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home - Liver - Liver Masses - Hepatic Haemangiomas Written by Dr Sebastian Zeki

Knows the epidemiology pathology clinical presentation and natural
history of benign tumours of the liver

Can define a programme of investigation and characterisation of
benign liver lesions including haemangioma focal modular
hyperplasia and adenoma

Demonstrates ability to make an appropriate differential diagnosis
Formulates appropriate plan of management
Recognises importance of the role of multidisciplinary team in
diagnosis and management



Understands the epidemiology risk factors pathology prevalence
and range of presentations of HCC

Knows the appropriate investigation and staging of the disease
Aware of treatment options including trans-arterial
chemoembolisation (TACE) radiofrequency ablation (RFA) local
ethanol injection

Appreciates the indications and contraindications of each and how
the most appropriate is selected Aware of surgical treatment options

Aware of role of surveillance and referral for specialist multidisciplinary management including liaison with oncology

Appreciates the indications and contraindications of each modality of
treatment and how the most appropriate is selected

Understands the process of selection of patients for liver resection or

Appreciates Involvement of multi-disciplinary team in management
decisions close liaison with surgical radiology oncology and
pathology colleagues

Hepatic Haemangiomas

Hepatic hemangioma Epidemiology and PathogenesisThis has a prevalence of 10%.The average age of onset is 40 years.M:F is 1:3.They are vascular malformation or hamartomas of congenital origin that enlarge by ectasia rather than by hyperplasia or hypertrophy.Hormonal influence over tumor growth is suggested by enlargement during pregnancy and oestrogen and progesterone therapy and regression after withdrawal of therapy. Percutaneous needle biopsy Associated with fatal hemorrhage; esp large superficial lesions in subcapsular locationsLow diagnostic yield from FNABs. Ca2+ Ca2+ Arterial phase Venous Phase Late phase (as in non-contrast) Peripheral nodular enhancement Centripetal flow Iso/ hypodense Clinical Presentations:Abdominal fullness/ liver mass.RUQ pain(esp if bleeding/ thrombosis). Normal LFT’sNormal AFP Natural HistoryThey remain stable over time.Spontaneous rupture is very rare and usually occurs in large peripheral tumours). Giant haemangiomas in childrenHypothyroidism can occur secondary to high levels of 3 iodothyronine deiodinase activity in the hemangioma tissue, which catalyzes the conversion of thyroxine and triiodothyro-nine to biologically inactive hormones, reverse triiodothyro-nine, and 3,3'-diiodothyronine. Associations: Cutaneous haemangiomas.Kasabach-Merritt syndrome (DIC type syndrome in children).Steroid resistant PMR (cured by resection).Hepatic haemangiomatosis (lots of haemangio-mas)- assoc with metaclopramide and HHT.Hemangiomas in other organs, bile duct hamar-tomas, and focal nodular hyperplasia. R lobe Size: Few mm to many cmLarger lesions can be pedunculated - can be cystic and dark.Location: R>L lobeWell circumscribed with a thin capsule.When cut- looks spongy red-brown with hemorrhage, scarring, or calcification. Histological Features:Cavernous vascular spaces of varying sizes lined by a single layer of flat endothelium and filled with blood.Vascular compartments separated by thin fibrous septae +/- thrombi.Large hemangiomas may develop a collagen-ous scar or fibrous nodule as thrombosis occurs.Focal stromal calcification and ossification- this is rare. <2 cm: echogenic.2-5 cm: mainly echogenic. >5 cm: mixed echogenicity (thrombosis and fibrosis)Good sensitivity if<6 cm. Well-demarcated homoge-neous hyperechoic mass. Doppler no help- only shows blood flow in 50% US CT—Well-demarcated hypodense mass; Calcified in10 % low signal intensity on T1 Hyperintense on T2 MRI GAD enhancement gives similar result to CT Retention of the isotope within the lesion remains on delayed images. Technetium-99m pertechnetate-labeled red blood cell pool study If >2 cm se:80%. Sp: 100 %.False -ve if fibrosis or thrombosis.False +ve in hypervascular malignancies and angiosarcomas.Single-photon emission CT (SPECT) using 99mTc-RBC increases the spatial resolution of planar scintigraphy, providing sensitivity and accuracy close to that of MRI for lesions >1 cm.The best use of 99mTc-RBC SPECT is for lesions >2 cm to confirm a suspected hemangioma seen as a hyperechoic lesion in ultrasound and to clarify the diagnosis when CT findings are unclear. Radiology Hypoperfusion during arterial flow, followed by gradual inc tracer peaking 30-50 mins post injection. Angiography —Rarely usedLarge feeding vessel with displacement and diffuse pooling of contrast producing "cotton wool" appearance- persists during venous phase. Asymptomatic patients (esp <1.5 cm) reassurance and observation.If >5 cm esp sub capsular- close radiological follow-upIf asymptomatic, bleeding risk is too low to justify prophylactic resection.Symptomatic PatientsIndications for surgery: Complications eg rupture/ intraperitoneal bleedingIncapacitating symptoms.Failure to exclude a malignancy.Surgery —Liver resection or transplantation/Enucleation/Hepatic artery ligation-sometimes pre-enucleation.Non-surgical treatment —Arterial embolization: No evidence of long-term efficacy and can get abscessesRadiotherapy if assoc. Kasabach-Merritt syndrome. if technically difficult resectionRecommendations regarding OCPs and pregnancy —Full-term pregnancies without complications have been reported.Assoc unclear Management Written by Dr Sebastian Zeki

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