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INTERVENTIONAL RADIOLOGY Table of Contents   
Year : 2007  |  Volume : 17  |  Issue : 2  |  Page : 81-83
Case report: Non-surgical management of a giant liver hemangioma


Department of Radiodiagnosis, Rural Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raibarely Rd, Lucknow 226016, India

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Keywords: Embolization, giant hemangioma, PVA particles

How to cite this article:
Mohan S, Gupta A, Verma A, Kathura M K, Baijal S S. Case report: Non-surgical management of a giant liver hemangioma. Indian J Radiol Imaging 2007;17:81-3

How to cite this URL:
Mohan S, Gupta A, Verma A, Kathura M K, Baijal S S. Case report: Non-surgical management of a giant liver hemangioma. Indian J Radiol Imaging [serial online] 2007 [cited 2020 Jun 2];17:81-3. Available from: http://www.ijri.org/text.asp?2007/17/2/81/33616
Cavernous hemangioma is the most common benign tumor of the liver, with a frequency of 0.4-7.3% in autopsy cases. [1] Small liver hemangiomas (< 4cms) are generally asymptomatic and can be ignored without risk of complications or missing malignant lesions. Adam et al [2] defined hemangiomas as "giant" if their diameters exceed 4 cm. These can be responsible for various complications and according to most authors, are to be treated by surgical resection. [3] Other modalities of treatment for large hemangiomas such as hepatic artery ligation or radiotherapy have had controversial results and hence have now been abandoned. [3] Trans-arterial embolization (TAE) has also been used as a non-surgical endovascular treatment option in the management of such patients.


   Case Report Top


A 36-years-old man presented with complaints of intermittent dull ache and fullness in the right upper abdomen. Physical examination revealed soft hepatomegaly with a smooth surface. Laboratory studies including liver function tests and serum alpha-fetoprotein levels were normal. Abdominal USG using a 2.5-6 MHz convex transducer, (Sonolyne G60S, Siemens Medical Solutions Inc. WA, USA) showed a large hepatic lesion, measuring 12.5 11.6 9.4 cms with heterogeneous echogenecity. Triple phase helical CT (Picker 5000, Picker International Inc. Cleveland OH, USA) was performed to characterize the lesion and showed a large hypodense mass occupying the entire right lobe with peripheral nodular enhancement and centripetal fill-in completely filling-in on the delayed scans. This was diagnostic of a liver hemangioma [Figure - 1]. The portal vein was patent and no other abnormality was detected.

The symptoms were attributed to the giant liver hemangioma and with informed consent TAE was performed under conscious sedation and pre-procedure antibiotic cover. A right trans-femoral arterial route was used, to cannulate the right hepatic artery selectively with a 5F catheter (SIM 1, Cook, Bloomington, IN, USA) and a selective angiogram was obtained, which showed a hypervascular lesion with no arterio-portal fistula or arterio-venous shunting and with the typical "cotton- wool" appearance of a hemangioma [Figure - 2]A-B. The left hepatic artery was seen arising from the left gastric artery. The feeding arteries from the right hepatic artery were cannulated using a 3 French, superselective, microcatheter-wire system (Microferret and Cirrus-14, Cook, Bloomington, IN, USA) and embolization was done with poly-vinyl alcohol particles (PVA) of size 300-500 m (Ivalon).

A post-embolization check angiogram showed pruning of the feeding vessels and non-opacification of the hemangiomas [Figure - 3]. Postprocedure, the patient complained of mild pain and fever, which resolved on symptomatic treatment with oral paracetamol and diclofenac sodium, within 48 hours. Intravenous antibiotics (combination of ciprofloxacin and metronidazole) were given for five days. No signs of biliary channel necrosis (hemobilia, increase in serum transaminases, serum bilirubin, serum alkaline phosphatase, biliary colic) were noted. The patient was discharged on the seventh day in a satisfactory condition.

At six-months follow-up the patient was clinically asymptomatic, pain free and was doing well with normal liver function tests. USG showed minimal reduction in size with a slight increase in heterogeneity of the lesion.


   Discussion Top


Cavernous hemangiomas are the most common benign tumors of the liver. [1] They are more common in the right lobe of the liver in a sub-capsular or marginal location. Since most are small and asymptomatic, showing no changes during long term follow up periods, observation without any treatment may be acceptable. [4] Giant liver hemangiomas can present with pain, abdominal fullness, upper abdominal mass and rarely with jaundice, consumption coagulopathy (Kasabach-Merritt syndrome) or intra-abdominal hemorrhage due to rupture. [5] The risk of mortality is still a major issue due to congestive heart failure and severe intraperitoneal hemorrhage. [6]

Surgical resection is recommended for symptomatic giant hemangiomas because definite pre-operative diagnosis is difficult to obtain, per-cutaneous biopsy is dangerous and alternative treatment options such as steroids, hepatic artery ligation and radiotherapy show controversial results. [3],[7] Hepatic arterial embolization is, after surgical resection, the next most widely reported method for treatment of symptomatic giant hemangiomas. [7]

Endovascular management in the form of trans-arterial embolization (TAE) is offered in cases of symptomatic hemangiomas that are unresectable i.e, involving both lobes, [8] as a pre-operative temporizing procedure in ruptured hemangiomas, [9] in diffuse hemangiomatosis, in progressively growing hemangiomas and those at high risk of bleeding. Recent studies have shown that TAE is a safe and effective treatment option for lesions that are large and located on the inferior surface of liver and are at high risk of rupture. [10] Use of TAE, as an alternative to hepatic resection is controversial because of the theoretical risk of ischemia of liver and intracavitary bleed or infection. However, with increasing expertise and technical improvements and consequent minimal complication rates, there has been an increase in the number of such embolization procedures, which has led to broadening of the spectrum of indications for lesions treated by the endovascular route.

Temporary embolic material used is gel-foam [11] and permanent materials include steel coils, [11] poly-vinyl alcohol [10],[12] and iso-butyl cyanoacrylate. Histologically, hemangiomas are un-encapsulated and made up of large, cavernous vascular spaces lined essentially by normal endothelial cells. In TAE, the vascular interstices within the hemangioma and the feeding arterioles are obliterated with gel-foam or polyvinyl alcohol particles. Some authors have embolized the feeding artery by steel coils, once the peripheral spaces were occluded. [11] In cases, where arterio-portal or arterio-venous fistulas are noted on the angiogram, the use of particulate embolic material is best avoided to prevent their passage into the systemic or portal circulation. [12] In our case we used poly-vinyl alcohol particles 300-500 m (Ivalon) in size, without any complications.

The most common side-effects are the post-embolization syndrome in the form of pain, pyrexia, leucocytosis and nausea that lasts for a few days. [11] Serious complications are rare and include infection, liver abscess and sepsis. Our patient tolerated the procedure well with a mild-post- embolization syndrome that lasted for a few days.

This case report describes the successful use of TAE in the management of symptomatic giant liver hemangiomas.

 
   References Top

1.Ishak KG, Robin L. Benign tumors of the liver. Med Clin North Am 1975;59:995-1013.  Back to cited text no. 1    
2.Adam YG, Huvos AG, Fortner JG. Giant hemangiomas of the liver. Ann Surg 1970;172:239-45.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Iwatsuki S, Todo S, Starzl TE. Excisional therapy for benign hepatic lesions. Surg Gynecol Obstet 1990;171:240-6.  Back to cited text no. 3  [PUBMED]  
4.Bruneton JN, Drouilland J, Fenart D, Roux P, Nicolau A. Ultrasonography of hepatic cavernous hemangiomas. Br J Radiol 1983;56:791-5.  Back to cited text no. 4    
5.Schwartz SI, Husser WC. Cavernous hemangioma of the liver. Ann Surg 1987;205:456-65.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Drolet BA, Esterley NB, Frieden IJ. Hemangiomas in children. N Engl J Med 1999;341:173-81.  Back to cited text no. 6    
7.Hobbs KE. Hepatic hemangiomas. World J Surg 1990;14:468-71.  Back to cited text no. 7  [PUBMED]  
8.Panis Y, Fagneiz PL, Cherqui D, Roche A, Schaal JC, Jaeck D. Successful arterial embolization of giant liver hemangioma: Report of a case with five-yr computed tomography follow-up. HPB Surg 1993;7:141-6.  Back to cited text no. 8    
9.Yamamoto T, Kawarada Y, Yano T, Noguchi T, Mizumoto R. Spontaneous rupture of hemangioma of the liver: Treatment with transcatheter hepatic arterial embolization. Am J Gastroenterol 1991;86:1645-9.  Back to cited text no. 9  [PUBMED]  
10.Jesic R, Radojkovic S, Tomic D, Krstic M, Jankovic G, Milinic N, et al . Personal experience in embolization of liver hemangiomas. Srp Arh Celok Lek 1998;126:349-54.  Back to cited text no. 10    
11.Allison DJ, Jordan H, Henneisy O. Therapeutic embolization of the hepatic artery: A review of 75 procedures. Lancet 1985;1:595-9.  Back to cited text no. 11    
12.Stanley P, Grinnek VS, Stanton RE, Williams KO, Shore NA. Therapeutic embolization of infantile hepatic hemangiomas with poly-vinyl alcohol. AJR Am J Roentgenol 1983;141:1047-51.  Back to cited text no. 12    

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Correspondence Address:
S S Baijal
Dept of Radiodiagnosis, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raibarely Rd, Lucknow 226016, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.33616

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