eMedicine Specialties > Radiology > Gastrointestinal
Cavernous Hemangioma, Liver
Updated: Aug 12, 2009
Introduction
Background
Cavernous hemangioma is the most common primary liver tumor; its occurrence in the general population ranges from 0.4-20%, as reported by Karhunen in an autopsy series.1 Cavernous hemangiomas arise from the endothelial cells that line the blood vessels and consist of multiple, large vascular channels lined by a single layer of endothelial cells and supported by collagenous walls. These tumors are frequently asymptomatic and incidentally discovered at imaging, surgery, or autopsy. Hemangiomas are uncommon in cirrhotic livers; the fibrotic process in cirrhotic liver may prohibit their development.2
Contrast-enhanced computed tomography (CT) scan. These images reveal the pathognomonic features of a hemangioma, namely, peripheral nodular enhancement and progressive centripetal fill-in (arrow). The smaller, peripheral lesion (circled) shows homogeneous enhancement.
Magnetic resonance image (MRI) of a hemangioma. The lesion appears as a hypointense mass on T1-weighted MRIs (T1WI) and as a hyperintense mass on dual-echo T2-weighted MRIs (T2WI). Note that the signal intensity of the lesion is similar to that of the adjacent cerebrospinal fluid.
Dynamic gadolinium (Gd)-enhanced magnetic resonance images (MRIs). These images demonstrate the progressive, centripetal contrast enhancement in a hemangioma.
Gray-scale and Doppler ultrasonographic (US) images. These sonograms show a well-defined, uniformly hyperechoic liver mass with peripheral feeder vessels that are characteristic of a hemangioma.
Usually, cavernous hemangiomas occur as solitary lesions; however, they may be multiple in as many as 50% of patients.3 No lobar predilection exists, and the tumors may be associated with focal nodular hyperplasia.4 Hemangiomas typically measure less than 5 cm; those larger than 4-5 cm are sometimes called giant hemangiomas.5,6,7
Recent studies
Belli et al reported on 12 giant symptomatic hemangioma treated between January 2000 and April 2006, of which 4 anterior, superficial tumors were treated by enucleation. According to the authors, detailed pathologic examination demonstrated an interface between the hemangiomas and the normal liver tissue that allowed the enucleation. The dissection in the plane between the tumor and the adjacent normal liver tissue was facilitated by an ultrasonically activated device. Median operative blood loss was 90 ml (range, 50-190 ml), and no transfusions were used. The procedure described, according to the authors, allowed a safe enucleation of giant hemangiomas with reduced blood loss and preservation of virtually all normal hepatic parenchyma.8
Kobayashi et al studied the use of contrast-enhanced ultrasound (CEUS) with Levovist for hepatic hemangioma in 34 patients with 38 hemangiomas and in 12 patients with 15 hypervascular hepatocellular carcinomas. In the early phase of hemangioma, nodular enhancement (NE) was found transiently in 13 lesions (34%) and continuously in 25 lesions (66%), while hepatocellular carcinoma did not show this pattern. In the liver-specific phase of hemangioma, diffuse enhancement patterns were observed in 12 lesions (31%) and partial enhancement in 26 lesions (69%). Liver-specific findings were affected by taking early-phase sonograms or changing the posture of the patient. This method provided sensitivity of 79% and specificity of 100% for the diagnosis of hemangioma.9
Pathophysiology
The natural history of liver hemangioma is not completely understood. Hemangiomas are probably congenital in origin, and hereditary factors may play a role in the pathogenesis of some familial forms of these tumors. Although the growth of hemangiomas is reported in the literature, ectasia is believed to contribute to lesion enlargement.10 Moreover, according to the findings in a study by Brancatelli et al, hemangiomas may become fibrotic and shrink in patients with progressive cirrhosis, leading to more difficulty with radiologic and pathologic diagnoses.11
Sex
A distinct female preponderance has been reported in surgical series, with a female-to-male ratio ranging from 5:1 to 6:1. However, in children and in autopsy series, cavernous hemangioma of the liver affects males and females equally .
Age
Hemangiomas can occur in individuals of any age. The tumors frequently occur in middle-aged women.
Presentation
The vast majority of hemangiomas (as many as 85%) are asymptomatic; however, hemangiomas may cause symptoms because of the compression of adjacent structures, rupture, acute thrombosis, or consumptive coagulopathy (ie, Kasabach-Merritt syndrome).12
Pressure on the stomach and duodenum caused by large pedunculated hemangioma lesions may cause vague abdominal pain, early satiety, nausea, and vomiting. Pedunculated hemangiomas may twist and cause acute abdominal pain.13 Compression of the inferior vena cava may result in Budd-Chiari syndrome.14 Acute thrombosis may result in acute inflammatory changes that cause fever, abdominal pain, and abnormal results in liver function tests.15 Spontaneous or posttraumatic rupture is a catastrophic complication that occurs in about 1-4% of hemangiomas; this condition has a considerable mortality rate, as high as 60%.6
Preferred Examination
Most patients with liver hemangioma are asymptomatic. Clinical findings usually do not contribute to the diagnosis. Laboratory test results may suggest anemia, and reduced hematocrit levels may be present in patients who have ruptured hemangiomas. In patients who have giant hemangiomas that are associated with Kasabach-Merritt syndrome,12 bleeding and clotting laboratory parameters may be abnormal.
Most hemangiomas are incidentally detected on imaging studies. Ultrasonography is a cost-effective imaging modality for the diagnosis of a hemangioma. However, computed tomography (CT) scanning and/or MRI may be required to specifically diagnose a hemangioma.
Limitations of Techniques
Ultrasonography is a heavily operator-dependent technique; its performance depends on the expertise and experience of the ultrasonographer. In addition, the acquisition of satisfactory images in obese patients is technically difficult. Contrast-enhanced CT scanning is relatively contraindicated in patients who have renal insufficiency and in those who have a previous history of hypersensitivity to iodinated contrast agents; thus, MRI may be the preferred modality of choice in the characterization of hemangiomas in such patients. Angiography is an invasive method that is used for the characterization of liver hemangiomas; this imaging modality is associated with low but definite risks of morbidity and mortality.
Differential Diagnoses
Focal Nodular Hyperplasia
Hepatocellular Carcinoma
Liver, Metastases
Other Problems to Be Considered
Hepatoma
Adenoma
Hypervascular metastases
More on Cavernous Hemangioma, Liver |
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References
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Further Reading
Related eMedicine topics
Hemangiomas, Hepatic
Hemangioma, Cavernous
Kasabach-Merritt Syndrome (Hematology)
Kasabach-Merritt Syndrome (Pediatrics)
Budd-Chiari Syndrome
Clinical guidelines
AASLD practice guidelines: evaluation of the patient for liver transplantation. American Association for the Study of Liver Diseases - Private Nonprofit Research Organization. 2000 Jan (revised 2005 Jun). 26 pages. NGC:004333
ACR Appropriateness Criteria® liver lesion characterization. American College of Radiology - Medical Specialty Society. 1998 (revised 2006). 7 pages. NGC:005115
Surgery for hepatic colorectal metastases. Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society. 2004 May 15. 3 pages. NGC:003837
Clinical trials
Incidence of Hepatic Hemangiomatosis in Patients With Cutaneous Hemangiomas
A Comparison of Contrast Enhanced Ultrasound (CEUS) and Contrast Enhanced Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) for Characterization of Focal Liver Masses
Keywords
cavernous hemangioma of liver, hepatic cavernous hemangioma, hepatic hemangioma, hemangioma of the liver, giant hemangioma of the liver, primary liver tumor, focal nodular hyperplasia, Kasabach-Merritt syndrome
