JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
performed that revealed classic findings of a hepatic hemangioma (Figure 1D/2C/2D). 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 performed that revealed classic findings of a hepatic hemangioma (Figure 1D/2C/2D). A radiolabeled/tagged red blood cell scan supported the diagnosis of hemangioma for both the right hepatic lobe and the large pedunculated left hepatic lobe lesion. Angiogram of the abdominal viscera was performed to evaluate sources of perfusion and to plan for resection (Figure 1B). Fine needle aspiration biopsy (FNAB) of the abnormal-appearing left hepatic lobe confirmed hemangiomatosis of this area. Her case was presented at a multidisciplinary gastrointestinal and hepatobiliary tumor conference where the consensus decision was to proceed with surgical resection of the pedunculated mass and observation the smaller hemangioma. During the operation, the mass was exposed via a sub-costal incision extending to the left of the midline in order to maximize visualization of its margins. The operative team identified and ligated several branching vessels of the splenic artery that were supplying the mass as well as several large draining veins. An en-bloc resection of this mass was performed, which included removal of segments 1-4 as the mass extended well
beyond the left lateral segments (segments 1 and 2) of the liver. A formal left hepatectomy was performed without complication and with minimal blood loss (<100ml). Figure 3A and 3B refer to the surgical and histologic specimens, respectively. The patient was discharged on the third post-operative day without further complications. At follow up in clinic, she reported that her abdominal pain had improved. The smaller hemangioma is being monitored with periodic ultrasounds.
Figure 2: A and B) Axial IV Contrast enhanced portal venous phase and 3 minute delayed phase images demonstrates a normal right hepatic lobe and a small normal portion of the left hepatic lobe and then a large mass that branches off from the left hepatic lobe which demonstrates peripheral nodular discontinuous enhancement that fills in centripetally on the delayed series. Notice its mass effect on the adjacent stomach. C and D) Axial Fat-Sat T1 Post Contrast MRI images at 70 seconds and 5m again show normal right hepatic lobe and a small normal portion of the left hepatic lobe with a large mass that demonstrates peripheral nodular discontinuous enhancement that fills in centripetally on the delayed series. Mass effect is again noted on the stomach and spleen.
MATERIALS AND METHODS
Figure 1: A) Ultrasound Doppler image reveals a heterogeneous and predominantly hypoechoic mass with internal echoes and no significant internal vascularity. B) Abdominal Angiogram from a branch of the left hepatic artery demonstrates a highly vascularized mass. The mass progressively opacified with contrast through the portal venous and more delayed phases (not shown). C) Coronal IV contrast enhanced portal venous phase CT image demonstrates a mass emanating from the left hepatic lobe that displays a peripherally nodular discontinuous mural enhancement pattern typical for hemangiomas. This image in particular illustrates the lesion’s narrow stalk from the left hepatic lobe (which measure 4.5 cm ) and the lesion’s mass effect on the adjacent stomach and small bowel. The mass itself measured 8.5 x 14.6 x 14.2cm. D) Fast spin single shot T2 weighted coronal MRI image demonstrates a large pedunculatedmasswith a peripheral nodular discontinuous enhancement pattern. It also provides better characterization of the lesion’s fat planes and demonstrates its separation from the stomach and other adjacent organs more clearly. Mass effect on the stomach, gallbladder indirectly, small bowel, spleen and left kidney is clearly evident.
All imaging studies were performed at the University Medical Center in New Orleans from May-June 2016. The ultrasound images were obtained using a GE Logic E9 machine with a C1-6 transducer. Computed tomography images were obtained using a Philips iCT 256 model. We utilized two phases of contrast administration with Omnipaque 350 - a portal venous phase (65 seconds) and a delayed phase (3m) of intravenous contrast administration were used. Magnetic Resonance images were obtained using a Philips Ingenia 1.5T Model. Phases utilized for this study include: a Coronal T2 Fast spin single shot, an axial T1 70 second post contrast series and an axial T1 3 minute post contrast series with Magnevist 46.9%.
J La State Med Soc VOL 170 JULY/AUG 2018 125
Made with FlippingBook Digital Publishing Software