Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study

Transarterial embolization with bleomycin-lipiodol emulsion: a successful minimal invasive approach for giant liver hemangioma

Hemangiomas are most common benign liver tumor. Most patients have an excellent prognosis because of the small size and benign nature of tumor. On some occasions, giant liver hemangioma may cause symptoms and significant challenges due to its complication. We report a case of giant liver hemangioma treated with minimal invasive approach by transarterial embolization (TAE). Following three TAE sessions over a specific timeframe, the patient was successfully managed, addressing that TAE may be a useful alternative to hepatic surgery in such cases.

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.

Early vascular embolization of large orbital and periorbital infantile capillary hemangiomas; A case report

Purpose

Infantile hemangiomas (IH) are the most common benign vascular tumors in childhood. Although they tend to have a benign nature, some hemangiomas may be complicated with astigmatism or deprivation amblyopia. We report a unique case of using an interventional radiological vascular embolization treatment modality for the early management of amblyogenic large right orbital and periorbital infantile capillary hemangiomas.

Observations

After the confirmation of the diagnosis using a magnetic resonance imaging (MRI) of the brain and orbit, and an initial trial of systemic propranolol, an early interventional radiological vascular embolization was done. This was combined with the use of a tapering systemic corticosteroid. The functional and cosmetic outcomes were satisfactory.

Conclusions and Importance

The use of arterial embolization is a promising modality of treatment as a possible alternative or adjunct to medical and surgical treatment cases of IH. To the authors’ knowledge, this is one of the rare cases reported in the ophthalmic literature addressing the use of this technique for early management of orbital and periorbital capillary hemangiomas.

A Nomogram Model for Predicting the Response to Transcatheter Arterial Embolization in Patients With Symptomatic Hepatic Hemangioma

Background: Transcatheter arterial embolization (TAE) is regarded as an effective treatment for patients with symptomatic hepatic hemangioma. However, few studies have evaluated the efficacy of TAE alone for treating hepatic hemangioma. The aim of this study was to identify the factors that influence the response to TAE and formulate a quantitative nomogram to optimize the individualized management of hepatic hemangioma.

Methods: We retrospectively studied 276 patients treated with TAE for hepatic hemangioma at our center from January 2011 to December 2019. The full cohort was randomly divided into training and validation cohorts. After assessing the potential predictive factors for the efficacy of TAE in the training cohort, a nomogram model was established and evaluated by discrimination and calibration.

Results: During follow-up, the symptom relief rate was 100%. The tumor blood supply (p < 0.001), tumor number (p = 0.004), and tumor size (p = 0.006) were identified as significant predictors of the failure of tumor shrinkage in response to TAE. The nomogram model showed favorable discrimination and calibration, with a C-index of 0.775 (95% CI, 0.705–0.845) in the training cohort, which was further confirmed in the validation cohort (C-index 0.768; 95% CI, 0.680–0.856). The side effects of TAE were relatively minor and included mainly abdominal pain, nausea, vomiting, fever, and the presence of elevated hepatic transaminases.

Conclusion: TAE is a safe and effective treatment for symptomatic hepatic hemangioma. The established nomogram performed well for the estimation of the effect of TAE in patients with hepatic hemangioma and can facilitate the selection of patients who would benefit most from the treatment.

Surgical management of giant hepatic hemangioma: A 10-year single center experience

Background

Hepatic hemangiomas are the most typical benign mesenchymal lesions of the liver. Most of these lesions are asymptomatic. Giant hepatic hemangiomas (GHH) (>10 cm) are often symptomatic and require surgical intervention. This study aimed to describe the clinical findings, risk factors, diagnostic approach and management of GHH.

Methods

We performed a retrospective analysis of patients with GHH treated at our hospital from January 2008 to December 2018. The medical records of each patient were reviewed to obtain the clinical and surgical data.

Results

Twelve patients with GHH were treated during the study period. 9 were female and 3 were male. The mean age of diagnosis was 48,2 years. The most common presenting symptom was abdominal pain. Eight patients presented an abdominal mass. Indications for surgical resections were rupture (n = 2), Kasabach-Merritt syndrome (n = 1) and abdominal pain (n = 9). Right hepatectomy was done in four patients, left lobectomy in four patients, and enucleation in four patients. Embolization was performed in 4 patients, but due to the persistence of symptoms or bleeding, surgery was indicated. The mean operative time was 3.5 h, and median blood loss was 870 ml. The median hospital stay was 5.3 days. For four patients, we registered postoperative complications causing death in one case. All alive patients were asymptomatic at a median follow-up of 55 months.

Conclusion

Despite limitations and alternative modalities, surgery remains the only effective curative treatment for GHH.

•

Hepatic hemangiomas are the most common benign tumors of the liver with the incidence of 0.4–20%.

•

Giant hepatic hemangiomas (GHH) are usually responsible for overt clinical symptoms and complications.

•

Management of liver hemangiomas ranges from close observation to surgery depending upon the site, size and symptoms.

•

Surgical resection is indicated in patients with abdominal complaints or complications, or when diagnosis remains inconclusive.

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

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

Combining On-Table Embolization with Immediate Resection to Safely Excise Giant Hepatic Hemangiomas

The management of symptomatic giant hepatic hemangiomas (> 10 cm) varies in the literature. Multiple interventional approaches have been described including surveillance, embolization, enucleation, and resection based on tumor size, location, relationship to vascular and biliary structures, and the quality and quantity of the functional liver remnant. Resection is often performed as a last resort due to the risk of major hemorrhage. Preoperative arterial embolization is an option; however, many patients will experience severe pain, fever, transaminitis, acidosis, recanalization, and collateral inflow that limit its utility. Furthermore, patients require post-procedure inpatient observation, and there is no consensus on the appropriate time interval between procedures. We present and demonstrate a technique in the video that utilizes a hybrid operating room with on-table angiogram capabilities to perform hemangioma inflow embolization and immediate hepatic resection under the same anesthesia in a single procedure. Combining on-table embolization with immediate resection avoids many of the pitfalls of preoperative embolization, while enhancing the safety of the resection by decreasing the size of the tumor, enabling compressibility, and facilitating exposure of the vascular inflow and outflow. It is an efficient use of hospital resources and eliminates an intervening hospital admission. We have found it to be a preferred approach to enhance the safety and feasibility of resection for massive hepatic hemangiomas with minimal intraoperative blood loss and reduced risk.

Spontaneous internal hemorrhage of a giant hepatic hemangioma with infection: a case report and literature review

Spontaneous internal hemorrhage from a hepatic hemangioma is rare. This case describes a 59-year-old woman who was hospitalized with recurrent cough and fever for 6 months. The doctor thought that she had pneumonia, but other infectious diseases could not be ruled out. Therefore, related tests were performed and strong antibiotics were used, but the symptom of fever was persistent and recurred. Enhanced computed tomography (CT) findings showed a right hepatic giant hemangioma with hemorrhage, while tuberculosis, liver abscess, and immune disease were excluded by the physician. Because the patient’s fever was associated with a large hepatic hemangioma, the patient was transferred to surgery. During treatment, the amount of bleeding increased, so she underwent a right hepatic hemangioma resection in the emergency department. Her postoperative fever symptoms subsequently resolved. Pathological examination confirmed hemorrhagic necrosis with infection in hepatic hemangioma. Follow-up showed that the patient was afebrile.

A case of diffuse hepatic hemangiomatosis coexistent with giant hemangioma: case report and literature review

We report a case of hepatic hemangiomatosis coexistent with a giant hepatic hemangioma diagnosed in the context of the study for SARS-CoV-2 infection. Computed tomography showed irregular contours of the left hepatic lobe with a lesion that compromised the whole lobe, with peripheral uptake and a centripetal tendency in the late phase, compatible with bulky cavernous hemangioma, as well as another lesion with the same characteristics in segment VI. Magnetic resonance imaging of the abdomen showed multiple hepatic hemangiomas observed in both lobes involving all segments, some of them smaller than 1 cm, which were hyperintense in the T2-weighted sequences and showed progressive contrast enhancement. This case illustrates the incidental diagnosis of this condition during the study for another pathology, the radiological features that are important to differentiate from other tumoral findings, and the possible management strategies to follow.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

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

RESULTS

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

CONCLUSION

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

Spontaneous intracapsular hemorrhage of a giant hepatic cavernous hemangioma: a rare case report and literature review

Background

Hepatic cavernous hemangioma is the most common type of benign liver tumor. Although ruptures and hemorrhages of hepatic hemangioma are rare complications, they are associated with high mortality. Most practitioners only pay more attention to abdominal hemorrhages caused by the rupture of hepatic hemangiomas. However, spontaneous intracapsular hemorrhages can often be neglected and poorly understood.

Case presentation

A 65-year-old man was referred to our institution with right upper quadrant pain, which had occurred suddenly and without a history of recent trauma. The blood test results were normal. Magnetic resonance imaging (MRI) of the abdomen showed a cystic mass in the right liver lobe. Considering the possibility of hepatic cystadenoma with hemorrhage, the patient underwent a right hepatic lobectomy. The pathological findings unexpectedly revealed intratumoral hemorrhage of hepatic hemangioma. The patient recovered well and was discharged eight days after surgery.

Conclusions

Intracapsular hemorrhage of hepatic cavernous hemangioma is challenging to diagnose and has a high potential risk of rupture. MRI is beneficial for diagnosing subacute internal hemorrhage cases, and it is recommended to undergo surgery for patients with a definitive diagnosis.

Transcatheter Arterial Sclerosing Embolization for the Treatment of Giant Propranolol-Resistant Infantile Hemangiomas in the Parotid Region

PURPOSE

To report the effectiveness and safety of transcatheter arterial sclerosing embolization (TASE) for the treatment of parotid infantile hemangiomas that did not respond appreciably to propranolol.

MATERIALS AND METHODS

A total of 21 infants (12 male and 9 female) with large propranolol-resistant infantile hemangiomas in the parotid region were enrolled in this study. During TASE, the feeding arteries of the lesions were embolized using pingyangmycin-lipiodol emulsion and polyvinyl alcohol particles (300-500 μm) to reduce the blood flow rate. All children were followed up as outpatients at 2 weeks and monthly thereafter. The curative effect was evaluated at the 1- and 3-month follow-up visits.

RESULTS

Nine lesions were located on the right side of the parotid gland, whereas 12 were located on the left side. The feeding arteries in all patients originated from branches of the external carotid artery. TASE was technically successful in all patients. The mean (± SD) maximal diameter of the hemangiomas significantly decreased from 6.50 cm ± 2.28 before treatment to 3.56 cm ± 1.84 at 1 month after TASE (P <. 05). Three months after TASE, the mean maximal diameter further significantly decreased to 1.94 cm ± 1.58 (P <. 05). During the follow-up period, 16 cases were rated as excellent and 5 as good; no recurrence or serious complications were noted. Minor side effects, such as slight pain, mild fever, and tissue swelling, were observed.

CONCLUSIONS

TASE significantly decreased the size of the parotid hemangiomas with minor side effects during a short follow-up period.

Effectiveness of Transarterial Embolization in Treatment of Symptomatic Hepatic Hemangiomas: Systematic Review and Meta-analysis

PURPOSE

To evaluate the current evidence for the effectiveness of transarterial embolization (TAE) in treatment of symptomatic hepatic hemangiomas.

MATERIALS AND METHODS

A systematic literature review was conducted in PubMed, CINAHL and Scopus databases to identify studies of hepatic hemangiomas treated with transarterial embolization. Main outcome was defined as the mean difference between pre- and post-TAE hemangioma diameters. Treatment agents were categorized as Lipiodol based [bleomycin (L + BE), pingyangmycin (L + PYG) or ethanol (L + ethanol)] and non-Lipiodol based (polyvinyl-alcohol-only). Conventional random-effect meta-analysis technique was applied to analyze data.

RESULTS

Of 3080 initially inspected publications, 21 studies were included in the meta-analysis comprising of 1450 patients with total of 1871 hemangiomas (36.2% male, mean age: 46.3 ± 3.6 years). One hundred and twenty-six, 1666, 41 and 38 lesions were treated with L + BE, L + PYG, L + ethanol and PVA, respectively. Median follow-up time after embolization was 12 months. Lipiodol-based treatments showed significant effect in reducing hemangioma size after TAE compared to PVA (P < 0.001). Pooled diameter reduction (cm) (95% confidence interval) was - 4.37( - 5.32, - 3.42), - 4.70( - 5.70, - 3.71), - 0.93( - 2.02, 0.16) for overall TAE treatment, Lipiodol-based and non-Lipiodol-based treatments, respectively. Main complications included post-embolization syndrome and transient liver enzyme elevation (pooled incidence for Lipiodol-based and non-Lipiodol-based techniques: 36% and 33%; and 37% and 0, respectively). No fatal complications were reported. Symptomatic improvement was reported in 63.3%-100% of the cases with majority of studies (15/21) reporting improvement in all cases (pooled response rate: 98%).

CONCLUSIONS

Transarterial embolization with bleomycin, pingyangmycin or ethanol in combination with Lipiodol is safe and associated with reduced size of hemangiomas resulting in symptoms alleviation.

Robotic, laparoscopic or open hemihepatectomy for giant liver haemangiomas over 10 cm in diameter

Background

To evaluate the clinical efficacy of robotic, laparoscopic, and open hemihepatectomy for giant liver haemangiomas.

Methods

From April 2011 to April 2017, consecutive patients who underwent hemihepatectomy for giant liver haemangiomas were included in this study. According to the type of operation, these patients were divided into the robotic hemihepatectomy (RH) group, the laparoscopic hemihepatectomy (LH) group, and the open hemihepatectomy (OH) group. The perioperative and short-term postoperative outcomes were compared among the three groups. The study was reported following the STROCSS criteria.

Results

There were no significant differences in age, sex, tumour location, body surface area (BSA), future liver remnant volume (FLR), standard liver volume (SLV), liver haemangioma volume, FLR/SLV, resected normal liver volume/resected volume, hepatic disease, rates of blood transfusion, liver function after 24 h of surgery, operative morbidity and mortality among the three groups. Compared with patients in the RH group (n = 19) and the LH group (n = 13), patients in the OH group (n = 25) had a significantly longer postoperative hospital stay (P < 0.05), time to oral intake (P < 0.05), and time to get-out-of-bed (P < 0.05); a higher VAS score after 24 h of surgery (P < 0.05); and a shorter operative time (P < 0.05). There were no significant differences in these postoperative outcomes (P>0.05) between the RH group and the LH group. When the setup time in the RH group was excluded, the operative time in the RH group was significantly shorter than that in the LH group (P<0.05). There was no significant difference in the operative time between the RH group and the OH group (P>0.05). The amount of intraoperative blood loss in the RH group was the lowest among the three groups (P<0.05), and the amount of intraoperative blood loss in the LH group was less than that in the OH group (P<0.05).

Conclusion

Robotic and laparoscopic hemihepatectomies were associated with less intraoperative blood loss,better postoperative recovery and lower pain score. Compared with laparoscopic hemihepatectomy, robotic hemihepatectomy was associated with significantly less intraoperative blood loss and a shorter operative time.

Outcomes of ultrasound-guided percutaneous microwave ablation versus surgical resection for symptomatic large hepatic hemangiomas

Purpose: Microwave ablation (MWA) has become increasingly popular as a minimally invasive treatment for benign and malignant liver tumors. However, few studies have demonstrated the benefits and disadvantages of MWA compared to surgical resection (SR) for large hepatic hemangiomas. This study aimed to evaluate the safety and effectiveness of MWA compared to SR for large (5-10 cm) hepatic hemangiomas. Methods and materials: This retrospective comparative study included 112 patients with large, symptomatic hepatic hemangiomas who had been treated with MWA (n = 44) or SR (n = 68) and followed up for a median of 44 months using enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Intraoperative information, postoperative recovery time, postoperative discomfort and complications and treatment effectiveness between groups were compared using a chi-square test or an independent t-test. Results: The operative time was significantly shorter (31.3 ± 21.76 versus 148.1 ± 59.3 min, p < .001) and the blood loss (10.2 ± 60.6 versus 227.9 ± 182.9 mL, p < .0001) and rate of prophylactic abdominal drainage [1 (2.3%) versus 57 (83.8%), p < .001] were significantly lower in the MWA group than in the SR group. Postoperative recovery of the MWA group in regard to indwelling catheter time, normal diet time, incision cicatrization time and hospital stay (p < .001) was significantly better than the SR group. However, no statistically significant difference in effectiveness was noted between the groups (p = .58). Conclusions: MWA may be as effective as SR, and potentially safer for treating large, symptomatic hepatic hemangiomas. To confirm our findings, large-sample, multicentered, randomized controlled trials are needed.

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.

Feasibility, safety, and efficacy of ultrasound-guided percutaneous microwave ablation for giant hepatic hemangioma

BACKGROUND

Hepatic hemangioma is a common benign liver tumor. The majority of cases are asymptomatic and require no specific treatment. The aim of this study was to evaluate the feasibility, safety and efficacy of microwave ablation (MWA) for symptomatic or enlarging giant hepatic hemangioma (≥10 cm).

METHODS

From December 2013 to June 2016, 12 patients with giant hepatic hemangioma (≥10 cm) underwent ultrasound-guided percutaneous MWA, and ablation-related complications were observed. All patients were followed up with magnetic resonance or enhanced CT imaging at one month postoperatively to evaluate efficacy.

RESULTS

This study included a total of 13 giant hepatic hemangiomas (mean: 11.7 ± 1.6 cm) in 12 patients who initially underwent 16 sessions of MWA; three lesions were treated with two sessions of planned ablation. The average ablation time for a single hepatic hemangioma was 39.0 ± 14.4 minutes. Two patients had acute postoperative non-oliguric renal insufficiency without intra-abdominal hemorrhage, liver failure or other complications. Initially, complete ablation was achieved in ten lesions in nine patients (76.9%, 10/13). One patient underwent a second session of MWA at 5 months postoperatively due to fast growing residual tissue; complete necrosis was achieved after treatment. The remaining two cases did not receive any invasive treatment due to small residual volumes. The total complete ablation rate was 84.6% (11/13).

CONCLUSION

Image-guided MWA is a safe, feasible, effective treatment for giant hepatic hemangioma; these findings may open a new avenue for treatment.

Transarterial Bleomycin-Lipiodol Embolization (B/LE) for Symptomatic Giant Hepatic Hemangioma. Cardiovasc Intervent Radiol. 2018;41:1674-1682. [PMID: 29922860 DOI: 10.1007/s00270-018-2010-4]

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.

Spontaneous internal hemorrhage of a giant hepatic hemangioma: A case report

RATIONALE

Hepatic hemangioma, a benign liver tumor, can rarely spontaneously rupture and hemorrhage, which is then associated with significant mortality. The diagnosis of internal hemorrhage is challenging and the management is disputed.

PATIENT CONCERNS

We describe the case of a 52-year-old female patient with chief complaints of fever and anemia, with no history of recent trauma.

DIAGNOSES

Ultrasound suggested the possibility of a liver abscess and computed tomography (CT) examination revealed a giant space occupying lesion (SOL) (approximately 16 cm) in the right hepatic lobe, indicating a hepatic tumor or abscess. The patient did not respond to antibiotics and blood transfusion. Liver needle biopsy revealed blood clots suggestive of intratumoral hemorrhage, possibly of a hepatic hemangioma.

INTERVENTIONS

Interventional radiologic approach revealed active bleeding at the phrenic artery that supplied the liver SOL. Thus, embolization was performed and re-angiography showed no active bleeding from the embolized vessel. The patient became afebrile, but fever recurred the next day. Hence, an exploratory open right hemihepatectomy was undertaken and the intraoperative frozen biopsy confirmed hepatic hemangioma with internal hemorrhage, but malignancy could not be excluded for some focal tissues. Postoperative pathology report confirmed the diagnosis of hepatic hemangioma with internal hemorrhage and excluded malignancy.

OUTCOMES

The fever subsided and the patient was discharged in good health. A follow-up CT performed three months, postoperatively, indicated compensatory growth of the left hepatic lobe.

LESSONS

This case demonstrates that the diagnosis of hepatic hemangioma with internal hemorrhage can be confirmed by needle biopsy and surgical resection is the optimal treatment for such a lesion.

Role of selective intra-arterial embolization in benign liver tumors

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous microwave ablation for benign focal liver lesions: Initial clinical results

Benign focal liver lesions (BFLLs) have become a common disease diagnosed in the clinical setting following the advancement of imaging techniques. The aim of the present study was to evaluate the safety and clinical outcomes of percutaneous microwave (MW) ablation, guided by ultrasound (US), for the treatment of BFLLs. Between May 2005 and January 2011, 44 BFLLs (mean maximum diameter, 33.9±13.1 mm) in 37 patients (23 women and 14 men) were treated by US-guided percutaneous MW ablation with cooled-shaft antennae. The pathological diagnosis of a BFLL was confirmed in 91.9% (34/37) of patients using a US-guided core needle biopsy prior to ablation. The BFLLs in the other 3 cases were diagnosed by typical presentations on contrast-enhanced imaging, as the patients refused to undergo biopsies. Five inclusion criteria, including indeterminate diagnoses of nodules on contrast-enhanced imaging prior to pathological verification, were recommended. The median follow-up period was 27.0 months (range, 6-73 months). The mean MW ablation energy and time were 55.0±41.6 kJ (range, 13.5-207 kJ) and 1,039.9±706.2 sec (range, 270-3,450 sec) per lesion, respectively. In total, 40 nodules (90.9%) were completely ablated, and no evidence of recurrence was demonstrated on contrast-enhanced imaging follow-up. The other 4 nodules (9.1%) were partially ablated due to the proximity of adjacent vital organs. Minor complications without sequelae included local pain and transient hemoglobinuria and no major complications occurred in peri-ablation. Overall, US-guided percutaneous MW ablation is a safe, effective and minimally invasive therapy for BFLLs in selected patients who are non-surgical candidates.

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.

New recognition of the natural history and growth pattern of hepatic hemangioma in adults

AIM

Surgical indications for hepatic hemangiomas are still not clearly defined due to limited data on their natural history. This study aimed to investigate the natural history and growth pattern of hepatic hemangiomas in adults.

METHODS

From April 2010 to March 2013, adult patients with hepatic hemangioma who had no prior treatment were enrolled. A routine follow up was performed to observe the natural history of the lesions and their tendency to cause complications.

RESULTS

A total of 236 patients were enrolled in the study. The median size of hemangiomas was 4.5 cm (range, 0.6-19.2). During a median follow-up period of 48 months (range, 3-266), 61.0% patients had hemangiomas that increased in size, 23.7% patients had stable lesions and 8.5% patients had hemangiomas that decreased in size. The peak growth period of hemangiomas was in patients of less than 30 years of age (0.46 ± 0.41 cm/year) and the growth rate decreased significantly after 50 years of age (0.21 ± 0.40 cm/year). Hemangiomas of less than 2 cm had the lowest growth rate (0.16 ± 0.42 cm/year). The peak growth rate of hemangioma size was 8-10 cm (0.80 ± 0.62 cm/year), then decreased rapidly to 0.47 ± 0.91 cm/year while the hemangiomas were of more than 10 cm. Only nine patients had severe symptoms caused by hemangioma. No patients presented with hemangioma-related complications.

CONCLUSION

The majority of hepatic hemangiomas have the tendency to increase in size but rarely cause complications. All the hemangiomas can be safely managed by observation, and surgery is only considered for patients with severe complications.

Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: A large retrospective cross-sectional study

BACKGROUND

Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications.

AIMS

The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture.

METHODS

We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course.

RESULTS

Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding.

CONCLUSION

Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases.

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

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

Preoperative arterial embolization of large liver hemangiomas

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pre-operative Arterial Embolization of Symptomatic Giant Hemangioma of the Liver

The cavernous hemangiomas of the liver are usually small sized and asymptomatic. Most of them are incidentally diagnosed and a very small portion requires therapy. Giant hemangioma can be symptomatic, and this condition is the indication for treatment. The striking complication of surgical treatment of cavernous hemangiomas is intra-operative bleeding. In this case, we aimed to demonstrate that the risk of intraoperative bleeding can be eliminated with the preoperative percutaneous trans-catheter arterial embolization technique.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Comparison of laparoscopic radiofrequency ablation versus open resection in the treatment of symptomatic-enlarging hepatic hemangiomas: a prospective study. Surg Endosc. 2016;30:756-763. [PMID: 26123327 DOI: 10.1007/s00464-015-4274-y]

BACKGROUND

Radiofrequency ablation (RFA) has been demonstrated to be a promising therapy for symptomatic large hepatic hemangioma. However, there is a lack of studies to demonstrate the benefits and disadvantages of RFA as compared with surgical resection for managing hepatic hemangioma. The aim of this study was to evaluate the outcomes of RFA compared with conventional open resection (ORES) for the treatment of symptomatic-enlarging hepatic hemangiomas.

METHODS

A total of 66 patients with symptomatic-enlarging hepatic hemangiomas (4 cm ≤ diameter < 10 cm) who required surgical treatment were divided into two groups: 32 patients underwent laparoscopic radiofrequency ablation (LRFA) and the other 34 patients underwent ORES. We compared the two groups in terms of radiologic response, clinical response, operative time, estimated blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications and hospital cost.

RESULTS

The radiologic and clinical responses were comparable between groups. LRFA had significantly shorter operative time (138 vs. 201 min, P < 0.001) and less blood loss (P < 0.001) than ORES. Patients after LRFA experienced significantly less pain and required less analgesia use. Moreover, patients underwent LRFA had significantly shorter length of hospital stay (P < 0.001) and lower hospital cost (P = 0.017). No severe morbidities or mortality was observed, and the overall morbidity rate was similar between groups.

CONCLUSIONS

As a new minimal invasive treatment option, laparoscopic radiofrequency ablation is as safe and effective a procedure as open resection for patients with symptomatic-enlarging hepatic hemangiomas smaller than 10 cm.

Hemorrhagic hemangioma in the liver: A case report

Hemangioma is the most common type of benign tumor that arises in the liver. Although rupture and hemorrhage of hepatic hemangioma are rare complications, they can be the cause of mortality. The authors report a case of hemorrhagic hepatic hemangioma: in a 54-year-old woman who was admitted with epigastric pain. She had taken oral contraceptives several weeks prior. The results of a blood examination were normal. An abdominal computed tomography scan revealed a tumor in hepatic segment 4, and a hemorrhage inside the cystic mass was suspected. The mass was removed laparoscopically to confirm the tumor properties and control the hemorrhage. The pathologic findings of the resected mass were consistent with hepatic hemangioma with intratumoral hemorrhage. The patient was discharged 8 d after the surgery, without further complications or complaints, and the patient’s condition was found to have improved during follow-up.

Management of liver hemangioma using trans-catheter arterial embolization

BACKGROUND

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Microwave ablation of giant hepatic cavernous hemangiomas

PURPOSE

This study was designed to explore the safety and efficacy of percutaneous microwave (MW) ablation as an alternative treatment for symptomatic giant hepatic hemangiomas.

METHODS

Patients (n = 7; 6 females, 1 male; mean age = 44 years) with symptomatic, giant hemangiomas (n = 8) were treated with ultrasound-guided percutaneous MW ablation and followed for a mean of 18 months. Patient pain was recorded both before and after the procedure according to the 10-point visual analog scale. All patients were treated using one or three gas-cooled 17-gauge antennas powered by a 2.4-GHz generator (Neuwave Medical, Madison, WI). Mean ablation time was 11.6 min. Four patients received hydrodissection to protect the abdominal wall, colon, or gallbladder (5 % dextrose in water, mean volume 900 mL). Immediate postablation biphasic CT of the abdomen was performed, and four of seven patients have undergone delayed follow-up imaging.

RESULTS

All ablations were technically successful with no major or minor complications. Average pain score decreased from 4.6 to 0.9 (p < 0.05), and six of seven patients report resolution or improvement of symptoms at 18-month average follow-up (range 1-33 months). Immediately postablation, mean tumor diameter decreased 25 % (from 7.3 to 5.5 cm, p < 0.05) and volume decreased 62 % (from 301 to 113 cm(3), p < 0.05).

DISCUSSION

In this series, percutaneous MW ablation was safe, well-tolerated, and effective in markedly shrinking large hepatic hemangiomas and improving symptoms in most patients.

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.

Management of bleeding liver tumors

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

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

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

Minimally invasive treatment of giant haemangiomas of the liver: embolisation with bleomycin

PURPOSE

The management of patients with giant haemangioma of the liver remains controversial. Although the usual treatment method for symptomatic giant haemangioma is surgery, the classical paradigm of operative resection remains. In this study, we evaluated the symptomatic improvement and size-reduction effect of embolisation with bleomycin mixed with lipiodol for the treatment of symptomatic giant hepatic haemangioma.

METHODS

This study included 26 patients [21 female, five male; age 41-65 years (mean 49.83 ± 1.53)] with symptomatic giant haemangioma unfit for surgery and treated with selective embolisation by bleomycin mixed with lipiodol. The patients were followed-up (mean 7.4 ± 0.81 months) clinically and using imaging methods. Statistical analysis was performed using SPSS version 16.0, and p < 0.05 was considered to indicate statistical significance.

RESULTS

Embolisation of 32 lesions in 26 patients was performed. The mean volume of the haemangiomas was 446.28 ± 88 cm(3) (range 3.39-1559 cm(3)) before intervention and 244.43 ± 54.38 cm(3) (range 94-967 cm(3)) after intervention. No mortality or morbidity related to the treatment was identified. Symptomatic improvement was observed in all patients, and significant volume reduction was achieved (p = 0.001).

CONCLUSION

The morbidity of surgical treatment in patients with giant liver hemangioma were similar to those obtained in patients followed-up without treatment. Therefore, follow-up without treatment is preferred in most patients. Thus, minimally invasive embolisation is an alternative and effective treatment for giant symptomatic haemangioma of the liver.

Giant cavernous hepatic hemangioma shrunk by use of sorafenib

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

Percutaneous radiofrequency ablation of symptomatic giant hepatic cavernous hemangiomas: report of two cases and review of literature

The presented cases detail percutaneous radiofrequency (RF) ablation of multiple giant hepatic hemangiomas in two patients who presented with right upper-quadrant pain and fullness and chose not to undergo surgical resection. Treatment of two hemangiomas per patient, 7 cm and 6 cm in one and 9 cm and 2 cm in the other, was accomplished in single ablation sessions with 12 and nine cycles, respectively. Patients had durable resolution of symptoms with reduction of lesion size by 68%-82% at a mean follow-up of 13 months. These cases, along with promising results in the current literature, support RF ablation as a safe and effective surgical alternative.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Hepatic angiomyolipoma with a giant hemangioma

Hepatic angiomyolipoma is a rare hepatic mesenchymal tumor. We report a case of hepatic angiomyolipoma that was successfully resected along with a giant hemangioma. A 53-year-old Japanese woman was admitted to our hospital for further evaluation of a liver tumor in segment 4. The tumor was detected on positron emission tomography during a health check-up. Abdominal ultrasonography revealed a well-defined mass of mixed echogenicity, 1.5 cm in diameter, in segment 4, and a giant hemangioma of mixed echogenicity, 7 cm in diameter, in segment 7. On enhanced computed tomography, the tumor in segment 4 showed hyperattenuation in the early phase and hypoattenuation in the delayed phase. On magnetic resonance imaging, the tumor in segment 4 showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and hyperintensity on diffusion-weighted images. On angiography, the tumor in segment 4 appeared as a circumscribed hypervascular mass in the early phase and a slightly hypovascular mass in the delayed phase. The imaging findings suggested a primary hepatocellular carcinoma. The patient consented to resection of the tumor in segment 4 along with the giant hemangioma in segment 7. These tumors were resected with tumor-free surgical margins by partial resection of segments 4 and 7 of the liver. The cut surface of the resected specimen of segment 4 showed a yellowish tumor consisting of mature adipose tissue. The histopathological diagnoses of the resected specimens were angiomyolipoma in segment 4 and cavernous hemangioma in segment 7. The tumor in segment 4 consisted of mature lipocytes with angiomatous and small lymphocytic components, but no mitotic figures. The tumor showed immunoreactivity to smooth muscle antigen and homatropine methylbromide 45 and no immunoreactivity to AE/E3. The postoperative course was uneventful, and the patient remains well 1 year after the operation.

A symptomatic giant hepatic hemangioma treated with hepatectomy

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