Diffuse hepatic hemangiomatosis in an adult

Exceptional Liver Transplant Indications: Unveiling the Uncommon Landscape

Liver transplantation represents the definitive intervention for various etiologies of liver failure and encompasses a spectrum of rare indications crucial to understanding the diverse landscape of end-stage liver disease, with significantly improved survival rates over the past three decades. Apart from commonly encountered liver transplant indications such as decompensated cirrhosis and liver cancer, several rare diseases can lead to transplantation. Recognition of these rare indications is essential, providing a lifeline to individuals facing complex liver disorders where conventional treatments fail. Collaborative efforts among healthcare experts lead not only to timely interventions but also to the continuous refinement of transplant protocols. This continued evolution in transplant medicine promises hope for those facing diverse and rare liver diseases, marking a paradigm shift in the landscape of liver disease management.

Gd-EOB-DTPA Enhanced MRI Features of Liver Hemangiomatosis Coexistent with GCH

OBJECTIVES

This study aimed to clarify features of giant cavernous hemangioma (GCH) and liver hemangiomatosis, existing simultaneously on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI).

METHOD

A total of 17 patients with reported hepatic hemangiomatosis between 2015 and 2017 were identified retrospectively. All our patients underwent pre-contrast MRI, triphasic (atrial, portal, venous) Gd-EOB-DTPA dynamic enhancement and hepatobiliary phase (20 minutes delayed). The location, size, morphology and signal characteristics on T1-weighted (T1WI) and T2-weighted images (T2WI), and Gd-EOB-DTPA-enhanced MRI of liver hemangiomatosis were evaluated.

RESULTS

Hemangiomatosis involved the liver adjacent to the edge of the GCH with no normal liver tissue found in 13 cases; in the other 4 patients, a small area of normal liver tissue separated GCH from hemangiomatosis was seen. On non-contrast MRI images, hemangionmatosis presented as numerous microcystic lesions, with low signal intensity on T1WI and high signal intensity on T2WI, compared with unaffected liver. After administration of Gd-EOB-DTPA, heterogeneous enhancement was presented in the arterial phase, during portal and venous phase imaging, becoming more homogeneous. 11 cases showed hypointensity in the hepatobiliary phase (6 cases with intratumor necrosis), and 6 cases showed hyper-intensity in the hepatobiliary phase with a remaining unfilled portion.

CONCLUSION

Hemangiomatosis is extremely rare in the liver adjacent to a GCH. MRI is of great diagnostic and clinical value for this kind of tumor according to the configuration, size, signal, and style of enhancement, but the final diagnosis depends on pathology. Gd-EOB-DTPA-enhanced MRI may help in diagnosing hemangiomatosis coexistent with GCH.

Adult diffuse hepatic hemangiomatosis: A case report and review of the literature

Diffuse hepatic hemangiomatosis (DHH) is an extremely rare disease, especially in adults. We present a case of DHH involving the entire liver in a 62-year-old male with a giant hemangioma next to the superior mesenteric vein. Based on what we could find in PubMed with pathological evidence, there are only seventeen cases of adult DHH reported in the literature. The female-to-male ratio is 2.4:1. Most patients consult for abdominal pain or distension. Radiographic examination shows multiple diffuse liver nodules. On MRI, these lesions show hypointense T1 and hyperintense T2. Some lesions may show peripheral rim enhancement in the arterial phase but no portovenous washout. In total, 47% of patients with DHH have one or more giant hemangioma(s). Pathology shows that the lesions are lined with flat endothelial cells without cellular atypia, which are stained positive for vascular endothelial markers. Liver failure is the main cause of death. Some patients can be improved by partial hepatectomy. However, there is no effective treatment for most patients. Liver transplantation should be considered in patients with liver failure or congestive heart failure caused by DHH. We attempt to classify DHH into two types based on the distribution of DHH and their treatment.

A rare case of cavernous hemangioma accompanied with diffuse hepatic hemangiomatosis

Background

Hepatic cavernous hemangioma (CH) is the most common hepatic benign tumor. Most cases are solitary, asymptomatic, and found incidentally. In symptomatic cases with rapidly growing tumors and coagulopathy, surgical treatment is considered. In rare cases, diffuse hepatic hemangiomatosis (DHH) is reported as a comorbidity. The etiology of DHH is unknown.

Case presentation

A 29-year-old female patient had a history of endometriosis treated with oral contraceptives. Hepatic CH was incidentally detected in the segment IVa of the liver according to the Couinaud classification. Follow-up computed tomography (CT) and ultrasound sonography showed the growth of the lesion and formation of multiple new lesions near the first. Enhanced CT and magnetic resonance imaging (MRI) revealed that the new lesions were different from CH. Although oral contraceptives were stopped, all lesions grew in size. Malignancy and possibility of rupture of these tumors were considered due to the clinical course, and we opted for surgical removal of the tumors. Left liver lobectomy and cholecystectomy were performed. Surgical findings were small red spot spreading and a mass in segment IV of the liver. Pathological examination revealed a circumscribed sponge-like tumor with diffuse irregular extension to the adjacent area. Both of the lesions consisted of blood-filled dilated vascular spaces lined by flat endothelium without atypia. The diagnosis was hepatic CH with DHH. The patient was discharged on postoperative day 12 uneventfully.

Conclusion

We report the successful resection of CH with DHH. The case findings suggest a relationship between oral contraceptive use and enlargement of CH and DHH. Although DHH has been poorly understood, a few previously published cases reported DHH occurrence in patients using oral contraceptives. In such cases, the decision to perform surgical resection should be made after careful examination.

Isolated hepatic hemangiomatosis in 2 septuagenarians

We report 2 cases of isolated hepatic hemangiomatosis: a 76-year-old woman who is, to our knowledge, the oldest person with this diagnosis, and a 74-year-old woman. Magnetic resonance imaging of the abdomen showed T2 hyper intense lesions throughout the liver, peripheral nodular arterial enhancement, and filling of contrast on the portal venous and delayed phases. Computed tomography showed liver lesions with peripheral nodular enhancement in the early phase and a centripetal pattern or "filling in" during the late phase; the lesions opacified after a delay of 3 or more minutes and remained isodense or hyperdense on delayed scans. Both images were consistent with hepatic hemangiomatosis. These cases help increase awareness about benign and unusual liver lesions with radiologic characteristics similar to those of malignant liver tumors. The authors also present a review of 15 other cases of isolated hepatic hemangiomatosis reported in English literature from 1970 to present.

Diffuse Hepatic Hemangiomatosis in the Adult without Extra-hepatic Involvement: An Extremely Rare Occurrence

We present a case of a pathologically proven multinodular diffuse hepatic hemangiomatosis (DHH) with no extra-hepatic involvement in a 68-year-old male. Cavernous hemangioma is the most common hepatic tumor. However, DHH, which is characterized by extensive replacement of liver parenchyma with hemangiomatous lesions, has been rarely reported in adults. The etiology and clinical course are not completely understood because of its rareness, although the diagnosis might be suggested by the magnetic resonance imaging findings.

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.

Giant cavernous hemangioma coexistent with diffuse hepatic hemangiomatosis presenting as portal vein thrombosis and hepatic lobar atrophy

A combination of giant hepatic hemangioma and diffuse hemangiomatosis is extremely rare in adults. Even when they are large, hemangiomas are soft and rarely compress adjacent structures. A 78-year-old man presented with abdominal pain and distension. Ultrasonography, computed tomography, and magnetic resonance imaging demonstrated a large expansile mass replacing the medial segment and caudate lobe with diffusely scattered nodules in the entire liver. The large hilar mass contained a central nonenhancing area and had a mass effect, leading to left portal vein occlusion. The image findings also revealed two unprecedented findings: left lateral segmental atrophy of the liver and recent portomesenteric vein thrombosis. The hepatic lesions were confirmed with hemangiomas by ultrasonography-guided biopsy. We diagnosed intrahepatic portal vein obstruction caused by a mass effect of giant hepatic hemangioma coexistent with diffuse hemangiomatosis, resulting in hepatic segmental atrophy and extrahepatic portal vein thrombosis.

Nodular hemangiomatosis of pleura and peritoneum

Multiple, simultaneously occurring hemangiomas in one or more organs are known as hemangiomatosis syndromes in the context of phacomatosis manifesting in childhood. Nevertheless, hemangiomas of the serous membranes are extremely rare and often present as solitary lesions. We report the case of an elderly patient who suffered from diffuse hemangiomatosis of the visceral peritoneum and pleura and deceased due to acute respiratory distress syndrome following persistent and unmanageable pulmonary hemorrhage. We present an unusual case of a disseminated but histologically benign appearing hemangiomatosis of the serous membranes.

Association of hepatic hemangiomatosis with giant cavernous hemangioma in the adult population: prevalence, imaging appearance, and relevance

OBJECTIVE

The purpose of our study was to evaluate the association of hepatic hemangiomatosis with giant cavernous hemangioma (GCH) and describe the imaging appearances and clinical relevance.

MATERIALS AND METHODS

Forty-one patients who had undergone CT or MRI with reported GCH (> 8 cm) between 1997 and 2009 were identified retrospectively. Three readers interpreted 27 MRI studies, 36 CT studies, and 16 ultrasound studies of these patients. Prevalence, extent, and imaging appearance of coexistent hemangiomatosis in the surrounding liver parenchyma were evaluated.

RESULTS

Forty-two GCHs were identified in 41 patients and hemangiomatosis was present in 18 of 41 patients (44%) with GCH. Twelve patients had a diffuse pattern of hemangiomatosis (67%), and six patients showed a nodular pattern consisting of multiple coalescent nodules measuring < 5 mm (33%). There was no association between the size of the GCH and presence and extent of hemangiomatosis. The common hepatic artery was enlarged (> 5 mm) in 14 patients with GCH, of whom 12 had associated hemangiomatosis. There was a statistically significant association between the size of the hepatic artery and presence of hemangiomatosis (p < 0.001).

CONCLUSION

Hemangiomatosis is not rare in the liver parenchyma adjacent to a GCH. The presence and extent of hemangiomatosis must be specifically communicated to referring physicians. Surgical candidates have to be carefully selected to avoid complications, such as excessive blood loss and diminished risk of postoperative liver decompensation from apparent overestimation of functional residual volume due to oversight of involved liver areas by hemangiomatosis.

Diffuse hepatic hemangiomatosis without extrahepatic involvement in an adult patient

We report an extremely rare case of a diffuse hepatic hemangiomatosis without extrahepatic involvement in an adult. The imaging findings of this tumor were similar to those of a hepatic hemangioma and included contrast enhancement with a centripetal filling pattern of the entire hepatic tumor on the delayed phase of a dynamic CT and inhomogeneous diffuse uptake of the entire tumor on blood-pool images obtained five hours later on a 99mTc-labeled red blood cell scan. Despite its rarity, diffuse hepatic hemangiomatosis can be suggested in adult patients with diffusely involved hepatic tumors showing the radiological findings of a hepatic hemangioma.

Enhanced growth of hepatic hemangiomatosis in two adults after postmenopausal estrogen replacement therapy

Liver hemangiomatosis is defined as extensive hemangioma in the liver. Although hemangioma is the most common hepatic tumor, diffuse hepatic hemangiomatosis is very rare. Most cases of hepatic hemangiomatosis are seen in infancy, but it is extremely rare in adults. This is the first report, showing the enhanced growth of diffuse hepatic hemangiomatosis after hormone replacement therapy. We report herein two unrelated women, 47 and 42 year-old, from different regions of Turkey, who admitted to hospital because of right abdominal pain with diffuse hepatic hemangiomatosis, developed after hormone replacement therapy for menopause. The patients were healthy, except for hemangiomatosis, and their physical examination, routine laboratory tests, and tumor marker levels were within normal limits. It should be noted that their abdominal ultrasonography was normal before hormone therapy, but ultrasonography on admission revealed numerous, ill defined, diffusely located liver nodules in both patients. Dynamic magnetic resonance imaging and scintigraphy have revealed that these lesions are compatible with hemangiomatosis. These results suggest that hepatic hemangiomatosis was induced by estrogen therapy. Consequently, hormone replacement therapy was discontinued, and the patients were followed up for 3 years. Their physical examination and blood chemistry, including liver enzymes, remained within normal range, and the follow-up examination with ultrasonography showed no changes in size of lesions. Because of the possible association of hemangioma with estrogen administration, decisions should be made carefully about estrogen therapy for patients who already have hemangioma, and the periodic ultrasonograpy examination should be planned to detect possible new growth of liver hemangiomatosis.

Benign liver tumors

Benign liver tumors are becoming a subject of great interest because increased access to medical care has allowed discovery of many incidental focal lesions. These tumors may be hepatocellular, biliary, or stromal in nature. Several new lesions have been described in recent years causing a need to reassess the pathogenesis and classification of hepatic tumors. Hepatocellular nodules may be neoplastic or a regenerative response to injury. The size and structure of regenerative nodules varies with the distribution and severity of the hepatic injury, leading to a complex classification. Variation in fat content is easily detected on ultrasonography as focal fatty change and focal fatty sparing. Biliary and stromal cells also produce neoplastic or regenerative lesions. Biliary lesions are often cystic in nature. Stromal lesions are varied because of the many nonparenchymal cell types in the liver.