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

Feasibility of laparoscopic enucleation for hemangioma in special hepatic segments

Background and aim

This study aims to evaluate the safety and efficacy of laparoscopic enucleation for liver hemangioma in special hepatic segments.

Methods

We retrospectively reviewed 58 patients who underwent laparoscopic surgery for hepatic hemangioma at a single center from January 2016 to January 2022. Segments I, IVa, VII, and VIII are defined as special hepatic segments, attributing to the bad visualization and adjacent to important vessels such as hepatic veins and inferior vena cava that lead to a high risk in laparoscopic surgery. Patients were categorized into a special location group (SLG) and a normal location group (NLG) according to the location of hemangioma. General data, intraoperative and postoperative outcomes, and postoperative complications of the two groups were compared and analyzed.

Results

There were no significant differences in age (p = 0.288), gender (p = 0.331), body mass index (p = 0.168), the maximum diameter of hemangioma (p = 0.330), ASA risk grading (p = 0.615), and comorbidities (p > 0.05) between the two groups. The operation time (p < 0.001), intraoperative blood loss (p < 0.001), and intraoperative blood transfusion rate (p = 0.047) were significantly higher in the SLG. The rate of conversion to laparotomy was higher in the SLG, but there was no significant difference (p = 0.089). In addition, the exhaust time (p = 0.03) and postoperative hospital stay (p < 0.01) were significantly shorter in the NLG. The postoperative complications were comparable between the two groups, and there were no perioperative deaths.

Conclusion

Laparoscopic enucleation of hemangioma in special hepatic segments is difficult and has a critical risk of massive bleeding during surgery. Meanwhile, it is also safe, feasible, and effective.

Effectiveness of microwave ablation for the treatment of hepatic hemangioma - meta-analysis and meta-regression

BACKGROUND

The treatment of hepatic hemangioma includes surgical resection, radiofrequency ablation and Transarterial embolization. However, complications, mortality and compromised effectiveness limit their applications. Microwaves with effective heating generation and short ablation time become a promising treatment. The aim of this study is to conduct systematic review and meta-analyses to evaluate the effectiveness of Microwave Ablation (MWA) for the treatment of hepatic hemangioma.

METHODS

A systematic literature review was conducted in PubMed. Main outcomes were defined as hemangioma decreases in diameters and volume changes post-MWA. Conventional random-effect meta-analysis technique was applied to analyze the pooled data, and meta-regression model was established to explore the association among factors.

RESULTS

There were nine studies with a total of 501 patients retrieved. The pooled estimate of mean differences and 95% CI of hemangioma decreases after MWA treatment in diameter and in volume change (%) were 3.009 cm and (1.856, 4.161), and 53.169% and (51.274, 55.065), respectively. The pooled estimates of liver enzyme, ALT and AST, elevation were 219.905 with 95%CI (160.860, 278.949) and 315.679 with 95%CI (226.961, 404.397), respectively. Major complications were defined as acute kidney injury (AKI), pleural effusion, diaphragmatic hernia, and jaundice that needed to be treated, and the pooled incidence was 0.017 with 95% CI of (0.006, 0.029). No mortality related to MWA was reported. Meta-regression showed ablation time was associated with pre-operative lesion size (p = .001).

CONCLUSION

MWA is effective and safe in treatment of hepatic hemangioma, and our study suggests that hemangioma size should be investigated in the future MWA pretreatment difficulty scoring system study.

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.

Percutaneous ultrasound-guided 'three-step' radiofrequency ablation for giant hepatic hemangioma (5-15 cm): a safe and effective new technique

Purpose: To evaluate the safety and efficacy of percutaneous ultrasound-guided 'three-step' radiofrequency ablation (RFA) for the treatment of giant hepatic hemangioma.Materials and methods: Patients with giant hepatic hemangioma who underwent percutaneous ultrasound-guided 'three-step' RFA (n = 52) and conventional RFA (n = 54) at our center from June 2013 to December 2017 were retrospectively analyzed. The 'three-step' RFA proceeds as follows. Step 1: Ablate the feeding artery of the hemangioma. Step 2: Aspirate blood from the tumor. Step 3: Ablation the lesion. Intraoperative information, postoperative recovery, therapeutic effects, and complications were compared between the two groups.Results: The duration of RFA was significantly shorter (19.2 ± 0.8 min versus 44.5 ± 2.8 min, p < 0.001), the number of punctures was significantly lower (3.2 ± 0.1 versus 4.7 ± 0.3, p = 0.002), and the duration of hospital stay was significantly shorter (9.0 ± 0.5 versus 11.5 ± 0.7, p = 0.013) in the TS-RFA group than in the C-RFA group. The complete ablation rate (86.5% versus 40.7%), the maximum postoperative pain score (2.5 ± 1.3 versus 4.1 ± 2.0) and symptom relief were also significantly better in the TS-RFA group than in the C-RFA group (p < 0.05). No postoperative death occurred in either group. There were no grade III or higher complications in the TS-RFA group, but one patient in the C-RFA group developed the grade III complication of postoperative abdominal bleeding.Conclusions: 'Three-step' RFA is a safe and effective minimally invasive treatment for giant hepatic hemangioma. It is worthy of further promotion and application.

Surgical indication and strategy for liver hemangioma in the caudate lobe: a multi-institutional retrospective analysis with 137 patients

Objective

To investigate the surgical indication and tactics for liver hemangioma in the caudate lobe

Methods

From January 1994 to July 2019, 137 patients, including 51 males and 86 females with the average age of 49.2 years old were diagnosed with liver hemangioma in caudate lobe and received treatment at five tertiary referral hospitals. Clinical features, correlations between tumor size and clinical manifestations, treatments, and prognosis were analyzed.

Results

Of the 137 patients identified, 40 (29.20%) patients were asymptomatic, whereas other 94 patients had clinical symptoms mainly presented as upper abdominal discomfort, epigastric distention, upper abdominal dull pain, nausea, and vomiting. Fifteen (93.75%), 18 (39.13%), and 7 (10.45%) patients presented no clinical symptoms among those tumor size was less than 3 cm (D ≤ 3 cm, n = 16), 3 cm < D ≤ 6 cm (n = 46), and 6 cm < D ≤ 9 cm (n = 67), respectively, while all 8 patients with tumor larger than 9 cm were symptomatic. Tumor diameter was obviously associated with the presence of clinical symptoms. In follow-up period, 7 patients in the conservative group (n = 39) received surgery because of tumor growth or symptom appearance. Totally 105 patients received operation including partial resection or isolated complete resection of caudate lobe and caudate lobe resection combined with liver segment resection, right liver resection, or left liver resection. All operations went smoothly, and no severe complications appeared.

Conclusion

Tumor diameter was obviously associated with the presence of clinical symptoms in patients with hemangioma in caudate lobe. Surgical therapy is not recommended for asymptomatic patients and available for patient who has symptoms. Effective surgical strategies should be put into use to reduce operative bleeding.

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.

Percutaneous Sclerotherapy for Giant Symptomatic Liver Hemangiomas: A Pilot Study

This single-center prospective trial evaluated the safety and efficacy of percutaneous sclerotherapy for liver hemangiomas in 5 patients (1 man, 4 women; mean age 41.2 y) between 2016 and 2017. All patients were symptomatic (4 abdominal pain; 1 early satiety) and refused surgery. A single session of sclerotherapy with 20 cc mixture of 45 IU. Bleomycin in 10 cc distilled water and 10 cc Lipiodol (Ultra Fluide, Guerbet, France) was performed in all patients, achieving a 45.6%-71.1% lesion volume reduction and a 12.9%-41% reduction in the largest diameter of the lesion. Symptoms subsided in all patients during the 5-month follow-up period. Adverse events included a self-limited intraperitoneal hemorrhage in 1 patient.

Risk factors for hemoglobinuria after ultrasonography-guided percutaneous microwave ablation for large hepatic cavernous hemangiomas

Thermal ablation of large hepatic cavernous hemangiomas may lead to intravascular hemolysis, hemoglobinuria, and even acute renal failure. This study aimed to identify the risk factors associated with hemoglobinuria after ultrasonography-guided percutaneous microwave ablation for large hepatic cavernous hemangiomas. In our study, 11 related risk factors were analyzed using univariate and multivariate binary logistic regression model and Receiver operating characteristic curves to determine the contribution to hemoglobinuria after microwave ablation for 49 patients with 51 hepatic cavernous hemangiomas. By multivariate analysis, the ablation time (p = 0.021; Odds Ratio, 1.005), and the number of antenna insertions (p = 0.036; Odds Ratio, 3.568) were the independent risk factors associated with hemoglobinuria. The cutoff value for ablation time and the number of antenna insertions in predicting the presence of hemoglobinuria was 1185s (sensitivity, 75%; specificity, 69%) and 4.5 (sensitivity, 55%; specificity, 83%), respectively. Less than 5 of antenna insertions and less than 20 mins of ablation time may therefore be recommended in patients with microwave ablation of large hepatic cavernous hemangiomas, in order to reduce the occurrence of hemoglobinuria. This is the first report about the risk factors analysis associated with hemoglobinuria after thermal ablation for large hepatic cavernous hemangiomas.

Radiofrequency ablation for hepatic hemangiomas: A consensus from a Chinese panel of experts

Recent studies have shown that radiofrequency (RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the treatment of hepatic hemangiomas: minimal invasiveness, definite efficacy, high safety, fast recovery, relatively simple operation, and wide applicability. It is necessary to formulate a widely accepted consensus among the experts in China who have extensive expertise and experience in the treatment of hepatic hemangiomas using RF ablation, which is important to standardize the application of RF ablation for the management of hepatic hemangiomas, regarding the selection of patients with suitable indications to receive RF ablation treatment, the technical details of the techniques, therapeutic effect evaluations, management of complications, etc. A final consensus by a Chinese panel of experts who have the expertise of using RF ablation to treat hepatic hemangiomas was reached by means of literature review, comprehensive discussion, and draft approval.

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.

Radiofrequency ablation for huge hepatic hemangiomas: How far from being the first-line treatment

Huge hepatic hemangiomas (≥ 10 cm) are often growthful and harmful. Surgical resection is the traditional treatment for this disease, however, this treatment modality is rather invasive and the operative morbidity and mortality are relatively high. To avoid surgical risk, many minimally invasive procedures have been developed to treat hepatic hemangiomas. In the recent decade, radiofrequency ablation (RFA) has been performed successfully in patients with huge hepatic hemangiomas, showing many advantages over resection, including minimal invasiveness, low complication rate, reduced cost, short hospital stay and increased patient compliance. The treatment strategy for huge hepatic hemangioma is changing from the traditional surgical resection to the minimally invasive treatment with RFA. In the current review, we discuss the present situation and prospect of RFA application in the treatment of huge hepatic hemangiomas.

Microwave ablation of hepatic tumors abutting the diaphragm is safe and effective. AJR Am J Roentgenol. 2015;204:197-203. [PMID: 25539257 DOI: 10.2214/ajr.14.12879]

OBJECTIVE

The purpose of this study was to evaluate the incidence of clinically significant diaphragmatic injuries and local tumor progression after microwave ablation of hepatic tumors abutting the diaphragm.

MATERIALS AND METHODS

This retrospective study included 55 peripheral hepatic tumors abutting the diaphragm treated by microwave ablation versus a control group of 15 centrally located tumors. Treated tumors were further subdivided according to the use of artificial ascites (fluid vs no fluid) and whether instilled fluid achieved displacement of the liver surface away from the diaphragm (displaced vs nondisplaced). Measurements of tumor size, distance to the diaphragm, ablation zone size, displacement distance, length of the ablation zone along the liver capsule, diaphragm thickness, diaphragmatic hernia, and local tumor progression were made on pre- and postablation CT and MRI. The electronic medical record was reviewed for patient self-reported pain scores and other symptoms. Data were analyzed by use of the Kruskal-Wallis and Fisher exact tests.

RESULTS

There were no cases of diaphragmatic hernia in peripheral or central tumors. Postablation diaphragm thickness was higher in peripheral hepatic tumors than in control tumors. Peripheral tumors had an overall higher incidence of postprocedure shoulder pain (18% vs 0%) and local tumor progression (5.5% vs 0%) compared with control tumors, but these differences did not achieve statistical significance (p = 0.2 and p = 1, respectively).

CONCLUSION

Our study shows that microwave ablation of peridiaphragmatic hepatic tumors is safe, without incidence of diaphragmatic hernia, and can be performed with a low rate of local tumor progression.

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.

Brain stimulation, reinforcement and behavior. Cardiovasc Intervent Radiol. 1972;31 Suppl:193-Suppl:213. [PMID: 27387187 PMCID: PMC5052325 DOI: 10.1007/s00270-016-1415-1]

Objective

In patients that require treatment for hepatic giant cavernous hemangiomas (GCH), radiofrequency ablation (RFA) has been suggested to represent a safe and effective alternative to invasive surgery. In a recent report of bipolar RFA, using two expandable needle electrodes, was uneventfully performed in patients with large GCH (>10 cm). The objective of this report is to present two cases in which bipolar RFA of symptomatic GCH was complicated by acute kidney injury.

Materials and methods

In 2015 we treated two patients for very large symptomatic GCH (15.7 and 25.0 cm) with bipolar RFA during open laparotomy.

Results

In both patients the urine showed a red–brown discoloration directly after the ablation. They became anuric and presented with progressive dyspnea, tachypnea, and tachycardia, requiring hemodialysis for a period of 1 month in one case. Lab results revealed hemepigment-induced acute kidney. Both patients fully recovered and both showed a complete relief of symptoms at 3 months following the procedure.

Conclusion

RFA for large GCHs can cause hemepigment-induced acute kidney injury due to massive intravascular hemolysis. The presented cases suggest that caution is warranted and advocate an upper limit regarding the volume of GCHs that can be safely ablated.