Giant cavernous haemangioma

Clinical History

A 73-year-old male patient complained of 4 kg weight loss and chronic fullness for one month.
His medical history was significant for insulin-dependent diabetes mellitus for the past 8 years, hypothyroidism, dislipaemia, ischaemic cardiopathy with coronary right stent, prostatectomy, appendectomy, left inguinal hernia repair.

Imaging Findings

Non-contrast ultrasound was performed where a heterogeneous echogenic mass was found.
Computed tomography (CT) revealed hypo-dense large mass (11 x 9 cm) with some coarse calcifications in the left hepatic lobe and IV-segment with well-defined borders causing mass effect (Fig. 1).

Contrast material–enhanced CT showed a peripheral nodular enhancement that progressively filled the lesion with progressive centripetal enhancement (Fig. 2, 3 and 4).

Due to the portal-artery shunts inside the tumour, in the arterial phase a portal retrograde filling can be appreciated (Fig. 2).

Uniform enhancement was shown in venous phase (Fig. 4).

Preoperative embolization of the mass was performed.
A pigtail catheter was introduced into the aorta. Contrast material was injected and the left gastric and left hepatic arteries that fed the mass where displayed. Embolisation was performed with polyvinyl alcohol spherical particles (900-1200 microns) (Fig. 5, 6 and 7).

Seven days later the surgeons informed us that the tumour was completely devascularized.

Discussion

Giant cavernous haemangiomas 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, supported by collagenous walls (3).
Haemangiomas are the most common benign tumours of the liver and second most common liver tumour after metastases. Predominance female-to-male of 2-5:1 [1, 5].
They are usually solitary and grow slowly, although there may be multiple in up to 50% of cases.
Common location is the subcapsular area in posterior right lobe of liver and the size can vary to more than 20 cm. The term giant haemangioma is reserved for lesions larger than 5 cm. Calcification is rare (less than 10%).

Many patients are asymptomatic and the lesion is accidentally discovered at imaging, surgery or autopsy; some patients can exhibit symptoms secondary to mass effect, pain or fullness. In the absence of complications, physical examination and laboratory values are normal [5].

On non-enhanced CT scans, haemangiomas appear hypo-attenuating relative to the adjacent liver. During the arterial-dominant phase, small haemangiomas show intense and uniform contrast enhancement and retain their contrast enhancement during the portal venous phase but the giant cavernous haemangiomas show a peripheral, discontinuous, intense nodular enhancement during the arterial-dominant phase with progressive centripetal fill-in on CT scans that it is considered pathognomonic for haemangioma [3].

The best diagnostic clue is the peripheral nodular enhancement on arterial phase scan with slow progressive centripetal enhancement isodense to vessels. The venous and delayed phases show an incomplete centripetal filling of lesion but the scars or fat do not enhance and remain hypo-dense.

At angiography, the feeding vessels of the haemangioma have a normal calibre, except those in the large tumours. During the late arterial/hepatic parenchymal phases, a dense, nodular pattern of opacification of the dilated vascular spaces persists into the venous phase with a "Cotton wool" appearance [2, 5].

The prognosis is usually good and complications are rare but spontaneous rupture and abscess formation can occur.
The asymptomatic lesions less than 5 cm size just need a follow-up radiographic control. When haemangioma is symptomatic, the preferred treatment is resection.

Embolisation before the resection is a procedure that can help minimize the effects of the resection. Blocking the blood supply of the tumour often is an effective measure. Preoperative embolisation reduces the risk of complication associated with surgery and can improve the likelihood of a complete resection [4].

Differential Diagnosis List

Final Diagnosis

Giant cavernous haemangioma

URL:	https://www.eurorad.org/case/10070
DOI:	10.1594/EURORAD/CASE.10070
ISSN:	1563-4086