liver hemangioma

Overview

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] The radiologic characteristics of hemangiomas are demonstrated in the images below.

Contrast-enhanced computed tomography (CT) scan that was obtained during the arterial-dominant phase. This image demonstrates a hemangioma with homogeneous and intense contrast enhancement.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]}

Preferred examination

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 magnetic resonance imaging (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.

Recent studies

Kobayashi et al found a sensitivity of 79% and a specificity of 100% for the diagnosis of hepatic hemangioma using contrast-enhanced ultrasonography (CEUS) with Levovist. The study included 34 patients with 38 hemangiomas and 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 ultrasonograms or changing the posture of the patient.^[8]

Liver haemangioma

Lesion 1, the "big daddy" of the three. It's the white round looking thing in the middle


Lesions 2 and 3, the round white "eyeballs" in the middle left