Sclerosing cholangitis secondary to bleomycin-iodinated embolization for liver hemangioma

Percutaneous microwave ablation versus sclerotherapy for large hepatic hemangioma: a multi-center cohort study

OBJECTIVE

The study aimed to compare the effectiveness and safety of ultrasound-guided microwave ablation (MWA) and percutaneous sclerotherapy (PS) for the treatment of large hepatic hemangioma (LHH).

METHODS

This retrospective study included 96 patients who underwent MWA (n = 54) and PS (n = 42) as first-line treatment for LHH in three tertiary hospitals from January 2016 to December 2021. Primary outcomes were technique efficacy rate (volume reduction rate [VRR] > 50% at 12 months), symptom relief rate at 12 months and local tumor progression (LTP). Secondary outcomes included procedure time, major complications, treatment sessions, cost and one-, two-, three-year VRR.

RESULTS

During a median follow-up of 36 months, the MWA group showed a higher technique efficacy rate (100% vs. 90.4%, p = .018) and symptom relief rate (100% vs. 80%, p = .123) than the PS group. The MWA group had fewer treatment sessions, higher one-, two- and three-year VRR, lower LTP rate (all p < .05), longer procedure time and higher treatment costs than the PS group (both p < .001). MWA shared a comparable major complications rate (1.8% vs. 2.4%, p = .432) with PS. After multivariate analysis, the lesion's heterogeneity and maximum diameter >8.1 cm were independent risk factors for LTP (all p < .05). In the PS group, lesions with a cumulative dose of bleomycin > 0.115 mg/cm3 had a lower risk of LTP (p = .006).

CONCLUSIONS

Both MWA and PS treatments for large hepatic hemangioma are safe and effective, with MWA being superior in terms of efficacy.

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.

Safety and Feasibility of Transarterial Bleomycin-Lipiodol Embolization in Patients with Giant Hepatic Hemangiomas

Giant hepatic hemangiomas present a significant clinical challenge, and effective treatment options are warranted. This study aimed to assess the safety and feasibility of transarterial bleomycin-lipiodol embolization in patients with giant hepatic hemangiomas. A retrospective analysis was conducted on patients with giant hepatic hemangiomas (>5 cm). Transarterial chemoembolization (TACE) was performed using 7-20 cc of lipiodol mixed with 1500 IU of bleomycin. Safety outcomes, including post-embolization syndrome (PES), hepatic artery dissection, systemic complications, and access site complications, were evaluated. Radiation doses were also measured. Feasibility was assessed based on the achieved hemangioma coverage. Seventy-three patients (49 female, 24 male) with a mean age of 55.52 years were treated between December 2014 and April 2023. The average hospitalization duration was 3.82 days, and 97.3% of lesions were limited to one liver lobe. The average bleomycin dose per procedure was 1301.5625 IU, while the average lipiodol dose was 11.04 cc. The average radiation dose was 0.56 Gy. PES occurred after 45.7% of TACE procedures, with varying severity. Complications such as hepatic artery dissection (three cases), access site complications (two cases), and other complications (one case) were observed. No treatment-related mortality occurred. Hemangioma coverage exceeding 75% was achieved in 77.5% of cases. The study results suggest that transarterial bleomycin-lipiodol embolization is a safe and feasible treatment option for a heterogeneous group of patients with giant hepatic hemangiomas. This approach may hold promise in improving outcomes for patients with this challenging condition.

Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging

Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.

Giant hepatic hemangioma treatment with transcatheter arterial embolisation and transcatheter arterial chemoembolisation; Comparative results

Background/aim

Treatment of hepatic hemangiomas is a controversial topic, and traditional treatment is surgical excision. Transcatheter arterial embolisation (TAE) and transcatheter arterial chemoembolisation (TACE) have been reported as minimally invasive treatment methods. To the best of our knowledge, there are no studies comparing use of TACE and TAE for hepatic hemangioma treatment. The aim of the study is to compare symptom resolution, size reducing effects, and complications of TACE and TAE for the treatment of giant hepatic hemangiomas.

Materials and methods

A total of 104 patients underwent TACE using bleomycin, and 108 patients underwent TAE. The patients were followed-up for 2 year and follow-up images at 6 months, 12 months, and 24 months were acquired. Lesion volumes in both follow-up images were calculated. The patients were examined for any possible procedure related complications as well as the status of their initial symptoms.

Results

The shrinkage period was determined to have ended after 12. month in both groups. The results of the two-way mixed ANOVA showed that there was significant main effect of procedure type (p ≤ 0.001) on hemangioma volumes. Similarly, there was a significant interaction between procedure and time (p ≤ 0.001).

Conclusion

Both methods are effective in symptomatic relief in properly selected patients. However, TACE causes greater volume reduction with less pain and, therefore, is the better endovascular treatment option.

Transarterial Embolization in Neonatal Kasabach-Merritt Syndrome

Background: Kasabach-Merritt syndrome (KMS) is characterized by large hemangiomas and persistent thrombocytopenia, which may result in visceral hemorrhage and disseminated intravascular coagulation. This study aimed to evaluate the value of transarterial embolization (TAE) in neonatal KMS patients. Patients and Methods: The clinical course of 11 neonates with KMS who underwent TAE in the Department of Neonatology, Anhui Provincal Children's Hospital, Anhui Medical University, China, were reviewed retrospectively. Results: Eleven neonates with KMS (nine male and two female) were admitted to our hospital between the age of 1 h and 6 days. All were born with progressively enlarged hemangiomas and persistent thrombocytopenia. The largest lesion had its maximum size reached at 15 × 8 × 8 cm. Eight patients had cutaneous hemangiomas (1 right face, one oropharynx, one left upper arm, two back, one left lumbar, one right lower leg, and one right thigh), and three patients had liver hemangiomas. All 11 patients underwent TAE. Nine patients underwent two TAEs, and two patients underwent only one embolization procedure. They all obtained >80% devascularization of their lesions without a major complication. The platelet count increased at 2-5 days after treatment and reached normal count and coagulation profile at 18-28 days after the TAE. Conclusions: TAE is a safe and effective alternative therapy for neonatal KMS patients.

Hepatic hemangioma: What internists need to know

Hepatic hemangioma (HH) is the most common benign liver tumor and it is usually found incidentally during radiological studies. This tumor arises from a vascular malformation; however, the pathophysiology has not been clearly elucidated. Symptoms usually correlate with the size and location of the tumor. Less commonly the presence of a large HH may cause life-threatening conditions. The diagnosis can be established by the identification of HH hallmarks in several imaging studies. In patients that present with abdominal symptoms other etiologies should be excluded first before attributing HH as the cause. In asymptomatic patient’s treatment is not required and follow up is usually reserved for HH of more than 5 cm. Symptomatic patients can be managed surgically or with other non-surgical modalities such as transcatheter arterial embolization or radiofrequency ablation. Enucleation surgery has shown to have fewer complications as compared to hepatectomy or other surgical techniques. Progression of the tumor is seen in less than 40%. Hormone stimulation may play a role in HH growth; however, there are no contraindications for hormonal therapy in patients with HH due to the lack of concrete evidence. When clinicians encounter this condition, they should discern between observation and surgical or non-surgical management based on the clinical presentation.

Invasive management of symptomatic hepatic hemangioma

Hepatic hemangioma is common among benign liver tumors and usually grows slowly. About 50-70% of hepatic hemangiomas are asymptomatic, and management is not necessary; however, management should be considered in symptomatic patients. The optimal management of symptomatic hepatic hemangioma depends on multiple factors. Invasive management of symptomatic hepatic hemangioma mainly consists of surgery and interventional radiology, including transarterial embolization, ablation, percutaneous sclerotherapy, and percutaneous argon-helium cryotherapy. Although both surgery and interventional radiology are promising in the management of symptomatic hepatic hemangioma, multiple and/or giant hemangiomas represent a clinical dilemma because the complication rate and recurrence rate are relatively high, and symptom relief is not always achieved. However, a review of recent advances in treatment is lacking. We therefore summarized the current invasive management techniques for symptomatic hepatic hemangioma to potentially facilitate clinical decision-making.

Safety and effective of laparoscopic microwave ablation for giant hepatic hemangioma: A retrospective cohort study

Introduction

The purpose of this study was to evaluate the advantages and disadvantages of laparoscopic microwave ablation (LMWA) as compared with conventional open resection (ORES) for the treatment of giant hepatic hemangioma.

Methods

and analysis: A retrospective chart review was conduct on patients with hepatic hemangioma underwent LMWA or ORES between 2014 and 2016.

Results

Of 131 patients, 37 patients underwent ORES and 94 patients underwent LMWA. Blood loss, operative time, postoperative hospital stay, hospital cost (RMB) were significantly different between two groups. Patients after LMWA experienced significantly less pain than those patients undergoing ORES. At a mean follow-up period of 12.8 ± 3.6 months in ORES group and 13.5 ± 2.5 months in LMWA group, no long-term complication was observed.

Conclusion

Compared with ORES, LMWA is a safe and effective minimally invasive for treating giant hepatic hemangioma.

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Retrospectively analysed the clinical data of patients with hepatic haemangioma and investigated the efficacy of operation.

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Technical aspects of laparoscopic microwave ablation for giant hepatic haemangioma were listed base on operation experience.

Transarterial Bleomycin-Lipiodol Embolization (B/LE) for Symptomatic Giant Hepatic Hemangioma

BACKGROUND

Large hepatic hemangiomas can cause symptoms such as pain and bleeding. No consensus currently exists on the optimal management of large and symptomatic hemangiomas. The purpose of this study was to evaluate the role of transarterial bleomycin-lipiodol embolization (B/LE) in the treatment of symptomatic large hepatic hemangioma.

MATERIALS AND METHODS

We retrospectively reviewed 23 patients (29 hemangiomas) treated between July 2011 and August 2017. Transarterial B/LE was performed using 7-15 cc of Lipiodol mixed with 30-45 IU of bleomycin by standard three-way stopcocks. All patients were followed clinically and by imaging for an average of 7.5 months. Patterns of bleomycin-lipiodol distribution in the periphery of hemangiomas were categorized into four different grades. Technical success was defined as proper delivery of bleomycin-lipiodol into the hemangioma confirmed by post-embolization computed tomography. Clinical success was defined as more than 50% reduction of hemangioma volume and symptom improvement during follow-ups.

RESULTS

Technical success and clinical success were 100 and 73.9% (17 patients), respectively. Six patients (26.08%) experienced transient post-embolization syndrome. Significant size reduction was seen in patients with grade 4 hemangioma border coverage (P = 0.042).

CONCLUSION

Transarterial B/LE is a safe and efficient alternative for controlling symptoms related to large hemangiomas.

Superselective Transarterial Chemoembolization as an Alternative to Surgery in Symptomatic/Enlarging Liver Hemangiomas

BACKGROUND

Transarterial embolization of liver hemangiomas has not been considered to be consistently effective.

METHODS

The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively.

RESULTS

Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cm³ (p < 0.01), after a median period of 4 months (range 2-8). A second session was performed in eight patients (median (range) initial volume 1276 (441-8435) cm³) with persistent complaints and/or large lesions receiving feeders from both right and left hepatic arteries (staged treatment). Median (range) lesion size decreased further from 806 (245-4710) to 464 (159-2150) cm³ (p < 0.01). Three patients experienced a postembolization syndrome that persisted after the first week. Seventeen of the 22 symptomatic patients (77%) reported resolution or marked amelioration of complaints. Regrowth after initial regression was not observed during median (range) 14 (8-39) months of follow-up (n:18).

CONCLUSION

Transarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (>1000 cm³) lesions may require two sessions.

Secondary Sclerosing Cholangitis: a Review of Recent Literature

PURPOSE OF REVIEW

Secondary sclerosing cholangitis is an emerging entity. Yet, because of the low incidence and varying etiologies of this disease, the literature is not robust. There are mainly case reports and small studies evaluating the disease. Our aim in this review is to bring the reader up to date with recent literature on secondary sclerosing cholangitis including the disease presentation, course, prognosis, and treatment options.

RECENT FINDINGS

Numerous case reports have been published the last 5 years on secondary sclerosing cholangitis. We have divided them into infectious, drug-induced, ischemic, obstructive, and autoimmune etiologies. The bulk of the literature describes secondary sclerosing cholangitis in the critically ill patient. Secondary sclerosing cholangitis due to drugs or autoimmune causes seem to have the best prognosis. However, causes such as critical illness seem to have worse outcomes.

Enucleation is Better for a Giant Hemangioma Proximal to the Hepatic Portal Vascular Structures

The aim of this study is to compare the effect of liver enucleation with resection of a giant hemangioma proximal to the hepatic portal vascular structures. From 2008 to 2014, 53 patients with giant hemangiomas proximal to the hepatic portal vascular structures underwent surgery in our hospital by the same surgical team. The indications for surgery included a tumor size greater than 8 cm, a middle size greater than 4 cm but with abdominal pain, a rapidly increased tumor size with uncertain malignancy, or tumor rupture. Thirty-two patients (60 %) had pain only, 15 (29 %) had pain with tumor growth, 5 patients (9 %) had an uncertain diagnosis, and 1 patient (2 %) had tumor rupture. Enucleation was performed in 31 patients and liver resection was performed in 22 patients. There were no significant differences in the size of the hemangioma (13.9 ± 3.1 vs 12.3 ± 5.5 cm; P > 0.05), preoperative liver function tests, hemoglobin levels, and platelet counts between the enucleation and resection groups. The mean intraoperative blood loss was significantly less in the enucleation group compared with the resection group (350.9 ± 89.8 vs 988 ± 91.7 mL; P < 0.01), and the enucleation group had a significantly shorter mean operative time (1.7 ± 0.4 vs 2.9 ± 0.9 h; P < 0.01) and significantly shorter duration of hospital stay (9.6 ± 4.2 vs 14.7 ± 3.7 days; P < 0.05). Five patients in the resection group and only 1 patient in the enucleation group had major postoperative complications. Compared to liver resection, enucleation is safer and faster for liver hemangiomas proximal to the hepatic portal vascular structures and is associated with fewer complications.