Embolization of a giant hepatic hemangioma prior to urgent liver resection. Case report and review of the literature

Transarterial Bleomycin-Lipiodol Chemoembolization for the Treatment of Giant Hepatic Hemangiomas: An Assessment of Effectiveness

This study evaluates the effectiveness of superselective transcatheter arterial chemoembolization (TACE) using a bleomycin-lipiodol emulsion in treating giant hepatic hemangiomas. A retrospective review included 31 patients with a mean age of 53 ± 10.42 years who underwent TACE from December 2014 to October 2022, with follow-up imaging examinations to assess outcomes. Technical success was defined as successful embolization of all feeding arteries, and clinical success was defined as a reduction in hemangioma volume by 50% or more on follow-up imaging. This study observed a 100% technical success rate. Post-embolization syndrome was common, and two cases of asymptomatic hepatic artery dissection were noted. Clinical success was achieved in 80.6% of patients, with significant volume reduction observed in the majority. Conclusively, superselective transcatheter arterial chemoembolization with bleomycin-lipiodol emulsions is presented as a viable and effective treatment option for giant hepatic hemangiomas. With no procedure-related mortality and significant volume reduction in most cases, this method offers a promising alternative to surgical intervention. This study's findings suggest a need for further exploration and validation in larger-scale prospective studies.

[Radiation therapy of hepatic haemangiomas: Review from a case report]

Haemangioma is the most frequent benign hepatic tumour. Haemangioma is generally asymptomatic but it can sometimes cause disabling symptoms depending on its size and location. Surgery and interventional radiology are the cornerstone of the treatment in this situation. Radiation therapy, already used with good efficacy and safety to treat hepatic malignant lesions as hepatocarcinoma and metastases, is a relevant option in case of contraindication to surgery because of multiple or very large lesions. In this context, we report the case of a patient presenting with multiple symptomatic hepatic haemangiomas, successfully treated by radiation therapy in our department. These good results justified a review of the literature to report series of patients treated in this indication and to describe the main treatment regimens used.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach-Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.

RESULTS

Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach-Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.

CONCLUSION

The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.

Giant hepatic haemangioma rupture in a patient on direct oral anticoagulant therapy

Rupture of a liver haemangioma is extremely rare, with less than 100 cases reported in the literature. This is the first case known to date reporting a rupture occurring with direct oral anticoagulant therapy. A 76-year-old woman presented with acute abdominal pain and syncope in the context of commencing apixaban 4 weeks prior. Abdominal computed tomography and angiography demonstrated a large heterogenous mass in the left liver lobe with contrast blush suggestive of a bleeding tumour. Urgent transcatheter arterial embolization successfully ceased haemorrhage. Due to persistent compressive symptoms, a left lateral hepatectomy was performed. CD34 immunostaining of the tissue revealed variably sized vessels, which was consistent with a ruptured giant hepatic haemangioma. Our case substantiates the limited available literature regarding ruptured haemangiomas. Combined with previous case reports, this report will significantly contribute to our understanding of the risk factors, diagnosis and surgical indications for ruptured hepatic haemangiomas.

Spontaneous hepatic haemangioma rupture and hemoperitoneum: a double problem with a single stage interventional radiology solution

Hepatic haemangioma is a congenital vascular malformation, considered the most common benign mesenchymal hepatic tumour. Spontaneous or traumatic rupture is the most severe complication. In case of rupture, surgical resection and enucleation, as a single therapy or after trans-arterial embolization are considered the treatments of choice. We report a case of spontaneous rupture of a hepatic haemangioma with massive hemoperitoneum successfully treated by percutaneous hepatic trans-arterial embolization and pelvic drainage alone.

Role of selective intra-arterial embolization in benign liver tumors

OBJECTIVE

To present cases of symptomatic benign liver tumors diagnosed and treated with intra-arterial embolization before surgery.

MATERIAL AND METHODS

We present the cases of 7 patients diagnosed with symptomatic benign liver tumors that required treatment: 1 focal nodular hyperplasia, 2 giant cavernous hemangiomas, 1 hepatic adenomatosis, and 3 hepatic adenomas. Once the feeding arteries were identified, tumors were embolized with polyvinyl alcohol particles (500μm-700μm) and then the feeding artery was plugged with coils if there was an arterial pedicle to ensure the total vascular exclusion of the tumor. The surgical intervention took place 4 to 7 days after embolization.

RESULTS

All 7 patients were women (age range, 23-74 years); presurgical intra-arterial embolization was done in 6. In 1 patient with adenomatosis, embolization was done to control intraparenchymal hepatic hemorrhage. In the 6 patients who underwent surgery, the tumor was completely excised and no intraoperative bleeding events or postoperative complications occurred.

CONCLUSIONS

Provided there is a consensus among the multidisciplinary team, embolization is a useful option in the perioperative management of giant and/or symptomatic benign liver tumors.

The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature

BACKGROUND

The risk of spontaneous bleeding or rupture of liver hemangiomas still remains unknown. The aim of this review was to analyze the problem of spontaneous bleeding or rupture in liver hemangiomas and to identify factors leading to bleeding in these cases.

METHODS

A MEDLINE search was undertaken to identify articles in English, French, German, Italian, and Spanish from 1898 to 2010. Basic data such as age and sex of patients were collected. Additional data such as risk factors or causes of rupture were also analyzed. Cases were divided into spontaneous and non-spontaneous ruptures.

RESULTS

A total of 97 cases are described. In 51 of the 97 patients (52.6%) a non-spontaneous rupture was identified. Only in 46 out of the 97 cases (47.4%) was a spontaneous rupture found. Non-spontaneous rupture was significantly more frequent in patients aged <40 years than in older ones (p = 0.0099). Mean size of the ruptured lesions was 11.2 cm (range 1-37 cm). Massive bleeding occurred in 88 patients (90.7%). Reported mortality over the past 20 years has been significantly lower than before (p < 0.001). The overall mortality for the period under study was ~35%.

CONCLUSIONS

The spontaneous rupture of a hepatic hemangioma is to be considered an exceptional event. Preventive surgery should be considered only for lesions of at least 11-cm size in special cohorts of patients.

Same day arterial embolisation followed by hepatic resection for treatment of giant haemangioma

Cavernous haemangiomas are the most common tumour of the liver; they are benign in nature and have an incidence of up to 7.3% at autopsy. Occasionally, they may cause symptoms necessitating intervention. We report the case of a woman who presented with non-specific abdominal pain and evidence of a giant hepatic haemangioma on abdominal imaging. She underwent selective hepatic arteriography with transcatheter arterial embolisation followed by same-day left hemi-hepatectomy, making an uneventful recovery. We discuss the management of giant hepatic haemangiomas and present same day transcatheter arterial embolisation prior to hepatic resection as a safe and viable treatment strategy in selected cases.

Preoperative arterial embolization of large liver hemangiomas

PURPOSE

We aimed to investigate the efficacy and safety of preoperative selective intra-arterial embolization (PSIAE) in the surgical treatment of large liver hemangiomas.

METHODS

Data of 22 patients who underwent resection of large liver hemangiomas were retrospectively analyzed. PSIAE was performed in cases having a high risk of severe blood loss during surgery (n=11), while it was not applied in cases with a low risk of blood loss (n=11).

RESULTS

A total of 19 enucleations and six anatomic resections were performed. Operative time, intraoperative bleeding amount, Pringle period, and blood transfusion were comparable between the two groups (P > 0.05, for all). The perioperative serum aspartate transaminase level was not different between groups (P = 1.000). Perioperative total bilirubin levels were significantly increased in the PSIAE group (P = 0.041). Postoperative hospital stay was longer in the PSIAE group. Surgical complications were comparable between groups (P = 0.476).

CONCLUSION

Patients who underwent PSIAE due to a high risk of severe blood loss during resection of large liver hemangiomas had comparable operative success as patients with a low risk of blood loss who were operated without PSIAE. Hence, PSIAE can be used for the control of intraoperative blood loss, especially in surgically difficult cases.

Enucleation after Embolization of Liver Failure-Causing Giant Liver Hemangioma

Patient: Female, 73

Final Diagnosis: Giant liver hemangioma

Symptoms: Abdominal discomfort • abdominal enlargement • Icterus

Medication: —

Clinical Procedure: Enucleation after embolization of liver failure-causing giant liver

Specialty: Surgery

Transcatheter arterial embolization for unresectable symptomatic giant hepatic hemangiomas: single-center experience using a lipiodol-ethanol mixture

Objective

The present article is aimed at reporting the author’s experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas.

Materials and Methods

The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009–2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture.

Results

Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure.

Conclusion

Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.

Management of liver hemangioma using trans-catheter arterial embolization

BACKGROUND

Hemangioma, a congenital vascular malformation, is the most common benign liver lesion that is usually remain stable subsequently requiring not treatment; however, complications such as abdominal pain or fullness, coagulation disturbances, and inflammatory syndrome may occur, demanding a specific treatment of hemangioma.

OBJECTIVES

To assess the safety, feasibility and efficacy of trans-catheter arterial embolization (TAE) for the treatment of Liver hemangioma.

PATIENTS AND METHODS

TAE was performed on 20 patients with liver hemangioma. The embolic agent used was polyvinyl alcohol (PVA) particles (300-400 micron, Jonson and Johnson Cordis, USA). All patients were followed up for 6 months. Imaging was carried out and patients were also evaluated symptomatically through telephone interview by a physician.

RESULTS

Twenty patients aged from 21 to 63 years (mean: 46.8, SD: 10.26) were included in this study. Post embolization syndrome, including abdominal pain, fever, and leukocytosis occurred in one patient 1 week after TAE and lasted for 3 days. No serious adverse event and TAE-related death was observed. None of the patient underwent another intervention including surgery. During follow up interval, decreased episode of abdominal pain was documented in all patients who had pain. Tumor enlargement was also stopped during the follow up. The average diameter of tumors was 97.00 mm (range: 25-200 SD: 47.85) and 88.95 mm (range: 23-195 SD: 43.27) before and after embolization, respectively. Comparison of images before and after TAE revealed statistically significant decrease in the size of lesion (P value: 0.004, t: 3.31).

CONCLUSIONS

Our findings indicate that TAE is a safe and efficient procedure for the treatment of liver hemangioma. Further studies with larger sample sizes are required to support therapeutic effects of TAE.

What is changing in indications and treatment of hepatic hemangiomas. A review

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature

Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.

Transarterial embolization for treatment of giant hepatic hemangiomas: An analysis of 46 cases

AIM: To evaluate the long-term outcome of transarterial embolization (TAE) in patients with giant hepatic hemangiomas.

METHODS: This retrospective study included 46 patients with giant hepatic hemangiomas who were treated by TAE at our hospital from February 2003 to October 2010. Changes in tumor size between pre- and post-treatment were evaluated, and complications such as changes in liver function were analyzed as well.

RESULTS: The mean diameter of hemangiomas before TAE was 9.2 cm. All the patients were followed by ultrasound (US)/computed tomography (CT)/magnetic resonance imaging (MRI) for 3 to 106 mo. Follow-up radiological examinations revealed that the mean diameter of hemangiomas was 4.0 cm after treatment, and the reduction of tumor size was statistically significant (P < 0.05). Symptoms related to hemangiomas were relieved in all the patients. Minor complications were found in 27 cases (58.7%) after embolization, and no severe complication occurred.

CONCLUSION: TAE is safe and reliable in the treatment of giant hepatic hemangiomas in terms of long-term efficacy.

Successful liver resection in a giant hemangioma with intestinal obstruction after embolization

Hepatic hemangiomas are the most common benign tumor of the liver. Most hepatic hemangiomas remain asymptomatic and require no treatment. Giant hepatic hemangiomas with established complications, diagnostic uncertainty and incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. We present a case of a giant hemangioma with intestinal obstruction following transcatheter arterial embolization, by which the volume of the hemangioma was significantly reduced, and it was completely resected by a left hepatectomy. A 21-year-old Asian man visited our hospital for left upper quadrant pain. Examinations at the first visit revealed a left liver hemangioma occupying the abdominal cavity, with a maximum diameter of 31.5 cm. Embolization of the left hepatic artery was performed and confirmed a decrease in its size. However, the patient was readmitted to our hospital one month after embolization for intestinal obstruction. A left hepatectomy was completed through a herringbone incision, and safely removed a giant hemangioma of 26.5 cm × 19.5 cm × 12.0 cm in size and 3690 g in weight. Pre-operative arterial embolization is effective for reducing tumor size, but a close follow-up to decide the time for hepatectomy is important.

Diagnosis and management of giant hepatic hemangioma: the usefulness of contrast-enhanced ultrasonography

Giant hepatic hemangiomas, though often asymptomatic, may require intervention if rapid growth occurs. The imaging studies including the computed tomography, magnetic resonance imaging, and ultrasonography, and so on are effective for the diagnosis and the management of this tumor; however, due to its size and various patterns of these studies, we need to carefully consider the therapeutic methods. Compared to the cost needed for these modalities, recently developed and approved Perflubutane- (Sonazoid-) based contrast agent enhanced ultrasonography is reasonable and safe. The major advantage is the real-time observation of the vascular structure and function of the Kupffer cells. By this procedure, we can carefully follow the tumor growth or character change in a hemangioma and decide the timing of therapeutic intervention, since abdominal pain, abdominal mass, consumptive coagulopathy, and hemangioma growth are the signs for the therapeutic intervention. We reviewed recent reports about Sonazoid-based enhancement and also showed the representative images collected in our department. This is the first review showing the detailed findings of the giant hemangiomas using Perflubutane (Sonazoid). This review will help the physician in making the decision, and we hope that Sonazoid will gain widespread acceptance in the near future.

Giant cavernous hepatic hemangioma shrunk by use of sorafenib

Here we report a case of a 76-year-old man with a giant cavernous hepatic hemangioma of more than 20 cm in diameter. Since the hepatic hemangioma was actually growing and might possibly rupture and he complained of abdominal symptoms, we decided to perform interventional therapy. First we performed transcatheter arterial embolization (TAE) of the hepatic arteries. However, since this was not sufficiently effective, we added sorafenib (600 mg/day). As a result, the tumor shrank with symptomatic improvement. Subsequently, an adverse event occurred, and we suspended the sorafenib therapy. Then, the tumor began to grow, and we resumed administering sorafenib at 400 mg/day. The tumor shrank again, and we continued the sorafenib therapy thereafter. The tumor shrinkage, although possibly induced by the effect of TAE, is considered primarily due to the effect of treatment with sorafenib, because (1) TAE did not sufficiently reduce the blood supply to the inside of the tumor; (2) other tumors shrank in the area not targeted by TAE; and (3) the tumor grew during suspension of sorafenib therapy and shrank again after resuming the treatment.

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

AIM

To describe initial clinical experience with bipolar radiofrequency ablation (RFA) for symptomatic giant hepatic haemangiomas.

MATERIALS AND METHODS

Four consecutive patients with a large-volume, symptomatic hepatic cavernous haemangioma of >10 cm were treated with bipolar RFA during laparotomy with ultrasound guidance. Complications were carefully noted. Clinical and radiological effectiveness were evaluated comparing baseline with 3 and 6 months follow-up of symptom assessments and upper abdominal magnetic resonance imaging (MRI) or computed tomography (CT).

RESULTS

RFA was successfully performed for all four giant haemangiomas. No major complications were observed. Peri-procedural shrinking was remarkable and intermediate-term volume reduction ranged from 58-92% after 6 months. Symptom relief after 6 months was complete in two patients and considerable in the other two.

CONCLUSION

Preliminary results suggest intra-operative bipolar RFA to be a safe, feasible, and effective technique for treatment of giant symptomatic hepatic cavernous haemangiomas.

A symptomatic giant hepatic hemangioma treated with hepatectomy

We describe a patient with symptomatic giant hepatic hemangioma treated with hepatectomy. A 53-year-old woman presented with upper abdominal distension and appetite loss. The medical history included multiple hepatic hemangiomas that had been detected 2 years earlier but were left untreated. Initial laboratory tests revealed pancytopenia and mild coagulopathy. Computed tomography and magnetic resonance imaging demonstrated a giant hemangioma, 27 cm in diameter, in the enlarged right lobe of the liver. The inferior vena cava was compressed by tumor without thrombus in the infrahepatic vena cava. The portal venous phase of supramesenteric arteriography revealed compression of the portal vein. There were several hemangiomas in the left lobe. Gastric outlet obstruction due to giant hepatic hemangioma in the right lobe was diagnosed. Laparotomy was performed, and a markedly enlarged liver was detected. Right hepatectomy was performed with an anterior approach. The liver-hanging maneuver could not be performed because of tumor compression of the inferior vena cava. Right hepatectomy was performed with intermittent clamping (Pringle maneuver). Hepatic hemangiomas of the left lobe were not resected because the remnant liver would be reduced. The weight of the resected specimen was 2,100 g. Pathologic examination of the surgical specimen confirmed the presence of benign hepatic hemangiomas. The postoperative course was uneventful, and the patient's appetite improved. The patient was discharged 8 days after the operation. Abdominal distension decreased and laboratory data improved after the operation. Computed tomography revealed hypertrophy of the left lobe of the liver after the operation.

A case of a ruptured sclerosing liver hemangioma

Hemangiomas are the most common benign tumors found in the liver, typically asymptomatic, solitary, and incidentally discovered. Although vascular in nature, they rarely bleed. We report a case of a 52-year-old woman with a previously stable hemangioma who presented to our hospital with signs and symptoms indicative of spontaneous rupture. We review the literature, focusing on diagnosis and management of liver hemangiomas.

Surgical treatment of giant liver hemangiomas: enucleation with continuous occlusion of hepatic artery proper and intermittent Pringle maneuver

BACKGROUND

The present study was designed to investigate the efficacy and safety of continuous occlusion of the hepatic artery proper combined with intermittent use of the Pringle maneuver for reduction of blood loss during enucleation of giant liver hemangiomas.

METHODS

A retrospective study was performed on 115 patients who underwent enucleation of giant liver hemangiomas with or without continuous occlusion of the hepatic artery proper at a tertiary care university hospital. The characteristics of patients and perioperative parameters including intraoperative blood loss, the degree of ischemia-reperfusion injury, the incidence and severity of postoperative complications, and the length of hospital stay were summarized and compared in the two groups.

RESULTS

Seventy-three and 42 patients underwent enucleation of hepatic hemangiomas with and without continuous occlusion of the hepatic artery proper, respectively. The Pringle maneuver was routinely used in all patients in cycles of 15/5 min of clamp/unclamp times. Patient characteristics were comparable between the two groups. Intraoperative blood loss and blood transfusion in the continuous occlusion group were significantly lower than in the non-occlusion group (P < 0.001 and P = 0.012, respectively). In a comparison of the two groups, there were no significant differences in the changes of the perioperative serum aspartate transaminase and total bilirubin levels (P = 0.086, P = 0.829, respectively), and in the postoperative hospital stay and surgical complications according to Clavien's classification (P = 0.378, P = 0.227, respectively).

CONCLUSIONS

Continuous occlusion of the hepatic artery proper when added to intermittent use of the Pringle maneuver significantly reduced intraoperative blood loss when compared with intermittent Pringle maneuver alone. Enucleation of giant hepatic hemangiomas using continuous occlusion of the hepatic artery proper in addition to intermittent application of the Pringle maneuver for up to 1 h was safe.

Giant liver hemangioma resected by trisectorectomy after efficient volume reduction by transcatheter arterial embolization: a case report

INTRODUCTION

Liver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.

CASE PRESENTATION

A 38-year-old Asian man was referred to our hospital with complaints of severe abdominal distension and pancytopenia. Examinations at the first visit revealed a right liver hemangioma occupying the abdominal cavity, protruding into the right diaphragm up to the right thoracic cavity and extending down to the pelvic cavity, with a maximum diameter of 43 cm, complicated with "asymptomatic" Kasabach-Merritt syndrome. Based on the tumor size and the anatomic relationship between the tumor and hepatic vena cava, primary resection seemed difficult and dangerous, leading us to first perform transcatheter arterial embolization to reduce the tumor volume and to ensure the safety of future resection. The tumor volume was significantly decreased by two successive transcatheter arterial embolizations, and a conventional right trisectorectomy was then performed without difficulty to resect the tumor.

CONCLUSIONS

To date, there have been several reports of aggressive surgical treatments, including extra-corporeal hepatic resection and liver transplantation, for huge hemangiomas like the present case, but because of its benign nature, every effort should be made to avoid life-threatening surgical stress for patients. Our experience demonstrates that a pre-operative arterial embolization may effectively enable the resection of large hemangiomas.

An update on indications for treatment of solid hepatic neoplasms in noncirrhotic liver

During recent years, we have experienced an increased detection of previously unsuspected liver masses in otherwise asymptomatic patients owing to the widespread application of imaging techniques. Regardless of the malignant or cystic tissues, a remarkable percentage of these masses are represented by benign solid neoplasms. Treatment of benign liver tumors still represents a major concern in the hepatic surgery field. Indications for surgery have remained unchanged for many years, but the laparoscopic approach could determine in some cases a broadening of indications, which may result in overtreatment. In this article, the main surgical indication for hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma are discussed with regard to the most recent advancements in literature. In addition, a separate section deals with the role of laparoscopy in the treatment of benign liver neoplasms.

Resection of a rapid-growing 40-cm giant liver hemangioma

Hemangiomas are the most frequent benign tumors of the liver. Most hemangiomas are asymptomatic and therefore largely diagnosed only in routine screening tests. Usually they are small and require no specific treatment. In some situations they can reach great dimensions, causing some discomfort to the patient. Resection of liver hemangioma is indicated in cases of great dimension tumors causing symptoms such as pain, nausea or bloating caused by compression of adjacent organs. We report a case of a rare giant hemangioma with rapid growth in short time: a 50 year old female reported to our institution with a 40 cm giant liver hemangioma and then underwent a left hepatectomy.

Right trisegmentectomy with thoracoabdominal approach after transarterial embolization for giant hepatic hemangioma

Hepatic hemangiomas need to be treated surgically in cases where they are accompanied with symptoms, have a risk of rupture, or are hardly distinguishable from malignancy. The present authors conducted embolization of the right hepatic artery one day before an operation for a huge hemangioma accompanied with symptoms and confirmed a decrease in its size. The authors performed a right trisegmentectomy through a J-shape incision, using a thoracoabdominal approach, and safely removed a giant hemangioma of 32.0 cm × 26.5 cm × 8.0 cm in size and 2300 g in weight. Even for inexperienced surgeons, a J-shape incision with a thoracoabdominal approach is considered a safe and useful method when right-side hepatectomy is required for a large mass in the right liver.

[A case of thoracic empyema with broncho-pleural fistula existing for 57 years. Histological findings of squamous cell carcinoma in the resected lung]

Background

Methods

Results

Conclusion

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