Safety and Efficacy of Laparoscopic Radiofrequency Ablation for Hepatic Hemangiomas: A Multicenter Retrospective Study

Laparoscopic microwave ablation for giant cavernous hemangioma coexistent with diffuse hepatic hemangiomatosis: Two case reports

BACKGROUND

Hepatic hemangioma represents the most common benign primary hepatic neoplasm. Although most such tumors are small and asymptomatic, giant cavernous hemangioma (GCH) is frequently symptomatic, and needs intervention. Moreover, diffuse hepatic hemangiomatosis (DHH) is not rare in the liver parenchyma adjacent to a GCH. The management strategy for hepatic hemangiomas can differ depending on the presence of associated hemangiomatosis and the amount and distribution of the residual hepatic parenchyma.

CASE SUMMARY

Herein, we report two patients with GCH coexistent with DHH successfully treated by laparoscopic microwave ablation. The two GCHs were ablated completely and the ablated zone atrophied obviously in imaging follow-ups after ablation. Surprisingly, there was a trend toward gradual reduction and diminishment of DHH.

CONCLUSION

Thermal ablation treatment might be an effective and less invasive treatment for GCH coexistent with DHH around the hemangioma.

Reconsideration of the clinical management of hepatic hemangioma

In this letter, we comment on the article by Zhou et al that was published in the recent issue of the World Journal of Gastrointestinal Surgery. This article proposes a new clinical grading system based on a multidisciplinary team, which prompts us to rethink the clinical management of hepatic hemangioma. Hepatic hemangioma is the most common benign solid liver tumor. In general, follow-up and observation for the vast majority of hepatic hemangioma is reasonable. For those patients with symptoms and severe complications, surgical intervention is necessary. Specific surgical indications, however, are still not clear. An effective grading system is helpful in further guiding the clinical management of hepatic hemangioma. In this article, we review the recent literature, summarize the surgical indications and treatment of hepatic hemangioma, and evaluate the potential of this new clinical grading system.

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Hepatic adenoma: evolution of a more individualized treatment approach

BACKGROUND

Hepatic adenomas (HAs) are benign, solid liver lesions, which carry a risk of hemorrhage and malignant transformation. This review article highlights the advances in the diagnosis and management of HAs.

METHODS

A comprehensive review was performed using MEDLINE/PubMed and Web of Science databases with a search period ending on September 30, 2023. Using PubMed, the terms "hepatocellular," "hepatic," and "adenoma" were searched.

RESULTS

HA has been classified into at least 8 subtypes based on molecular pathology, each exhibiting unique histopathologic features, clinical considerations, and risk of malignant transformation. The most common subtype is inflammatory HA, followed by hepatocyte nuclear factor 1α-inactivated HA, β-catenin exon 3-mutated HA (βex3-HA), β-catenin exon 7- or 8-mutated HA, sonic hedgehog HA, and unclassified HA. Magnetic resonance imaging is the best imaging method for diagnosis and can distinguish among HA subtypes based on fat and telangiectasia pathologic characteristics. The risk of malignant transformation varies among molecular subtypes, ranging from <1% to approximately 50%. Up to 42% of HAs present with spontaneous intratumoral hemorrhage and peritoneal hemorrhage. In general, only 15% to 20% of patients require surgery. HA larger than 5 cm are more likely to be complicated by bleeding and malignant transformation, regardless of subtype, and should generally be resected. In particular, βex3-HA carries a high risk of malignant transformation and can be considered a true precancerous lesion.

CONCLUSION

The management of HAs is based on a multidisciplinary approach. Clinical decision-making should integrate information on gender, tumor size, and HA subtyping. In the future, patients with HA will benefit from novel medical therapies tailored to the individual molecular subtypes.

Surgical indications for solid hepatic benign tumors: An updated literature review

Hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma are the most common benign solid liver tumors. However, their surgical indications have been the subject of debate. Minimally invasive liver resection reduces the cost of surgery and may lead to overtreatment of benign liver tumors. Recently, there has been a growing understanding of the etiology, pathogenesis, and natural history of these tumors. Great progress has also been made in imaging. The use of MRI and contrast agents has improved the accuracy of non-invasive diagnosis of these tumors, and especially in the identification of specific molecular subtypes of liver adenoma. These factors have resulted in alterations of surgical indications for these tumors. This article examines recent literature and it discusses the surgical indications for hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma while summarizing modifications in clinical management.

Thermal ablation of hepatic hemangioma: A multi-center experience with long-term outcomes

BACKGROUND

Thermal ablation, currently used extensively for liver tumors, also has been applied. successfully to hepatic hemangioma; however, it is still considered experimental because previous studies have comprised small sample sizes with short follow-up periods.

PURPOSE

We aimed to investigate the effectiveness, safety, and long-term outcomes of thermal ablation for hepatic hemangioma.

MATERIALS AND METHODS

From October 2011 to February 2021, the data of 357 patients with 378 hepatic hemangiomas treated by thermal ablation at six hospitals were analyzed in this retrospective study. The technical success, safety, and long-term follow-up results were analyzed.

RESULTS

A total of 252 patients (mean age, 49.2 ± 10.5 years) with 273 subcapsular hemangiomas underwent laparoscopic thermal ablation, whereas 105 patients with 105 hemangiomas located in the liver parenchyma underwent CT-guided percutaneous ablation. Of the 378 hepatic hemangiomas (5.0-21.2 cm), 369 lesions were subjected to one session of ablation, while 9 lesions were subjected to two sessions of ablation. Technical success was achieved in 100.0% of cases. Complete ablation was achieved in 361 of 378 hemangiomas (95.5%), while 17 hemangiomas (4.5%) were incompletely ablated, showing subtle enhancement at the peripheral rim. The major complication rate was 2.0% (7/357). The median follow-up period was 67 months (range, 12-124 months). Of the 224 patients with hemangioma-related symptoms, 216 demonstrated complete disappearance of symptoms (96.4%), while 8 were ameliorated (3.6%). Ablated lesion shrinkage was progressive, and 11.4% of hemangiomas almost completely disappeared over time (P < 0.01).

CONCLUSION

With a reasonable ablation strategy and comprehensive treatment measurements, thermal ablation could be a safe, feasible, and effective treatment option for hepatic hemangioma.

Ablation for Benign Liver Tumors: Current Concepts and Limitations

Percutaneous ablation under imaging guidance is a curative treatment that can induce complete tumor necrosis with advantages of minimal invasiveness and a low risk of complications. Thermal ablation, which includes radiofrequency ablation and microwave ablation, is a representative technique that has sufficient antitumor effects in cases of hepatocellular carcinoma with ≤3 lesions measuring ≤3 cm and preserved liver function. The short- and long-term outcomes of patients are comparable with those achieved with surgical resection. Despite their nonmalignant nature, some benign liver tumors require treatment for symptoms caused by the presence of the tumor and/or continuous enlargement. Ablation may be the treatment of choice because it has lower burden on patients than surgical treatment. This review describes the recent concepts, progress, and limitations of ablation-based treatment for benign liver tumors.

Ultrasound-guided percutaneous sclerotherapy versus surgical resection in the treatment of large hepatic hemangiomas: a retrospective study

BACKGROUND

It is no consensus on the best management for patients with large hepatic hemangiomas. This study was designed to evaluate the efficacy and safety of percutaneous sclerotherapy compared to surgical resection for large hepatic hemangiomas.

METHODS

A total of 89 patients with large hepatic hemangiomas from single center underwent either percutaneous sclerotherapy (n = 14) or surgical resection (n = 75) as first-line treatment was retrospectively studied, followed up for 9-24 months using ultrasound. Terms of intraoperative and postoperative information, postoperative complications, and treatment effectiveness were compared between the two groups.

RESULTS

Percutaneous sclerotherapy had shorter operative time (p < 0.001), less blood loss, lower rate of prophylactic abdominal drainage (97.3% vs. 0%, p < 0.001), fewer minor complications (48.0% vs. 7.1%, p < 0.01), shorter hospital stay (p < 0.001), lower hospital cost (p < 0.001), higher Alb level (p < 0.001) and lower postoperative clinical index including ALT, AST and WBC (p < 0.001 for both) than did surgical resection. The major complications were demonstrated no significant difference between the two groups. In addition, the mean maximum cross-sectional areas of hemangioma dropped from 5044.1 ± 2058.0 mm² to 1924.6 ± 1989.5 mm² (65.2% reduction) during 9-24 months follow-up (p < 0.001) in the percutaneous sclerotherapy group, while all patients in the surgical resection group achieved complete response.

CONCLUSION

Percutaneous sclerotherapy is the preferred method for the treatment of large hepatic hemangioma over surgical resection when compared with the items of postoperative recovery, blood loss, complications, hospital stays, and lower hospital costs. The reduction of the maximum cross-sectional area of hepatic hemangioma in the percutaneous sclerotherapy group is satisfactory.

Safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation of giant hepatic hemangioma: a matched case-control study and literature review

BACKGROUND

To report the safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation (LIRC) compared with laparoscopic hepatectomy (LH) in treating giant hepatic hemangioma.

METHODS

From 2017 to 2020, 19 consecutive patients with giant hepatic hemangioma (≥ 10 cm) received LIRC in one center. We selected a subgroup of 103 patients treated by LH in other four centers who well matched the 19 consecutive patients treated with LIRC, in a 1:1 fashion based on the tumor location, tumor size, and body mass index. Furthermore, the differences in technical success, operative time, operative blood loss, change of laboratory indexes, hospital stays, complication and clinical responds are compared between the two groups.

RESULTS

Technical success was achieved in all 38 patients. Patients in the LIRC group had a relative shorter operative time (P < 0.001) and less operative blood loss (P = 0.003). The serum levels of C-reactive protein (CRP), total bilirubin (TBil), alanine aminotransferase (ALT), and aspartate transaminase (AST) were elevated significantly (P < 0.05) 1 day after the resection and returned to normal within 7 days in both groups; however, relatively lower serum levels of those indexes were observed in the LIRC group (P < 0.05). The total complication rate was relatively lower in the LIRC group compared with the LH group (P = 0.029). Patients in the LIRC group had shorter hospital stays than those in the LH group (P = 0.010). The clinical response was similar in the two groups.

CONCLUSIONS

LIRC is safe and effective for treating giant hepatic hemangioma.

Real-world data on the clinicopathological traits and outcomes of hospitalized liver hemangioma patients: a multicenter study

Background

There is currently a lack of consensus regarding the clinical features, diagnosis, treatment indications and options, and risk assessment of hepatic hemangioma patients.

Methods

This was a multicenter, real-world study that analyzed a large number of hepatic hemangioma cases in China and included patient data on epidemiology, diagnosis, treatment methods, and outcomes.

Results

A total of 5,143 patients hospitalized for hepatic hemangioma were included, of whom 34.42% were male and 65.58% were female. The age distribution was concentrated between 30 and 60 years old, accounting for 87.41% of the patients. Among the hepatic hemangioma patients, 60.8% had only one tumor, with the most common pathological type being cavernous hemangioma (96.07% of cases). The treatment motivations and indications included anxiety, obvious clinical symptoms, rapid tumor growth, unclear diagnoses and acute emergencies. Overall, 41.4% of the patients were treated for psychological reasons, while 30.59% were treated because they presented obvious (primarily nonspecific) clinical symptoms. Hepatic resection was the main therapeutic method and was based on various indications. There were a small number of patients with Kasabach-Merritt syndrome, according to its generally recognized definition.

Conclusions

Most patients in this study who were hospitalized for hepatic hemangioma did not meet the indications for requiring treatment. Surveillance is the recommended course of action for definitively diagnosed hepatic hemangioma, and a new classification system is needed to standardize the diagnosis of this condition.

Complications of Radiofrequency Ablation for Hepatic Hemangioma: A Multicenter Retrospective Analysis on 291 Cases

Purpose

To report the complications of radiofrequency ablation (RFA) for hepatic hemangioma.

Patients and Methods

Investigators from six centers performed RFA for hepatic hemangioma and used a standardized follow-up protocol. Data were collected from 291 patients, including 253 patients with hepatic hemangioma 5 to 9.9 cm in diameter (group A) and 38 with hepatic hemangioma ≥ 10 cm (group B). Technical success, complete ablation, and complications attributed to the RFA procedure were reported. Analysis of variance was used to determine whether the major complication rate was related to tumor size or clinical experience.

Results

A total of 304 lesions were treated in 291 patients. Technical success was achieved without adverse events in all cases. A total of 301 lesions were completely ablated, including 265 of 265 (100%) lesions in group A, and 36 of 39 (92.31%) in group B. The rate of technology-related complications was similar in groups A and B (5.14% (13/253) and 13.16% (5/38), respectively; P = 0.121). Moreover, all technology-related complications occurred during the early learning curve period. The rate of hemolysis-related complications in two groups were 83.40% (211/253) and 100% (38/38) (P =0.007) and the systemic inflammatory response syndrome-related complications in two groups were 33.99% (86/253) and 86.84% (33/38) (P<0.001). There were no delayed complications in either group.

Conclusion

RFA is minimally invasive, safe, and effective for hepatic hemangiomas 5 to 9.9 cm in diameter. More clinical data are needed to confirm the safety of RFA for hepatic hemangiomas ≥ 10 cm.

Laparoscopy-guided percutaneous microwave ablation for symptomatic 12.8 cm hepatic hemangioma with low blood loss and short hospital stay post-operation: A case report and literature review

We described a patient with symptomatic giant hepatic hemangioma (GHH) treated with laparoscopic guided percutaneous microwave ablation (MWA). A 58 years' old woman was referred to our hospital who presented with upper abdominal distension and appetite loss for more than 1 year. The medical history included untreated multiple hepatic hemangiomas (HH) that had been detected 13 years ago and hypertension for more than 12 years. Initial laboratory tests revealed D-dimer mild increase and negative tumor markers. Magnetic resonance (MR) imaging demonstrated multiple nodules of different sizes in the liver and the largest lesion was located on the left lobe (longest diameter 12.8 cm), which replaced the whole enlarged left lobe and compressed the gastric body and inferior vena cava. Contrast-enhanced ultrasound (CEUS) and contrast-enhanced MR imaging both showed the typical enhancement pattern of hemangioma and abnormal perfusion was seen in the surrounding liver parenchyma. With the laparoscopy guidance, we performed microwave ablation till the whole tumor was seen atrophy. The total operation duration was 2 hours, with intra-operative blood loss less than 20 ml. The post-operative course was uneventful. The patient was discharged 3 days after the operation. Abdominal distension decreased, appetite improved, blood pressure controlled at normal level after the operation. MR revealed significant volume reduction of the tumor after the operation.

Microwave ablation versus transcatheter arterial embolization for large hepatic hemangiomas: clinical outcomes

PURPOSE

To evaluate the safety and effect of microwave ablation (MWA) compared with transcatheter arterial embolization (TAE) for the treatment of large hepatic hemangiomas.

MATERIALS AND METHODS

A total of 135 patients with symptomatic or/and enlarging hepatic hemangiomas (5-10 cm) from two centers underwent either MWA (n = 82) or TAE (n = 53) as first-line treatment. We compared the two groups in terms of radiologic response, clinical response, operative time, postoperative analgesic requirements, hospital stay and complications.

RESULTS

MWA had a significantly higher rate of complete radiologic response (89.0% vs. 37.7%, p<.001) and complete clinical response (88.6% vs. 69.2%, p=.046), fewer minor complications (43.9% vs. 66.0%, p=.019), shorter time of using analgesics (p<.001) and shorter hospital stays (p=.003) than did TAE. The operative time and major complications were comparable between the two groups.

CONCLUSION

Both MWA and TAE are safe and effective in treating patients with large hepatic hemangiomas. MWA had a higher rate of complete response than did TAE, and it was associated with fewer minor complications, faster recovery and shorter hospital stay.

The value of Cone-Beam CT-guided radiofrequency ablation in the treatment of pulmonary malignancies (≤3 cm)

The aim of this study is to explore the safety and efficacy of Cone-Beam computed tomography (CBCT) guided radiofrequency ablation (RFA) in the treatment of pulmonary malignancies. Thirty-one patients with pulmonary malignant tumors (≤3 cm in diameter) were enrolled to this study. Total 43 CBCT guided RFA treatments were performed, including 7 patients undergoing multiple treatments. The target tumor puncture success rate, tumor remission rate, postoperative cumulative survival rate, tumor-free survival rate and complication rate were analyzed. All 43 CBCT guided RFA procedures successfully punctured the target tumors. Complications included five cases of pneumothorax and three cases of hemoptysis. For the 31 patients who underwent CBCT guided RFA, the 1- and 2-year cumulative survival rates were 80.6 and 54.8%, respectively. The 1- and 2-year disease-free survival rates were 54.8 and 32.3%, respectively. The 1-, 3- and 6-month remission rates were 78.4, 68.7 and 63.3%, respectively. The average cumulative radiation dose and average effective radiation dose were 194.62 ± 105.51 mGy and 5.41 ± 3.45 mSv, respectively. CBCT help to shorten the operation time, reduce the unnecessary interventions and also reduce the incidence of complications. CBCT guided RFA is one safe and efficacious treatment for pulmonary malignancies.