Imaging Sciences Interesting Cases
Case 77
Samuel Madoff, MD
Clinical Presentation: Patient is a 27-year-old female with right upper quadrant pain.
Imaging Findings: See figure legend.
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| Figure 1. Digital subtraction image from selective angiogram of the right hepatic lobe demonstrates a large rounded mass containing numerous small "cotton wool" type contrast collections. These collections persisted into and beyond the venous phase. Supplying vessels are normal caliber. Note the absence of neovascularity or arteriovenous shunting. |
Diagnosis: Giant Hepatic Cavernous Hemangioma
Discussion: Hemangiomas are the most common benign liver tumor. They occur with greater frequency in women (5:1). While identified in all age groups, hemangiomas are most often identified in postmenopausal patients.
The differential diagnosis includes hypervascular metastases such as thyroid cancer or renal cell carcinoma, though these are usually multiple and do not retain contrast on delayed phase imaging. A peripheral cholangiocarcinoma is also a diagnostic consideration. However, cholangiocarcinomas do not follow the density of vessels on multiphasic CT scans and are usually heterogeneous.
Hepatic cavernous hemangiomas are considered giant when they surpass 10 cm. Their angiographic appearance is virtually pathognomonic. Many are asymptomatic, but they may present with pain, as in this case. The pain is presumably elicited as the enlarging mass stretches the liver capsule. Treatment options for symptomatic lesions include particle embolization and surgical resection.
References:
- Federle MP. Hepatic cavernous hemangioma. 9/21/2006. https://my.statdx.com.
- McLoughlin MJ. Angiography in cavernous hemangioma of the liver. Am J Roentgenol Radium Ther Nucl Med. 1971 Sep;113(1):50-5. [PubMed]
- Kassarjian A, Dubois J, Burrows PE. Angiographic classification of hepatic hemangiomas in infants. Radiology. 2002 Mar;222(3):693-8. [PubMed]