Reduction in size of hepatic haemangiomas following chemotherapy

Clinical History

Two patients with a diagnosis of malignancy (patient A - combined seminomatous and embryonal testicular tumour; patient B - non-Hodgkin's lymphoma and pulmonary adenocarcinoma) with hepatic lesions on staging CT.

Imaging Findings

This report describes two cases. Patient A is a 26-year-old man with combined (seminomatous and embryonal) testicular cancer with metastatic disease (ipsilateral para-aortic lymphadenopathy) on staging CT. Additionally, an indeterminate low-attenuation hepatic lesion was identified, thus raising the suspicion of a hepatic metastasis. Subsequent ultrasound and MRI, however, demonstrated typical imaging characteristics of a haemangioma following which this diagnosis was made. Patient B is a 60-year-old woman with non-Hodgkin’s lymphoma and pulmonary adenocarcinoma. In this case, the patient was known to have hepatic haemangiomas as diagnosed on a triple phase liver CT eight years prior to the diagnosis of malignancy. Both patients underwent chemotherapy (Patient 1 - Bleomycin, Etoposide, Cisplatin (BEP) and Patient 2 - Doxorubicin, Bleomycin, Vinblastine, Dacarbazine (ABVD) and Cyclophosphamide, Doxorubicin, Etoposide, Procarbazine, Prednisone, Bleomycin, Vincristine (BEACOPP) regimes). Follow-up post-chemotherapy imaging demonstrated an unexpected finding of reduction in size of these haemangiomas.

Discussion

Hepatic haemangiomas are the most common benign hepatic tumour and the second most common hepatic mass after metastasis, with an incidence of 0.4% to 7.3% [1, 2, 3]. Histologically, haemangiomas are composed of large endothelium-lined vascular spaces that are separated by fibrous septa [4]. They are typically asymptomatic but occasionally require surgical intervention [4]. Definitive diagnosis of a haemangioma is made histologically; however, very few cases proceed to a histological diagnosis with 90% of cases diagnosed on CT or MRI [5]. Hepatic haemangiomas are typically of low attenuation on CT and show hypointense T1 signal and hyperintense T2 signal on MRI with characteristic early peripheral nodular enhancement with filling-in on delayed images on both modalities [6, 7]. They can mimic liver metastases, particularly hypervascular metastases [8], with reports of diagnostic dubiety in nearly 10% of patients with hepatic haemangiomas [4].

In the case of patient A, the lack of further disseminated disease and typical imaging appearances of the liver lesion favoured the diagnosis of haemangioma over metastasis, hence staging and further management decisions were made accordingly. The unexpected finding of size reduction of the liver lesion after chemotherapy gave rise to doubt about the accuracy of the initial diagnosis. Following multi-disciplinary team discussion, it was felt that there was sufficient clinical confidence about the initial diagnosis, so that yearly MRI follow-up was favoured over the pursuit of a histological diagnosis. In the case of patient B, the presence of previous imaging could not be evaluated and such diagnostic challenges were avoided. Long term follow-up in patient A demonstrated stability of the lesions after chemotherapy with complete resolution of the para-aortic lymphadenopathy while patient B showed progression of disease elsewhere, which she later succumbed to but without significant change in the liver lesions.

While these cases rely on imaging rather than histological diagnoses, similar observations have been reported in cases of ovarian yolk sac tumours and mixed testicular tumours [4, 9] with histologically proven hepatic haemangiomas. It is unclear if the observed size reduction of these lesions relates to surrounding hepatic parenchymal changes in response to chemotherapy [10] or changes to the haemangioma itself [4, 11].

Regardless of the underlying cause, this observation is felt noteworthy due to the common occurrence of both haemangiomas and liver metastases and the potential challenges to clinical management, which could arise as a result.

Differential Diagnosis List

Final Diagnosis

Imaging diagnosis of hepatic haemangiomas

URL:	https://www.eurorad.org/case/12775
DOI:	10.1594/EURORAD/CASE.12775
ISSN:	1563-4086