Case#20

 

Ultrasound (US) examination of a 55 year old patient with some abdominal discomfort showed a small lesion in the liver. The appearance of the lesion was suggestive of benign hepatic cavernous hemangioma (venous malformation), but not characteristic. The patient was significantly concerned for a possibility of hepatic metastatic disease due to past medical history of colon carcinoma (surgically removed several years ago with no known metastases). Therefore, further imaging was performed. ... ... ... ...                            ....                                    .....                      .....  .. ..     First image is ultrasonografi, demonstrating a bright (echogenic) rounded lesion. This is most likely a hepatic (liver) hemangioma (venous malformation) based on its appearance. However, the margins of the lesion are not sharp and no distal enhancement seen. Some gastrointestinal metastatic lesions may be bright (echogenic) similar to this appearance. T2 MRI image (3rd image) shows a typical "light bulb" lesion in the liver, highly suggestive of a liver hemangioma. 2nd image is a gradient echo demonstrating inhomogeneous echo within the lesion.     MRI findings, particularly T2 weighted images also supported the diagnosis of hepatic cavernous hemangioma (venous malformation) (see above). However, nuclear scan findings (SPECT images were also obtained in multiple imaging planes) were inconclusive, probably mainly due to the lesion's small size (see below)......        Nuclear Scan (SPECT): There is a subtle small area of increased tracer uptake in the central portion of the liver, most likely due to a small hemangioma.

DISCUSSION: 

This lesion demonstrates ultrasonography and MRI findings of a hepatic hemangioma (or commonly called "cavernous hemangioma") (actually these lesions believed to be venous malformations of the liver). The patient was particularly concerned for a possibility of metastatic disease, mainly due to past history of colon cancer. Both MRI and nuclear scan are good imaging tests to confirm the diagnosis; however, as seen in this case, nuclear scan may be a misleading in small size hemangiomas. 

In general, it is believed that a significant bleeding from hepatic hemangioma is common when biopsied. I believe this is overstated (please see my disclaimer). However, it is important to traverse a good amount of normal liver tissue when it is biopsied; otherwise, slow continuous bleeding into the peritoneum may occur. 

In this particular case, mainly due to patient's significant concern for a possibility of metastatic liver disease, a decision was made to proceed with percutaneous contrast injection under fluoroscopy (see below). The reason this approach was selected was to use a really fine needle (22 g or above) and to confirm the diagnosis using fluoroscopy. Also, it is known that no real tissue can be obtained in hemangiomas other than blood. 

A 22 g Chiba needle was advanced into the lesion under ultrasonography guidance and iodinated contrast material was injected under fluoroscopy. The lesion demonstrates typical opaficiation of a venous malformation with multiple draining veins. Similar appearance is also seen in almost all soft tissue venous malformations. Aspiration biopsy did not reveal any tissue, but blood. Contrast injection under fluoroscopy may be an ideal diagnostic approach in challenging hepatic hemangioma cases, but requires a good experience with vascular anomalies, particularly venous malformations.  Percutaneous sclerotherapy may also be a feasible approach in symptomatic patients, particularly in patients who are not good surgical candidates. (please see the disclaimer)