Liver haemangioma

Section: Hepatobiliary Sub-section: Liver Curriculum: Curriculum, page 85

Definition

Benign tumour of mesenchymal origin consisting of clusters of blood-filled cavities lined by endothelial cells, fed by the hepatic artery.

Epidemiology

• Commonest benign liver lesion
• Incidence 3%
• Women > men (5:1).
• Mean age at diagnosis 50y.

Pathology

• Macroscopic: well-circumscribed compressible tumours with a dark colour.
• Microscopically: composed of multiple blood vessels lined by single layer of endothelial cells within thin, fibrous stroma.
• Blood supply from hepatic artery.
• Needle biopsy not necessary – debatable whether risk of bleeding

Clinical

• Usually incidentally
• Larger ones present with non specific abdominal symptoms e.g. vague pain, fullness, early satiety, nausea or vomiting. May be explained by compression of adjacent organs or stretch of Glisson’s capsule.
• If symptoms present, >50% had another cause for symptoms
• Spontaneous rupture or bleeding is rare – mainly in large, peripherally located exophytic
• Rare presentation with giant haemangioma is thrombocytopenia and hypofibrinogenaemia, caused by consumption of coagulation factors – Kasaback-Merritt syndrome. Serious complication and mortality between 10 – 37%

Investigations

Diagnosis:

• Ultrasound:
  • Well-defined, lobulated, homogenous hyperechoic masses
  • May have hypoechoic portions due to haemorrhage, fibrosis or calcification
  • Unenhanced ultrasound cannot differentiate small haemangioma from HCC, adenoma, FNH or solitary met
• CT:
  • CT Pre con: Hypodense
  • CT Arterial: Nodular peripheral enhancement
  • CT Venous: Centripetal filling
  • CT Delayed: Continued filling

• MRI:
  • Bright (hyperintense) on T2 (b)
  • Similar to CT on enhanced T1 (c). No uptake of contrast, and peripheral nodular enhancement pattern seen.

Management

• Non-operative appropriate for asymptomatic lesions
• Symptomatic; risk vs benefit of resection.
  • Indicaitons
    • Symptomatic
    • Complications
      • Obstructive jaundice
      • Kasaback-Merritt syndrome
      • High output CHF
    • Possible malignancy
  • If resection, then complete resection or enucleation (preferred) is best treatment.
  • High risk of major perioperative bleeding
• Transarterial embolization rarely used. Can be useful if rupture/shrink prior to resection.
• RFA has been used recently successfully.
• Very rarely need liver transplant for unresectable, complicated, giant haemangioma

Follow up

Nil