JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
The preferred surgical management is enucleation as first line therapy whenever possible, followed by partial hepatectomy of thecavernoushemangioma. Enucleation ispreferredoverwedge excision due to the minimal blood loss, shorter operative time, and prevention of bile leakage that is a common complication of this operation.¹⁰ If the hemangioma is deep within the liver and occupying multiple lobes or undivided from Glisson’s capsule, wedge resection is the ideal treatment of choice.¹¹ Wedge excision with radical liver resection was performed instead of enucleation in this case due to the large size of the hemangioma as well as adjacent parenchymal involvement of the left lateral lobes (segments 2 and 3). For non-surgical candidates, treatment options may include hepatic arterial embolization, radiation, or a vascular endothelial growth factor (VEGF) inhibitor such as bevacizumab. When considering the large size of a giant cavernous hemangioma, hepatic arterial embolization is a potential pre-operative approach to consider. It has been shown to reduce intraoperative blood loss and shrink the tumor allowing for easier resection and shorter operative time.¹² Embolization alone is not recommended for giant symptomatic cavernous hemangiomas due to the risks of tumor necrosis with formation of a hepatic abscess.¹³ Radiation therapy is a non-invasive treatment modality; however, it is not recommended as a definitive treatment option for such lesions. A dose of 30Gy can be given over three weeks resulting in damage of endothelial and smooth muscle cells ultimately causing thrombosis of the arterioles with subsequent tissue necrosis. This reduces the size of the tumor and provides pain relief, but it is not without side effects. Due to the risk of liver toxicity and malignancy, it is generally recommended only as a last resort for pediatric patients with giant hemangiomas in the setting of uncontrollable heart failure or coagulopathy.¹¹ Bevacizumab has been shown previously to be efficacious when combined with 5-fluorouacil (5-FU) to treat metastatic colorectal cancer; however, there is limited data on its use in the treatment of a giant cavernous hemangioma.¹¹ Mahajan et al. reported its efficacy in reducing the size of a hepatic hemangioma in a patient with invasive colorectal adenocarcinoma.¹⁴ This is the first documented response of a hepatic hemangioma to anti-angiogenic therapy. Further studies need to be performed in order to determine the utility of such agents in the future.¹⁴
Therapy for non-surgical candidates involves hepatic arterial embolization, radiation, or bevacizumab in rare cases. Our case was unique in that the hemangioma was pedunculated, giant, involved multiple lobes, and caused increasing pain as it enlarged. For these reasons, surgical resection was chosen as the best definitive treatment option, with a true left hepatectomy resulting in the complete removal of this giant hemangioma. A thorough multidisciplinary, pre-operative clinical and radiologic evaluation is useful for management of such rare tumors of the liver.
REFERENCES
1. Ha C, Kubomoto S,Whetstone B, et al.“Pedunculated hepatic hemangiomas often misdiagnosed despite their typical findings.” The Open Surgery Journal . 2013; 7: 1-5. 2. Kong J, Anaya DA. A giant cavernous hemangioma of the liver extending into the pelvis. Int J Surg Case Rep . 2015;13:51-54. 3. Bajenaru N, Balaban V, Savulescu F, et al. Hepatic hemangioma -review-. J Med Life . 2015;8 Spec Issue:4-11. 4. Berloco P, Bruzzone P, Mennini G, et al. Giant hemangiomas of the liver: Surgical strategies and technical aspects. HPB (Oxford) . 2006;8(3):200-201. 5. El Hajjam M, Lacout A, Marzouqi MK, et al. Pedunculated hepatic hemangioma masquerading as a peritoneal tumor. A case report. Pol J Radiol . 2016;81:51-53. 6. Luning M, Muhler A. CT diagnosis of pedunculated liver tumors. Eur J Radiol . 1988; 8:221-225. 7. Bader TR, Braga L, Semelka RC. Exophytic benign tumors of the liver: appearance on MRI. Magn Reson Imaging . 2001; 19: 623-628. 8. Jhaveri KS, Vlachou PA, Guindi M, et al. Association of hepatic hemangiomatosis with giant cavernous hemangioma in the adult population: Prevalence, imaging appearance, and relevance. AJR Am J Roentgenol . 2011;196(4):809-815. 9. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology . Philadelphia, Pa: Williams &Wilkins; 2012: 692-719. 10. UlasM, Ozer I, Bostancil EB, et al. Giant hemangiomas: Effects of size and type of surgical procedure on postoperative outcome. Hepatogastroenterology. 2014;61(133):1297-1301. 11. Toro A, Mahfouz AE, Ardiri A, et al. What is changing in indications and treatment of hepatic hemangiomas. A review. Ann Hepatol . 2014;13(4):327- 339. 12. Vassiou K, Rountas H, Liakou P, et al. Embolization of a giant hepatic hemangioma prior to urgent liver resection. case report and review of the literature. Cardiovasc Intervent Radiol . 2007;30(4):800-802. 13. Vishnevsky VA, Mohan VS, Pomelov VS, et al. Surgical treatment of giant cavernous hemangioma liver. HPB Surg . 1991;4(1):69-78; discussion 78-9. 14. Mahajan D, Miller C, Hirose K, et al. Incidental reduction in the size of liver hemangioma following use of VEGF inhibitor bevacizumab. J Hepatol. 2008;49(5):867-870. Caroline Smith, PA is affiliated with Louisiana State University Health Sciences Center-New Orleans Department of Surgery in New Orleans, Louisiana. Richard Hartsough, MD, Richard Marshall, MD and Bradley Spieler, MD are affiliated with Louisiana State University Health Sciences Center-NewOrleans Department of Radiology in New Orleans, Louisiana. Taylor Dickerson, MD is affiliated with Louisiana State University Health Sciences Center-New Orleans Department of Internal Medicine in New Orleans, Louisiana. Fred Lopez, MD is the Richard Vial Professor and Vice Chair for Education in the Department of Internal Medicine for the Louisiana State University Health Sciences Center-New Orleans in New Orleans, Louisiana. Adam Riker, MD is affiliated with Louisiana State University Health Sciences Center-New Orleans Department of Surgical Oncology in New Orleans, Louisiana.
CONCLUSION
Pedunculated giant cavernous hemangiomas are exceedingly rare hepatic tumors which can provide a diagnostic challenge due to frequent atypical imaging findings. This case report provides a detailed illustration of the radiographic appearance of a pathologically confirmed lesion across ultrasound, CT, MRI, and nuclear medicine exams. As for treatment modalities, there are multiple options for asymptomatic as well as symptomatic patients. Patients without symptoms are often observed, and those with symptoms who are surgical candidates are best treated with either enucleation or a wedge resection.
J La State Med Soc VOL 170 JULY/AUG 2018 127
Made with FlippingBook Digital Publishing Software