed, three were treated with digitalis, diuretics, and steroids, and one received epsilon-aminocaproic acid. Nonhemangiomatous tumors included four hamartomas, one focal nodular hyperplasia, and one nodular transformation. All six were resected. There was one death early in the series. At a mean follow-up of 38 months, 21 of the 22 patients are cured or asymptomatic. In the past, mortality rates of close to 90% have prompted many investigators to advocate resection of every symptomatic hemangioma. With the availability of more sophisticated imaging techniques and refinements in the treatment of cardiac failure, surgery can be used more selectively. Hepatic resections, once considered heroic, can now be performed with minimal morbidity and virtually no mortality. The 96% survival in this series of benign liver tumors contrasts with high mortality rates reported in the literature and illustrates the spectacular improvements that have been made in the diagnosis and management of these once ill-reputed tumors.

Infantile hepatic haemangioma: investigation and treatment

Infantile hepatic haemangiomas are benign tumours which tend to regress in late infancy. We describe five infants with hepatic haemangioma, three of whom developed congestive cardiac failure. Technetium-99m labelled red blood cell scan was useful in the diagnosis and follow-up of the lesion. The three symptomatic infants were treated with prednisone (2 mg/kg per day) for 2 months in addition to digoxin and diuretics. Significant clinical improvement occurred within 3 weeks in each case. We conclude that the red blood cells scan is a good non-invasive diagnostic test and recommend corticosteroids as initial management for symptomatic infantile hepatic haemangiomas.

Experience with hepatic hemangioendothelioma in infancy and childhood

This report describes our experience with 16 infants and children with a mean age of 7 months and a median age of 6 weeks with hepatic hemangioendothelioma. Fifteen patients presented with hepatomegaly. Seven had congestive heart failure and four had associated cutaneous lesions. Although diagnosis was clinically evident in 15 of the 16 patients, arteriography and computerized tomography (CT) were diagnostic. A variety of treatment approaches were used including radiation, resection, systemic steroids, hepatic artery ligation, angiographic embolization, and various combinations of these modalities. The following information was gained from this experience. CT with enhancement is as specific a diagnostic tool as hepatic arteriography. Angiographic and CT appearances do not correlate with prognosis. Most patients can be treated successfully with steroids; those who do not respond should have other approaches tried such as embolization or ligation. The angiographic appearance determines whether embolization therapy is worthwhile, as we found that hemangioendotheliomatosis with portal as well as hepatic arterial supply will not respond to embolization. The survival rate in this series was 80%.

Infantile hemangioendothelioma: angiographic features and factors determining efficacy of hepatic artery embolization

The angiographic features of infantile hepatic hemangioendothelioma are discussed as well as the role of hepatic artery embolization in its management when more conservative measures have failed. A unique case with portal vein supply of the tumor is presented, and the impact of this angiographic feature is discussed.

Benign neonatal eruptive hemangiomatosis in identical twins

Two cases of neonatal hemangiomatosis occurred in identical twins. Work-up for internal hemangiomas were performed on both infants and were negative. Twin no. 1, with extensive lesions, is currently taking oral prednisone, 2 mg/kg/day, with gradual resolution of the lesions. So far, no new hemangiomas have developed in twin no. 2.

Benign liver tumors in infancy and childhood. Report of 48 cases

This is a clinicopathologic study of 48 patients with benign liver tumors seen during a 32 year period; 2 adenomas, 3 focal nodular hyperplasias, 14 mesenchymal hamartomas, and 29 hemangiomas were reviewed. All patients except those with adenomas were younger than 5 years. Thirty-four patients were symptomatic, 24 of whom were diagnosed by open liver biopsy, whereas 10 with hemangioma had their diagnoses based on clinical and radiologic findings. Death due to tumor occurred in four patients with hemangioma. Infants and children with liver hemangioma and congestive heart failure should receive steroids, digitalis, diuretics, and radiation, alone or in combination. If medical treatment is unsuccessful and the hemangioma is localized to one lobe, resection of the tumor can be performed, but if the lesion is massive, ligation or embolization of the hepatic artery should be considered.

Hepatic benign vascular tumor in infancy: correlative imaging

The use of multiple imaging modalities to diagnose hepatic hemangioendothelioma in a neonate is demonstrated. This approach avoided operative intervention to establish the diagnosis. Tc-99m sulfur colloid and Tc-99m PIPIDA scintigraphy was used to define the nature of sonographic hypoechoic structures in the liver, and angiography was employed to confirm the suspected diagnosis.

Benign neonatal hemangiomatosis

Diffuse neonatal hemangiomatosis is a serious multisystem syndrome of multiple cutaneous hemangiomas, visceral hemangiomatosis with arteriovenous shunts, high output congestive heart failure, thrombocytopenia with hemorrhage and central nervous system involvement. Some neonates with multiple cutaneous hemangiomas, however, may follow a benign course of spontaneous resolution without symptomatic visceral involvement. Such cases may be called benign neonatal hemangiomatosis.

Infantile hepatic hemangioendothelioma with subsequent malignant degeneration

A 4 year old child was seen because of an enlarging epigastric mass and a rapidly falling hematocrit 31/2 years following steroid treatment for multiple hepatic hemangioendotheliomas. Technetium 99m sulfur colloid liver scan and hepatic angiography confirmed the presence of a large, vascular mass involving the left lobe of the liver. A left hepatic lobectomy was performed and histopathology showed angiosarcoma. As children with hemangioendotheliomas of the liver begin to survive for longer periods of time, surveillance for the possible development of neoplastic disease is recommended.

Infantile hepatic haemangioendothelioma. Angiographic considerations

Angiographic abnormalities in infantile hepatic haemangioendothelioma are analysed on the basis of previos reports and on 3 new cases. It is emphasized that the high specificity of angiography of the hepatic artery should make other diagnostic procedures unnecessary.

Concurrent cutaneous and hepatic hemangiomata in infancy: report of a case and a review of the literature

Fifty-eight cases of concurrent cutaneous and hepatic hemangiomatosis in infants have been reported in the world literature. A fifty-ninth case is herewith reported and the literature is reviewed. Untreated cases have a mortality rate of 81%, whereas the mortality of treated cases is 29%. The main cause of death appears to be the consequence of arteriovenous shunting in the liver. Early and aggressive treatment by prednisone, radiotherapy to the liver, partial resection of liver, and ligation of the hepatic artery, each alone or in combinations, have been effective.