Sclerosed hemangioma and sclerosing cavernous hemangioma of the liver: a comparative clinicopathologic and immunohistochemical study with emphasis on the role of mast cells in their histogenesis

Hepatic Cavernous Hemangioma Mimicking Malignancy on 18 F-FDG PET/CT Imaging

ABSTRACT

A 65-year-old woman was referred to our hospital because of a liver lesion revealed by ultrasound and CT in an outside institution. 18 F-FDG PET/CT images revealed an FDG-avid lesion in the left lateral lobe of the liver. Malignancy cannot be excluded. A subsequent resection was performed to remove the lesion. Postoperative pathology was hepatic cavernous hemangioma. This case suggests that PET/CT findings of FDG-avid hepatic cavernous hemangioma could mimic malignancy.

Case report: Sclerosed hemangioma of the liver: A diagnostic challenge

Hemangiomas are the most common noncystic benign hepatic tumors and are usually incidentally discovered during routine radiological examinations. The diagnosis of hepatic hemangiomas with a typical presentation is generally easy with plain and cross-sectional imaging; however, it can be complicated when hemangiomas undergo histological changes such as fibrosis. Sclerosed hepatic hemangioma (SHH) is the extreme presentation of this fibrotic process. These atypical lesions can be misdiagnosed as primary hepatic malignancies or metastasis. Their diagnosis is established by histological examination. We report the case of a patient with an SHH, which was misdiagnosed as an intrahepatic cholangiocarcinoma. This article's aim is to draw attention to this infrequent pathology and underline the features of this benign tumor that could suggest its diagnosis prior to surgery to avoid unnecessary hepatic resections.

Added Value of Ultrasound-Based Multimodal Imaging to Diagnose Hepatic Sclerosed Hemangioma before Biopsy and Resection

Imaging methods have the overwhelming advantage of being non-invasive in the diagnosis of hepatic lesions and, thanks to technical developments in the field of ultrasound (US), radiation exposure can also be avoided in many clinical situations. In particular, contrast-enhanced US (CEUS) outperforms other radiological methods in regard to real-time images, repeatability, and prompt reporting and demonstrates relatively few contraindications and adverse reactions. In this study, we reported in detail a rare benign tumor: hepatic sclerosed hemangioma (HSH). We described US-based multimodal imaging (B-flow imaging, US elastography, and Sonazoid CEUS) features of this HSH case. Furthermore, by summarizing the recently published literature on the imaging diagnosis of HSH, we offered readers comprehensive knowledge of conventional imaging methods (CT, MRI) and CEUS in the diagnosis of HSH and preliminarily discussed their mechanism of pathology-based diagnosis. Our multimodal imaging approach may provide a diagnostic strategy for HSH, thus avoiding unnecessary biopsy or resection.

VEGF Pathway Gene Expression Profile of Proliferating versus Involuting Infantile Hemangiomas: Preliminary Evidence and Review of the Literature

Background. Infantile hemangiomas may have unexpected behavior. Initial regression (spontaneously or drug-induced) may be followed by unexplained recurrences. At this moment, there are no well-established criteria to predict infantile hemangioma reccurrences. Methods. We compared the VEGF pathway gene expression profile for one case of involuting infantile hemangioma versus one case of recurrent proliferative infantile hemangioma using TaqMan Array. Results. We found ten genes upregulated for both involuting and recurrent proliferative hemangiomas: ACTB, KRAS, MAP2K1, HRAS, NOS3, BAD, HSPB1, HPRT1, GUSB, and CASP9. Thirteen genes were downregulated for both involuting and proliferative hemangiomas: FIGF, ACTG1, GRB2, MAPKAPK2, ACTG2, MAP2K2, MAPK3, HSP90AA1, MAP2K6, NRAS, ACTA1, KDR, and MAPK1. Three genes showed divergent expression between proliferating and involuting hemangiomas. Proliferating hemangioma had MAPK14 and AKT1 gene upregulation and ACTA2 downregulation. Involuting infantile hemangioma was characterized by ACTA2 upregulation and AKT1 and MAPK14 downregulation. Conclusions. Three genes, AKT1, p38/MAPK14, and ACTA2, were found to have divergent expression in proliferating and involuting infantile hemangiomas. Excepting AKT1, which was mentioned in the last ISSVA classification (strictly related to Proteus Syndrome), none of the other genes were reported. An accurate gene expression profile mapping of infantile hemangiomas together with a gene expression-based hemangioma classification is stringently needed.

Hepatic sclerosing haemangioma showing restricted diffusion: A case report with histopathologic correlation

Hepatic sclerosing haemangiomas are rare benign tumours that are often difficult to distinguish from malignant tumours because these tumours do not show the typical imaging features of cavernous haemangiomas. We report a case of a sclerosing haemangioma that showed restricted diffusion and was difficult to differentiate from a malignancy.

A 60-year-old female was referred to our hospital for evaluation of a hepatic mass that was incidentally diagnosed after a CT scan for right lower quadrant abdominal pain.

Contrast-enhanced dynamic CT showed hepatic capsular retraction, with a small peripheral enhancement of the mass. The lesion appeared homogeneously hypointense on T1-weighted images, heterogeneously hyperintense on T2-weighted images, hyperintense on diffusion-weighted images, and hypointense on apparent diffusion coefficient (ADC) map. The lesion was suspected to be a cholangiocellular carcinoma and was surgically resected, but a final diagnosis of hepatic sclerosing haemangioma was made.

Hepatic sclerosing/sclerosed haemangiomas are usually considered to show an increased ADC, which is useful for distinguishing them from malignant tumours. However, in this particular case, most of the lesion contained many obliterated or narrowed vascular channels, which might have acted as septa restricting the diffusion of water molecules in the intervening fibrous and/or hyalinized tissue. Hepatic sclerosing haemangiomas in the process of becoming completely fibrotic may show restricted diffusion, similar to malignant tumours.

Hepatic sclerosed hemangioma and sclerosing cavernous hemangioma: a radiological study

Purpose

To investigate and compare the CT and MRI features of hepatic sclerosed hemangioma (HSH) and sclerosing cavernous hemangioma (SCH).

Materials and methods

Twelve HSH cases and 36 SCH cases were included, the imaging findings on CT (9 HSH and 34 SCH) and MRI (8 HSH and 10 SCH) were analyzed. Qualitative image analysis included the location, size, shape, capsular retraction, density, calcification, signal intensity on T₁-weighted image (T₁WI) and T₂-weighted image (T₂WI), presence of diffusion restriction, apparent diffusion coefficient (ADC) map, transient hepatic attenuation difference around the lesion, and the dynamic enhancement patterns.

Results

The presence of liver cirrhosis in patients with HSH (3/12) was higher than SCH (1/36) (P = 0.043). The morphology appearance before enhancement showed no significant difference between HSH and SCH. Moreover, SCH had a stronger trend of centripetal enhancement patterns of cavernous hemangiomas (83.3%) compared to HSH (25%) (P < 0.001). Due to more frequent atypical enhancement features, containing rim-like enhancement, no enhancement, and peripheral heterogeneous enhancement, the misdiagnosis rate of HSH (75%) was significantly higher than that of SCH (16.7%) (P < 0.001). Furthermore, the ADC values of HSH and SCH were both higher than that of the surrounding liver parenchyma (P = 0.009, P = 0.002); however, there was no significant difference in ADC values between themselves (P = 0.613).

Conclusion

SCH showed the same trend of centripetal enhancement characteristics as typical hemangioma, while HSH exhibited atypical enhancement features due to complete sclerosis. Higher ADC values might contribute to the identification of atypical HSH and SCH from malignancies.

Cholangiocarcinoma - Part 2, Tumoral and Nontumoral Mimics and Imaging Features Helpful in Differentiation

Each of the 3 morphological subtypes of cholangiocarcinoma has a different set of imaging differentials. Emulators of mass-forming cholangiocarcinoma include other primary and secondary hepatic malignancies, benign tumors and tumor-like mimics such as abscess, hemangioma and confluent hepatic fibrosis. Benign inflammatory biliary strictures constitute the major differential of periductal-infiltrative type and intraductal calculi are the main consideration for intraductal-growth type. CT and MRI are the standard imaging tools for characterization of cholangiocarcinoma and differentiating it from close mimics. Here we will describe the various tumoral and non-tumoral mimics of cholangiocarcinoma and discuss specific imaging features useful in differentiation.

The humbling hemangioma: uncommon CT and MRI imaging features and mimickers of hepatic hemangiomas

Cavernous hemangiomas are among the most common liver lesions encountered in abdominal imaging. While classical imaging characteristics usually aid the radiologist in confidently arriving at its diagnosis, atypical hemangiomas can prove to be difficult to distinguish from other more worrisome hepatic lesions such as metastases and hepatocellular carcinoma. Furthermore, some malignant lesions can display features that simulate hemangiomas. The radiologist must be aware of these pitfalls to make an accurate diagnosis, when possible.

Hepatic Sclerosing Hemangioma Mimicking Malignancy: A Case and Literature Review

BACKGROUND

Sclerosing hemangiomas of the liver are rare, benign tumors with degenerative changes. These degenerative changes, however, often obscure the true, benign nature of the tumor and give them features indistinguishable from other malignant processes, thus making the diagnosis difficult.

CASE PRESENTATION

A 70-year-old male without any previously diagnosed liver disease or malignant process presented with incidental right hepatic mass in ultrasonography and weight loss. Physical exam was unremarkable. The labs were significant for mild pancytopenia, elevated total bilirubin and slightly decreased transferrin. Follow-up triple phase-contrast CT scan of the abdomen revealed a lobulated, poorly demarcated lesion measuring 4.8 x 4.5 cm, located in segment V of the liver with encasement of the left portal branch. The overall picture was indeterminate but highly suspicious for malignancy. A decision was made to perform a CT-guided biopsy which revealed sclerosing hemangioma of the liver.

CONCLUSION

It is challenging to differentiate sclerosing hepatic hemangioma from atypical hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors utilizing only imaging modalities. The diagnostic workup should include biopsy of the atypical liver lesion which unveils the final diagnosis and avoid subjecting the patient to an extensive, and invasive surgical resection.

Imaging-based diagnosis of benign lesions and pseudolesions in the cirrhotic liver

Liver cirrhosis is a leading cause of death worldwide, with 1-year mortality rates of up to 57% in decompensated patients. Hepatocellular carcinoma (HCC) is the most common primary tumor in cirrhotic livers and the second leading cause of cancer-related mortality worldwide. Annually, up to 8% of patients with cirrhosis develop HCC. The diagnosis of HCC rarely requires histological confirmation: in fact, according to the most recent guidelines, the imaging features of HCC are almost always sufficient for a certain diagnosis. Thus, the role of the radiologist is pivotal because the accurate detection and characterization of focal liver lesions in patients with cirrhosis are essential in improving clinical outcomes. Despite recent technical innovations in liver imaging, several issues remain for radiologists regarding the differentiation of HCC from other hepatic lesions, particularly benign lesions and pseudolesions. It is important to avoid misdiagnosis of benign liver lesions as HCC (false-positive cases) because this diagnostic misinterpretation may lead to ineligibility of a patient for potentially curative treatments or inappropriate assignment of high priority scores to patients on waiting lists for liver transplantation. This review presents a pocket guide that could be useful for the radiologist in the diagnosis of benign lesions and pseudolesions in cirrhotic livers, highlighting the imaging features that help in making the correct diagnosis of macroregenerative nodules; siderotic nodules; arterioportal shunts; hemangiomas, including fast-filling hemangiomas, hemangiomas with pseudowashout, and sclerosed hemangiomas; confluent fibrosis; pseudomasses in chronic portal vein thrombosis; and focal fatty changes.

A hepatic sclerosed hemangioma with drastic changes in contrast-enhanced ultrasonography

Hepatic sclerosed hemangioma is a rare benign liver tumor that originated from hepatic cavernous hemangioma; however, the process of its formation has been unclear. We herein present the patient of a histologically proven hepatic sclerosed hemangioma that showed drastic changes in diagnostic images in a short period. A 56-year-old man was referred to our hospital for the treatment of suspicious hepatocellular carcinoma with hepatitis C, approximately 2 cm in diameter in liver segment 8. Initially, the tumor manifested as early entire enhancement with mildly delayed washout in contrast-enhanced ultrasonography; however, it manifested as continuous peripheral enhancement with the central non-enhanced area after 1 month in various diagnostic images. He completely quit drinking and smoking 1 month preoperatively. No special symptoms and signs were found to suggest tumor ischemia. Anatomical resection of segment 8 was completed. Histological examination confirmed the final diagnosis of common type hepatic sclerosed hemangioma, derived from atypically enhancing cavernous hemangioma. No signs of impaired blood flow were observed in both diagnostic images and histological examination. Sclerosing changes in hepatic cavernous hemangioma may be completed in a relatively short time with no apparent reason.

Sclerotic changes of cavernous hemangioma in the cirrhotic liver: long-term follow-up using dynamic contrast-enhanced computed tomography

PURPOSE

To determine the intra- and extralesional factors that predict sclerotic degeneration of hepatic hemangiomas in the cirrhotic liver on long-term follow-up computed tomography (CT) examinations.

MATERIALS AND METHODS

Fifty-seven hepatic hemangiomas (> 5 mm in diameter) in 41 cirrhotic patients, recruited over a 5-year period (January 2005-December 2009), were subjected to CT to determine which factors predict sclerotic contraction or degeneration in hemangiomas. Prior and follow-up CT examinations (from 2000 to 2018) were included to observe time-related changes. The patients' gender, age, cause of cirrhosis, progression of background liver cirrhosis, lesion size/location/contrast enhancement pattern, and serum aspartate transaminase to platelet ratio index were correlated with sclerotic changes of each lesion.

RESULTS

According to the dynamic CT features, 36 of 57 (63%) hemangiomas were determined to have sclerotic changes during the follow-up period (1.1-14.4 years, median: 7.8 years), including 28 lesions (49%) reduced by ≥ 20% in diameter. In univariate analysis, age (p = 0.047) and morphological progression of background cirrhosis (p = 0.013) were significantly related to sclerotic change of hemangiomas. In the logistic regression analysis, only morphological progression of background liver cirrhosis independently predicted sclerotic change (odds ratio: 4.88, p = 0.007). With the exception of exophytic location free from size reduction (p = 0.023 in multivariate analysis), no other analyzed factors were significantly correlated with sclerotic changes.

CONCLUSION

Overall, sclerotic changes of hepatic cavernous hemangioma followed the morphological progression of background liver cirrhosis, while exophytic lesions tended to be free of size reduction.

Hepatic sclerosing hemangioma mimics hepatic malignancies: a case report and multidisciplinary approach

Background

Hepatic sclerosing hemangiomas (HSH) are rare benign vascular tumors that mimic radiologically hepatic malignancies. HSH is characterized by extensive fibrosis and hyalinosis as a result of degeneration and thrombosis. Pre-operative diagnosis is very difficult and most of the cases undergo surgical resections.

Case presentation

A 65 years old, hepatitis C virus-infected female presented by an accidentally discovered hepatic focal lesion. Magnetic resonance imaging (MRI) showed a T2 hyperintense mass displaying peripheral enhancement in porto-venous phase. The patient had a simultaneous typical hepatic hemangioma and multiple vertebral bodies’ hemangiomata. Tissue-guided biopsy revealed a densely sclerotic stroma containing vascular spaces with occasional obliteration of the lumen. Immunohistochemical staining was performed for Pan CK, CD34, SMA, VEGF, and c-Kit which confirmed the vascular nature of neoplasm and the involuting phase of hemangioma development. The patient was reassured and recommended for a regular radiological follow-up to reassess the lesion size.

Conclusion

The definitive preoperative diagnosis of HSH is still problematic. However, the awareness of surgeons by this entity, peripheral enhancement in porto-venous phase on dynamic MRI, the presence of simultaneous typical hepatic hemangioma in the absence of cancer history could raise suspicion for HSH. Liver biopsy is still the gold standard in approaching the accurate diagnosis.

Resection as first-line therapy for large hepatic sclerosing hemangioma: a case report

Hepatic sclerosing hemangioma is a rare benign disease that occurs in association with hepatic cavernous hemangioma degeneration and sclerosis. Recent studies have shown that radiofrequency (RF) ablation is an alternative treatment for hepatic cavernous hemangiomas, even for large hemangiomas (≥10 cm). However, RF ablation might not be suitable to treat large sclerosing hemangiomas. We herein report the successful surgical removal of a large hepatic sclerosing hemangioma after RF ablation treatment failure in a 65-year-old man. In conclusion, we suggest that resection should be chosen as a first-line therapy for the disease.

Hepatic sclerosing cavernous haemangioma can mimic the nodular elastosis stage of segmental atrophy

AIMS

Segmental atrophy (SA) of the liver is a recently described pseudotumour that can show a broad spectrum of histological changes. The previously described histological differential diagnosis of SA has included cystic disease of the liver, amyloid, cancer-associated elastosis, and epithelioid haemangioendothelioma. We have observed that sclerosing cavernous haemangiomas (SCHs) can mimic the nodular elastosis stage of SA; the aim of this study was to explore this differential diagnosis.

METHODS AND RESULTS

We identified 20 SCHs and 12 SAs, excluding haemangiomas with treatment effect. Several clinical and morphologic characteristics were examined, and elastin and CD34 staining was performed on cases with available tissue. SA was always asymptomatic, whereas SCH caused symptoms in 56% of patients (P = 0.026); SCH also tended to be larger (mean size: SCH, 47 mm; SA, 16 mm; P = 0.027). Thick-walled blood vessels were more common in SA than in SCH (92% versus 45%, P = 0.011), as was ductular reaction (50% versus 5%, P = 0.0057). The two lesions had similar rates of border irregularity, residual entrapped hepatocytes, matrix oedema, and at least mild elastic fibrosis as seen on special staining, although staining was typically dense and diffuse in SA. CD34 immunostaining demonstrated at least scattered vessels in all cases of SA and SCH.

CONCLUSIONS

SCH can mimic SA, although it is generally larger and more often symptomatic. Elastin staining provides a useful adjunct to standard haematoxylin and eosin histological examination in resolving this differential diagnosis.

Spectrum of Pitfalls, Pseudolesions, and Misdiagnoses in Noncirrhotic Liver

OBJECTIVE

The purpose of this article is to illustrate the various pitfalls, mimics, and atypical features that can lead to inaccurate diagnosis of focal lesions in a noncirrhotic liver. The content includes relevant pathogenesis and background as well as specific clues that can be used to reach an accurate diagnosis.

CONCLUSION

When assessing focal hepatic lesions, it is important to avoid pitfalls and misdiagnoses that can alter the management plan. Helpful strategies for avoiding pitfalls include paying close attention to the clinical history of the patient, carefully evaluating all of the available imaging studies, and being aware of the various radiologic mimics.

Spectrum of Pitfalls, Pseudolesions, and Potential Misdiagnoses in Cirrhosis

OBJECTIVE

The purposes of this article are to review a variety of pitfalls in liver imaging that can lead to the inaccurate diagnosis of focal hepatic lesions in cirrhosis, to describe the pathophysiologic processes of these pitfalls, and to provide specific clues for achieving the correct diagnoses.

CONCLUSION

Cirrhosis complicates liver imaging. The distortion and replacement of normal liver parenchyma by fibrous and regenerative tissue can change the typical appearance of many benign lesions, causing them to be misinterpreted as malignancy. In addition, the high incidence and prevalence of hepatocellular carcinoma among patients with cirrhosis put radiologists on high alert for any suspicious findings, especially because not all hepatocellular carcinomas have a typical imaging appearance.

A hepatic sclerosing hemangioma emerged in the postoperative course of multiple gastric carcinoid tumors masquerading as metachronous liver metastasis

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The authors present an unusual case of newly appearing hepatic sclerosing hemangioma newly emerged in the postoperative course after the resection of multiple gastric carcinoid tumors.

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Hepatic sclerosing hemangioma is often misdiagnosed as malignant lesion for its resemblance on the imaging studies.

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Although preoperative diagnosis is still difficult, hepatic sclerosing hemangioma must be included into the differential diagnosis of hepatic tumors.

Introduction

Hepatic sclerosing hemangiomas are rare tumors whose appearance on imaging is similar to that of malignant tumors. The resulting difficulties in preoperative diagnosis frequently lead to surgical resection in order to accurately identify the tumor.

Case presentation

A 68-year-old man was diagnosed with multiple gastric carcinoid tumors (T1N1M0, pStage IIIB) after total gastrectomy with D2 lymph node dissection. Enhanced computed tomography of the abdomen 2 years after the initial surgery revealed a novel solid lesion with ring enhancement measuring 22 × 15 mm at S5 of the liver. Metachronous liver metastasis from multiple gastric carcinoid tumors was suspected, and partial hepatectomy of S5 was successfully performed. Histopathological diagnosis was sclerosing hemangioma with no malignant findings.

Discussion

Ours is the first reported case of a newly appearing sclerosing hemangioma excised and diagnosed histopathologically. Hepatic sclerosing hemangiomas are rarely observed, but they are often resected under a preoperative diagnosis of malignant lesion due to the similarity on imaging studies.

Conclusion

Surgeons must consider that a hepatic tumor may be a sclerosing hemangioma, particularly when the lesion appears to be ring enhanced.

Hepatic Sclerosing Hemangioma Simulating Gallbladder Carcinoma: A Rare Case

Sclerosing hemangiomas of the liver are rare benign tumors of the liver. Although hepatic hemangiomas are the most common benign liver tumor, they are mostly cavernous in nature. A hepatic sclerosing hemangioma is defined by presence of fibrosis and hyalinization as a result of degenerative changes in a cavernous hemangioma. The radiological features of sclerosing hepatic hemangioma can resemble those of cholangiocarcinoma, fibrolamellar carcinoma, or metastasis. We present a case of a hepatic sclerosing hemangioma in which an unusual magnetic resonance imaging (MRI) and computed tomography (CT) appearance lead to radiographic concern for gallbladder carcinoma. To the best of our knowledge, this is the first case in the literature of a hepatic sclerosing hemangioma mimicking a gallbladder carcinoma.

Hepatic Sclerosing Hemangioma with Predominance of the Sclerosed Area Mimicking a Biliary Cystadenocarcinoma

We report here an extremely rare case of hepatic sclerosing hemangioma mimicking a biliary cystadenocarcinoma. A previously healthy 39-year-old woman was referred to our hospital because of a large tumor in the liver. Abdominal computed tomography revealed early peripheral ring enhancement in the arterial phase and slight internal heterogeneous enhancement in the delayed phase. Magnetic resonance imaging revealed a tumor with low intensity in the T1-weighted image and very high intensity in the fat-saturated T2-weighted image. The patient underwent hepatectomy for a possible malignant liver tumor. Grossly, the tumor appeared as a white, solid, and cystic mass (weighted 1.1 kg and measured 170×100×80 mm) that was elastic, soft, and homogeneous with a yellowish area. Histological examination showed that the tumor mostly consisted of fibrotic areas with hyalinization. The typical histology of cavernous hemangioma was confirmed in part, and the tumor was diagnosed as a sclerosing hemangioma with predominancy of the sclerosed area. A review of 20 cases reported previously revealed that only 2 (10%) patients were diagnosed as having sclerosing hemangioma preoperatively.

Multiple hepatic sclerosing hemangiomas: a case report and review of the literature

Background

Hepatic sclerosing hemangioma, a very rare benign tumor, is characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. Such atypical hemangiomas can be diagnosed incorrectly as primary or metastatic malignancies based on imaging characteristics. We present herein a rare case of giant and multiple hepatic sclerosing hemangiomas that are difficult to differentiate from hepatic malignancies and review the relevant literature.

Case presentation

The patient was a 48-year-old male who was found to have multiple hepatic tumors and a giant tumor (67 × 53 mm) superior to the inferior vena cave by an abdominal ultrasonography during a routine medical examination. The patient was referred to our hospital for further evaluations and diagnosis of the multiple hepatic tumors. Dynamic CT showed low-density tumors in the delayed phase suggestive of membrane-covered lesions. EOB-MRI demonstrated a mass with low-signal intensity mass on T1-weighted images and areas of high-signal intensity on T2-weighted images and a hypointense mass in the hepatobiliary phase, which showed high intensity on DWI-based ADC map. FDG-PET showed no accumulation of [¹⁸F]-FDG. A provisional diagnosis of multiple scirrhous hepatocellular carcinomas was made on the basis of these imaging studies, and caudate lobectomy of the liver and partial hepatectomy of S2 and S6 were performed. Histopathological examination showed that the tumors were composed of various sized irregularly dilated vessels with some blood thrombi, inflammatory cell infiltration, fibrous and hyalinized sclerotic or myxomatous stroma, resulting in a diagnosis of multiple hepatic sclerosing hemangiomas.

Conclusions

Differentiation of multiple sclerosing hemangiomas from other hepatic malignant tumors, such as intrahepatic cholangiocarcinoma, metastatic liver cancer, and scirrhous hepatocellular carcinoma characterized by abundant fibrous stroma, is difficult because the radiological findings are very similar. Inclusion of hepatic sclerosing hemangioma in the differential diagnosis of multiple liver tumors could enable optimal management; this possibility is important to consider before planning invasive therapies.

Hepatic sclerosed hemangioma with special attention to diffusion-weighted magnetic resonance imaging

BACKGROUND

A hepatic sclerosed hemangioma (HSH) is a very rare benign liver tumor. The correct preoperative diagnosis of HSH is very difficult because its features of imaging are similar to those of intrahepatic cholangiocarcinoma or colorectal liver metastasis.

CASE PRESENTATION

We experienced five patients who were diagnosed histologically with HSH. The preoperative diagnoses were HSH in two patients, cavernous hemangioma in one, intrahepatic cholangiocarcinoma in one, and colorectal liver metastasis in one. All patients were treated with hepatectomy (one laparoscopic and four laparotomies), and the diagnosis was completed by histological investigation of the resected specimen. In particular, we investigated the apparent diffusion coefficient (ADC) mean value using diffusion-weighted sequences of magnetic resonance imaging (DW-MRI). The average of the ADC mean (ADC_mean) value of HSH was 1.94 × 10^-3 mm²/s (range 1.73-2.10 × 10^-3 mm²/s), which was higher than the value of common malignant liver tumors. Interestingly, the ADC_mean values were almost the same between the degenerate (1.90 ± 0.17 × 10^-3 mm²/s) and the non-degenerate areas (1.95 ± 0.26 × 10^-3 mm²/s) in HSH.

CONCLUSIONS

The ADC_mean value seemed to be quite useful to preoperatively distinguish HSH from other malignant liver tumors.

Peritumoral Hyperplasia in Hepatic Sclerosed Hemangioma

Peritumoral hyperplasia (PTH) is a hyperplastic lesion located around hypervascular tumors. Hepatic sclerosed hemangioma is a very rare form of hemangioma with sclerotic changes and is distinct from sclerosing hemangioma. We present a patient with non-alcoholic steatohepatitis-induced cirrhosis who presented with a hypervascular tumor. The tumor showed atypical findings of hemangioma and was treated with surgical resection because hepatic malignancy could not be ruled out. Histopathologic examination revealed the tumor was a sclerosed hemangioma with PTH. Lesions with carcinogenic potential were found in the PTH lesion. Sclerosed hemangioma should be observed and managed carefully.

Cavernous hemangioma with extensive sclerosis masquerading as intrahepatic cholangiocarcinoma - A pathologist's perspective

A patient presented with an acute episode of bright red blood in her stool. The incidental liver mass seen in segment 4 was suspected to represent a cholangiocarcinoma due to associated mild intrahepatic biliary ductal dilatation and suspicion for capsular retraction. Pathology confirmed that this lesion represented a sclerosing hemangioma. This case report corroborates prior observations that degenerative changes in hemangiomas—sclerosis, narrowing of vascular channels, thrombosis, infarct, hemorrhage—may produce atypical radiographic findings. Since these atypical radiographic features may suggest a primary or metastatic malignancy, the protean appearance of hemangiomas remains an important consideration in the evaluation of hepatic masses.

Sclerosed Hemangioma Accompanied by Multiple Cavernous Hemangiomas of the Liver

BACKGROUND

A sclerosed hemangioma of the liver, an extremely rare type of benign hepatic tumor, was found at autopsy.

CASE REPORT

An 81-year-old Japanese man was admitted to our hospital for surgical resection of squamous cell carcinoma of the skin in his left forearm. At admission, serological tests for hepatitis B surface antigen and hepatitis C antibody were negative with no evidence of cirrhosis. At 2, 3, and 5 months after the removal of the forearm tumor, skin grafting was performed because of unhealed skin ulceration. Although anti-bacterial drugs were prescribed, the patient died after the 3rd skin graft (5 months after the surgery) because of pneumonia. During the treatment course, the patient was diagnosed as having multiple liver masses suspected to be cysts of the liver based on non-contrasted computed tomography results. Autopsy revealed a sclerosed hemangioma occupying the entire left lobe accompanied by multiple small cavernous hemangiomas in the right lobe of the liver.

CONCLUSIONS

Sclerosed hemangioma, a rare benign disease, occurred in association with degeneration and sclerosis of cavernous hemangiomas of the liver. The VEGF pathway may be involved in the genesis of cavernous and sclerosed hemangioma of the liver.

Hepatic Sclerosed Hemangioma: a case report and review of the literature

Background

Although cavernous hemangioma is one of the most frequently encountered benign hepatic neoplasms, hepatic sclerosed hemangioma is very rare. We report a case of hepatic sclerosed hemangioma that was difficult to distinguish from an intrahepatic cholangiocarcinoma by imaging studies.

Case presentation

A 76-year-old male patient with right hypochondralgia was referred to our hospital. Abdominal ultrasonography revealed a heterogeneously hyperechoic tumor that was 59 mm in diameter in segment 7 of the liver. Dynamic computed tomography showed a low-density tumor with delayed ring enhancement. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) demonstrated a low-signal intensity mass with ring enhancement on T1-weighted images. The mass had several high-signal intensity lesions on T2-weighted images. EOB-MRI revealed a hypointense nodule on the hepatobiliary phase. From these imaging studies, the tumor was diagnosed as intrahepatic cholangiocarcinoma, and we performed laparoscopy-assisted posterior sectionectomy of the liver with lymph node dissection in the hepatoduodenal ligament. Histopathological examination revealed a hepatic sclerosed hemangioma with hyalinized tissue and collagen fibers.

Conclusion

Hepatic sclerosed hemangioma is difficult to diagnose preoperatively because of its various imaging findings. We report a case of hepatic sclerosed hemangioma and review the literatures, especially those concerning imaging findings.

A hepatic sclerosed hemangioma with significant morphological change over a period of 10 years: a case report

INTRODUCTION

Liver cavernous hemangioma is the most common noncystic hepatic lesion, and a hemangioma that undergoes degeneration and fibrous replacement is called a hepatic sclerosed hemangioma.

CASE PRESENTATION

A 63-year-old Japanese man was admitted for detailed investigation of a liver tumor. Tumor markers carcinoembryonic antigen, alpha-fetoprotein, and CA19-9 levels in the peripheral blood were not elevated at any time. Plain computed tomography showed an approximately 1.5 cm low density mass in the periphery of segment 8, which was marginally enhanced on contrast-enhanced dynamic computed tomography. On magnetic resonance imaging, the tumor was hypointense on T1-weighted image and hyperintense on T2-weighted image. The tumor was suspected to be an atypical hemangioma, metastatic, hepatocellular carcinoma, or cholangiocellular carcinoma. Segmental hepatectomy was performed. Histological examination of the resected tumor specimen revealed a sclerosed hemangioma with marked hyalinization and sparse stromal fibrosis. Immunochemically, the tumor cells were positive for CD34 and alpha smooth muscle actin. Electron microscopically, the residual hemangioma consisted of numerous caveolae and vesicles in endothelial cells in irregular shapes and sizes. Immunostaining for caveolin-1 showed decreased or no caveolin-1 reactivity in the hyalinized lesions of the sclerosed hemangioma, but abundant caveolin-1 reactivity in the residual cavernous hemangioma. Of interest, computed tomography images of the tumor obtained 10 years earlier at our hospital depicted a 3 cm typical cavernous hemangioma.

CONCLUSIONS

Hepatic sclerosed hemangioma is a rare condition. Comparison of radiological findings of the lesion over a period of 10 years was valuable in providing insight for the evolutional process from liver cavernous hemangioma to hepatic sclerosed hemangioma.

Hepatic screlosed hemangioma which was misdiagnosed as metastasis of gastric cancer: report of a case

A screlosed hemangioma of the liver is rare among hepatic tumors. A 75 years old male was referred to our hospital for gastric cancer and a hepatic tumor. The histological finding of gastric cancer was revealed to be well differentiated adenocarcinoma. The liver tumor was 1.1×1.0 cm in size and located in segment 8 of the liver. Computed tomography (CT) showed it to be a tumor with ring enhancement. Magnetic resonance imaging (MRI) showed the tumor to have a low signal on T1-weighted and slightly high signal on T2-weighted images. Level of hemoglobin was 7.8 g/dl. It was thought to be persistent bleeding from gastric cancer. With diagnosis of liver metastasis from gastric cancer, chemotherapy is recommended. However, to control the bleeding from gastric cancer, we performed distal gastrectomy and wedge resection of liver (S8). The histological examination of the liver tumor revealed to be a hepatic sclerosed hemangioma with hyalinized tissue and collagen fibers. We report herein a case of the rare tumor which was misdiagnosed as a liver metastasis of gastric cancer.

[Atypical evolution of liver hemangioma: a report of two cases]

We present and illustrate two cases of atypical evolution of liver hemangiomas studied with magnetic resonance imaging. In the first case, the lesion was associated with capsular retraction and became progressively smaller until it completely disappeared. The second case involved a woman taking birth control pills in whom the lesion grew progressively larger, doubling its diameter.

Sclerosed hemangioma of the liver: possible diagnostic value of diffusion-weighted magnetic resonance imaging

We present a case of a sclerosed hemangioma (SH) of the liver that showed a high apparent diffusion coefficient (ADC) value. The patient was undergoing preoperative evaluation for a metastatic breast cancer lesion when a liver mass with a diameter of 3 cm was found. It was described as a heterogeneously hyperechoic mass on ultrasonography and as a well-defined, lobulated mass with early peripheral enhancement and internal heterogeneous enhancement in the delayed phase on computed tomography. The fat-suppressed T2-weighted images demonstrated a heterogeneously hyperintense mass, which showed an ADC value of 2.01 x 10(-3) mm(2)/s. Liver metastasis and cholangiocellular carcinoma could not be excluded based on the imaging findings. After surgery, a definite diagnosis of SH was obtained. Microscopically, many hyalinized portions with poor cellular and fibrous components were observed in the tumor, and this hyalinization accompanied with liquiform degeneration, which may have been one of the causes of the high ADC value. We discuss the diagnostic value of diffusion-weighted imaging for SH of the liver.

Sclerosing haemangiomas of the liver: two cases of mistaken identity

We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed.

Case report. Sclerosing liver haemangioma with pericapillary smooth muscle proliferation: atypical CT and MR findings with pathological correlation

We report a case of sclerosing liver haemangioma with pericapillary smooth muscle proliferation in a 63-year-old man who presented with abdominal pain. Because the tumour showed atypical features on CT and MRI, a correct diagnosis could not be made until surgery. In this report, the atypical radiological findings are illustrated and correlated with pathological findings.

Imaging Features of Sclerosed Hemangioma

OBJECTIVE

The purpose of this study was to review the imaging features of sclerosed hemangioma.

CONCLUSION

In our series, suggestive features of sclerosed hemangiomas include geographic outline, capsular retraction, decrease in size over time, and loss of previously seen regions of enhancement. Additional features include presence of transient hepatic attenuation difference (THAD), rim enhancement, and nodular regions of intense enhancement as seen in typical hemangiomas. Although not pathognomonic, some features of sclerosed hemangioma can suggest it as a diagnostic possibility and lead to biopsy rather than more extensive intervention.

The complex functions of mast cells in chronic human liver diseases

Mast cells (MCs) are multifunctional effector cells of the immune system. MCs were originally thought to be involved in IgE-associated immediate hypersensitivity and allergic disorders, but it is now known that they contain or elaborate an array of mediators with a multitude of effects on many other cells. A number of studies have found that MCs are involved in various liver diseases. Although still controversial, they seem to be involved in the liver's fibrotic response to chronic inflammation and parasitic infection. Hepatic fibrosis is the most frequent liver response to toxic, infectious, or metabolic agents. During the establishment of this pathological condition, there is an increase in the components of the basement membrane that leads to continuous basement membrane-like structures being raised within Disse's space and a decrease in the number of sinusoid endothelial fenestrae. This leads to a complex process called "sinusoidal capillarization." At the cellular level, liver fibrogenesis is initiated by hepatocyte necrosis, which induces the recruitment of a large number of inflammatory cells, including MCs, which can be considered the primary effectors of the process changing sinusoidal endothelial cells into capillary-type endothelial cells. We review the roles played by MCs in hepatic chronic diseases and describe a biopsy section of hepatic tissue taken from a patient with chronic C virus-related hepatitis showing diffuse sinusoidal capillarization and a high density of MCs. This observation has led us to hypothesize a relationship between these highly specialized cells and sinusoidal capillarization.

Hepatic cavernous hemangioma: underrecognized associated histologic features

BACKGROUND/AIMS

Cavernous hemangiomas (CH) are typically described as solitary, well-circumscribed lesions and are reported to have a distinct fibrous interface. This study describes underrecognized histological changes of large hepatic hemangiomas that contradict this long-standing view.

METHODS

Nineteen cases of hepatic resections for CH were reviewed. Stains for estrogen and progesterone receptors (ER/PR), MIB-1, alpha-smooth muscle actin, collagen IV, and elastic Van Gieson stains were applied to the lesions.

RESULTS

The CHs measured 5-31 cm (mean 16.6 cm). Sixteen (84%) CHs had an irregular interface with the liver parenchyma while only three had the well-defined fibrous capsule typically described for CH. Fifteen (79%) CHs had dilated vascular spaces filled with blood 0.1-2.0 cm beyond the confines of the main CH, which we have designated hemangioma-like vessels (HLVs). The histochemical and immunohistochemical stains in both CH and HLVs were similar, with the walls of the vessels composed predominantly of collagen with some faint elastic fibers and smooth muscle, endothelium underlined by collagen IV, negative ER/PR in all components, and a proliferation rate of <5/100 endothelial cells.

CONCLUSION

Irregular edges of CH and HLVs in the liver parenchyma adjacent to CH have been underrecognized. No significant differences in staining or proliferative rate were present between CHs and HLVs, suggesting the HLVs are within the spectrum of CH.