Hepatic Hemangioma

Benign tumour of liver ,characterised by abnormal proliferation of vascular channels.

1. Hepatic hemangioma Dr.Tanzilur Rahman Resident,Phase-B BSMMU

2. Commonest benign hepatic tumour. Multiple Haemangioma-10% cases. Composed of vascular channels of various sizes (cavernous to capillary) lined with endothelium often with intervening fibrous tissue of variable amount. 80% in female

3. Imaging R/F: USG :Homogeneous hyper echoic lesion ( 80 % ) Hypo echoic lesion 10% especially in fatty liver. Some adult and most neonatal and infantile H. are cavernous type, which are hypoechoic. (As larger vascular channels). Giant H. are heterogenous . Post .acoustic enhancement –common. No detectable signal in Doppler USG.

4. Hyperechoic area at the bifurcation of portal vain

5. Hypoechoic nodule in right lobe with echogenic border.Background fatty liver is noted.

6. CT scan Well defined, lobulated lesion ( hypo dense ) in pre-contrast scan . After contrast nodular heterogeneous peripheral enhancement with progressive centripetal fill - in & eventually merging with back ground parenchyma is seen.

7. MRI Most specific and sensitive method for DX. T1W-hypointense T2W-hyperintense ( light bulb sign ) After I/V Gd –DTPA-rapidly enhanced their periphery. Then centripetally to become isointense with the adjacent parenchyma.

8. Figure 35.26 Haemangioma . Typical appearance of enhancement following IV gadolinium with initial peripheral nodular high signal vessel signal followed by progressive infilling of the lesion. Images obtained at 40 s, 120 s, 5 min and 15 min following injection.

9. Types Capillary Cavernous Sclerosed

10. Capillary haemangioma Known as fast flow haemangioma. Accounts for 16% of all haemangiomas.42% are under 1cm in diameter. USG: Most often hypoechoic and homogenous(due to predominant fibrous stroma and fast flow). CT :Slightly hpodense in NECT. Enhancement kinetics is rapid.An early ,intense,homogenous contrast is observed by flash similar to the aortic enhancement in arterial phase.Late,this enhancement follows that of the aorta,without washing. MRI :Homogenous and high intensity signals on T2WI images as well as a contrast kinetics similar to that seen in CT.

11. Cavernous haemangioma Most common sub-type and corresponds to classic description of haemangioma in imaging. Consists of large vascular spaces with a central cavernous zone. In general ,This typical appearance is observed in lesions less than 3cm in diameter.

12. Sclerosed haemangioma Degeneration with an extensive fibrosis, beginning at the centre of the lesion, at the origin of the obliteration of vascular spaces.Also called thrombosed or hyalinsed haemangioma. USG: Heterogenous lesion with hypoechoic zones that may correspond to sclerotic zone in histology. CT: Focal patches are observed that are more spontaneously hypodense than rest of the lesion,also corresponding to sclerotic zones. MRI:T2W heterogenous signal with central hypointense zone is seen. Enhancement pattern is slow with a peripheral nodular enhancement,similar to cavernous haemangioma.

13. Giant haemangioma Controversial term since some authors consider as giant lesions measuring 4cm,6cm and even>12cm in diameter. On non contrast images they are usually heterogenous hypoattenuated mass with central areas of low attenuation. Contrst filling may be slow and central portion may never demonstrate complete contrast fill in. Potential complication includes Mass effect on adjacent structure Kasabach Merritt Syndrome (A form of consumptive cagulopathy) Rupture with haemoperitoneum

14. Flash haemangioma

15. Treatment

16. Transcatheter arterial embolisation Done by trained and experienced radiologists. Microcatheter is placed into feeding artery. Mixure of pingyangmycin,bleomycin,iohexol,lipiodol is injected until periphery of haemangioma is surrounded.

17. Fluoroscopic image:Deposited lipiodol completely surrounding the haemangioma

18. A.Before TAE B.After 3 months of TAE C.After 6 months of TAE.

19. Differentials

20. Looks like haemangioma but not HAEMANGIOMA

21. Not all lesions with blood pool are haemangioma .we should consider peliosis hepatis,haemangioendothelioma and liver sarcoma

22. Haemangioma diagnosis :How to do it right