JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
CLINICAL CASE OF THE MONTH
A 44-Year-OldWoman with Abdominal Pain Giant Pedunculated Cavernous Hepatic Hemangioma
Caroline Smith, PA, Richard W. Hartsough, MD, Bradley Spieler, MD, Taylor Dickerson, MD, Catherine Hudson, MD, Fred Lopez, MD, Richard Marshall, MD, Adam Riker, MD
Hemangiomas are the most common benign hepatic tumors in adults, but they are rarely pedunculated. To the best of our knowledge, less than 30 cases of giant pedunculated hepatic hemangiomas have been reported since 1985. This article focuses on a case of a woman who presented with mild epigastric pain and a large abdominal mass on imaging.
INTRODUCTION
Hepatic hemangiomas are the most common tumors of the liver with an estimated prevalence of up to 20%.¹ Liver hemangiomas tend to be small and mostly asymptomatic, rarely requiring further treatment due to their benign nature and tendency towards slow growth.² They consist of large blood-filled cavities lined by abnormal endothelial cells which are sustained by the hepatic arterial circulation.²,³ Hemangiomas mostly occur in women between the ages of 40-60 years and are often found incidentally on abdominal ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI).¹,⁴ Although the cause for the development of hepatic hemangiomas is not known, there are a few reports suggesting that they may be congenital and possibly genetically linked.³ Cavernous hemangiomas are thought to arise as congenital vascular malformations that form from vascular ectasia rather than hypertrophy, hyperplasia, or neoplasia.² These collections of blood vessels range in size from 0.4 centimeters to as large as 40 centimeters.³ A hemangioma larger than 4 centimeters is classified as “giant,” with a pedunculated giant cavernous hemangioma considered a rare variant.¹ To date, there are only 26 reported cases of giant pedunculated cavernous hemangiomas described in the literature.¹,⁵ A pedunculated hemangioma is defined as, “clearly extended beyond the border of the liver or if the center of the lesion was located outside of the expected margins of the liver.” ⁶,⁷ They most often present clinically with intense abdominal pain in over half of the cases and often require intervention due to the mass effect on adjacent organs, the potential for pedicle torsion, and the stretching of Glisson’s capsule.¹
CASE REPORT
A 44 year-old obese woman with a past medical history of iron deficiency anemia and abnormal uterine bleeding who presented to her primary care provider for intermittent, cramping epigastric abdominal pain usually within 30 minutes of her last meal. She noted a weight gain of approximately 35 pounds over the prior year as well as occasional nausea and acid reflux that was somewhat improved with a proton pump inhibitor. The patient denied fever, vomiting, constipation, and changes in bowel habits. An abdominal ultrasound revealed a large, heterogenous mass that appeared exophytic and seemed to extend from the left hepatic lobe or greater curve of the stomach (Figure 1A). Additionally, therewas a 2.6 x 2.6 centimeter isolated lesion visualized within the right hepatic lobe with the distinct characteristics of a small hepatic hemangioma. With the abnormal location and other atypical findings of the larger mass, the differential diagnosis included hepatocellular carcinoma, retroperitoneal sarcoma, and gastrointestinal stromal tumor for which she was referred to surgical oncology. At her first surgical oncology consultation, her blood pressure was 144/94 mmHg, pulse rate was 75/minute, respiratory rate was 20/minute, and temperature was 36.8°C. On physical examination, a soft, palpable tender mass was appreciated within the left upper quadrant of the abdomen. A CT scan of the abdomen revealed a mass abutting the left lobe of the liver and extending laterally to the spleen (Figure 1C/2A/2B). There was also a separate, small 2.3 x 2.9 centimeter lesion in the right lobe demonstrating peripheral enhancement. An MRI of the liver was
124 La State Med Soc VOL 170 JULY/AUG 2018
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