CASE 12684 Published on 26.04.2015

Pedunculated liver haemangioma: a challenging imaging diagnosis with potential danger

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD1; Rizzi Andrea, MD2; Gambitta Pietro, MD3

(1) Department of Radiology
(2) Department of Surgery
(3) Department of Digestive Endscopy
"Luigi Sacco" University Hospital
Via G.B. Grassi 74
20157 Milan, Italy
Email:mtonolini@sirm.org
Patient

80 years, male

Categories
Area of Interest Liver ; Imaging Technique CT, MR
Clinical History
Elderly male patient in good clinical condition was referred to Radiology to investigate suspected pyelonephritis. Medical history included radical prostatectomy, previous myocardial infarction treated with percutaneous coronary stenting, severe carotid artery stenosis, nephrolithiasis and tubercular nephritis, hepatitis C virus-related chronic liver disease.
No abnormal physical findings and routine laboratory assays.
Imaging Findings
Incidentally, CT (Fig. 1) detected a sizeable well-demarcated ovoid left-sided upper abdominal mass, extrinsic to the pancreas and spleen. Unknown from previous ultrasound reports, the lesion was mildly heterogeneous with some peripheral calcifications, eccentric enhancement foci that progressed in the delayed phase. Additional unenhanced MRI (Fig. 2) confirmed extrinsical compression of the stomach without infiltration, and showed intermediate T1 and moderately high T2 signal.
To clarify the lesion’s origin, the patient underwent transgastric endoscopic ultrasound (EUS)-guided fine-needle biopsy. Despite antiaggregation withdrawal, immediately thereafter the patient suffered from hypotension, with signs of blood loss. Immediate CT (Fig. 3) showed appearance of intralesional bleeding and massive haemoperitoneum.
At emergency laparotomy haemoperitoneum was confirmed and a brownish “spongy” mass with active bleeding attached to the liver margin was resected, pathologically diagnosed as pedunculated cavernous haemangioma. Retrospectively, focused maximum intensity projection CT reformations allowed identifying a very thin stalk connecting the mass abutting the stomach to the left liver lobe.
Discussion
The commonest focal liver lesion, haemangioma usually represents a straightforward imaging diagnosis unless atypical morphological or structural features are present. While exophytic forms are uncommon, pedunculated liver haemangiomas (PLHs) centred outside the liver margin are exceptional, since a recent literature review included only 24 cases. Predominantly found in women, PLHs are commonly asymptomatic despite large size (4-15 cm) and therefore incidentally discovered. Alternatively, epigastric discomfort, symptoms from mass effect or complications such as spontaneous torsion and haemorrhage have been reported. Palpable, symptomatic or growing masses require surgical treatment, and laparoscopic resection may prevent potential traumatic rupture, torsion or intraperitoneal bleeding [1-5].
Histologically, PLHs are cavernous well-demarcated blood-filled lesions, which originate from the bare area, the right posterior, right anterior, left inferior or left lateral segments of the liver. The greater surface area-to-volume ratio of the left liver lobe may favour PLH development. PLH usually show similar CT attenuation, MR signal intensity features and characteristic enhancement pattern to typical intraparenchymal haemangiomas. Unfortunately, correct preoperative diagnosis is reached in approximately 50% of patients, since PLHs are connected to the liver by a thin stalk, which is very difficult to identify at imaging. Similar to another case, in this patient the mass caused extrinsic compression of the stomach, and its origin was challenging to define in absence of an obvious vascular pedicle. PLHs are commonly misinterpreted as other extrahepatic abnormalities such as exophytic gastric submucosal tumours, colon or adrenal masses. Furthermore, other benign and malignant liver lesions may occasionally show exophytic growth [1-5].
Therefore, PLHs should be considered in the differential diagnosis of masses of unknown origin in the right, central, or left upper abdomen: misinterpretation may result in potential danger from inappropriate procedures such as biopsy. Percutaneous puncture of a haemangioma was traditionally considered hazardous, and requires interposition of liver tissue between the capsule and the lesion along the needle path [1-3, 6]. Endoscopic ultrasound (EUS) - guided fine-needle aspiration biopsy (FNAB) consistently provides accurate tissue diagnosis in a variety of intramural gastrointestinal and extraintestinal abnormalities, including pancreatic and selected hepatobiliary lesions, mediastinal and abdominal lymph nodes, perirectal and perigastric masses, and is increasingly used for lesions not amenable to or after unsuccessful percutaneous biopsy, and in patients at increased risk of bleeding. Generally considered safe, EUS-FNAB is associated with uncommon (1.6-6.3% of cases), mostly minor complications such as fever, local bleeding and hyperamylasemia, with occasional severe or fatal occurrences [7-11].
Differential Diagnosis List
Pedunculated liver haemangioma. Haemoperitoneum after endoscopic ultrasound-guided biopsy
Gastrointestinal stromal tumour (GIST)
Pedunculated focal nodular hyperplasia
Pedunculated hepatocellular adenoma
Pedunculated hepatocellular carcinoma
Sarcoma
Lymphoma
Final Diagnosis
Pedunculated liver haemangioma. Haemoperitoneum after endoscopic ultrasound-guided biopsy
Case information
URL: https://www.eurorad.org/case/12684
DOI: 10.1594/EURORAD/CASE.12684
ISSN: 1563-4086