Hepatic Cavernous Hemangioma

Published on 19/07/2015 by admin

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Last modified 19/07/2015

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 Arterial phase: Early peripheral, nodular or globular, discontinuous enhancement

• Small hemangiomas (capillary): < 2 cm

image Arterial and venous phases: Homogeneous enhancement (flash-filling)
• Typical hemangiomas: 2-10 cm in diameter

image Venous phase: Progressive centripetal enhancement to uniform filling, still isodense to blood vessels
• Giant hemangioma: > 10 cm in diameter

image Venous and delayed phases: Incomplete centripetal filling of lesion (scar does not enhance)
• US: Peripheral rim or homogeneously hyperechoic mass ± acoustic enhancement

TOP DIFFERENTIAL DIAGNOSES

• Cholangiocarcinoma (peripheral)
• Hypervascular metastases
• Hepatic angiosarcoma

DIAGNOSTIC CHECKLIST

• Small hepatocellular carcinomas and hypervascular metastases

image Can mimic small hemangiomas by their uniform homogeneous enhancement pattern
• Hemangiomas

image Remain isodense to blood vessels on portal venous and delayed phases of enhancement
• Other benign and malignant liver masses

image Usually become hypodense to blood vessels and liver (except cholangiocarcinoma)
image
(Left) Graphic shows 2 hemangiomas image as nonencapsulated collections of blood within enlarged sinusoidal spaces. The liver is otherwise normal.

image
(Right) Low-power photomicrograph shows dilated vascular spaces filled with blood. Note the somewhat irregular interface between the hemangioma and the surrounding liver. (Courtesy L. Lamps, MD.)
image
(Left) Axial T2WI MR demonstrates a mass image with marked hyperintensity, similar to that of CSF. A central scar image within the mass is even more hyperintense, a typical feature of a large or giant hemangioma.

image
(Right) Axial arterial phase T1WI MR in the same patient shows nodular, discontinuous, peripheral enhancement image of the hemangioma, isointense to hepatic vessels, that persisted and progressed on subsequent phases (not shown).

TERMINOLOGY

Synonyms

• Cavernous hemangioma of liver
• Capillary hemangioma (small lesion)

Definitions

• Benign tumor composed of multiple vascular channels lined by single layer of endothelial cells supported by thin fibrous stroma

IMAGING

General Features

• Best diagnostic clue

image Peripheral nodular enhancement on arterial phase scan with slow, progressive, centripetal enhancement isodense to vessels
• Location

image Common in subcapsular area in posterior right lobe of liver
• Size

image Varies from few mm to > 20 cm
image Giant hemangiomas: > 10 cm (arbitrary)
• Morphology

image Usually solitary and slow growing
image May be multiple in up to 50% of cases
image Calcification is rare (< 10%)

– Usually within scar of giant hemangioma

CT Findings

• NECT

image Small (1-2 cm) and typical (2-10 cm) hemangioma

– Well-circumscribed, spherical to ovoid mass isodense to blood
image Giant hemangioma (> 10 cm)

– Heterogeneous hypodense mass
– Central low-density scar ± calcification
• CECT

image Small hemangiomas (capillary): < 2 cm

– Arterial and venous phases: Usually show homogeneous enhancement (flash-filling)
image Typical hemangiomas: 2-10 cm in diameter

– Arterial phase: Early peripheral, nodular or globular, discontinuous enhancement
– Venous phase: Progressive centripetal enhancement to uniform filling, still isodense to blood vessels
– Delayed phase: Persistent complete filling
image Giant hemangioma: > 10 cm in diameter

– Arterial phase: Typical peripheral nodular, cloud-like, or globular enhancement
– Venous and delayed phases: Incomplete centripetal filling of lesion (scar does not enhance)
image Atypical hemangioma

– May appear to enhance from inside in centrifugal pattern
– Coronal imaging may reveal more typical centripetal enhancement pattern
image Hyalinized (sclerosed) hemangioma

– Shows minimal or no enhancement
– Cannot be diagnosed with confidence by imaging
– Probably the same as “solitary necrotic nodule” described by pathologists
image Hemangioma in cirrhotic liver

– Flash-filling of small lesion may mimic hepatocellular carcinoma (HCC)

image Does not washout, unlike HCC
– ↓ size and ↑ fibrosis over time

image May lose characteristic enhancement pattern
image Capsular retraction over shrunken lesion

MR Findings

• T1WI

image Small and typical hemangiomas

– Well marginated
– Isointense to blood or hypointense
image Giant hemangioma

– Hypointense mass
– Central cleft-like area of marked decreased intensity (scar or fibrous tissue)
• T2WI

image Small and typical hemangiomas

– Hyperintense, similar to CSF
image Giant hemangioma

– Hyperintense mass
– Marked hyperintense center (scar or fibrosis)
– Hypointense internal septa
• T1WI C+

image Same enhancement pattern as on CT
image Small hemangiomas (< 2 cm)

– Homogeneous enhancement in arterial and portal phases
image Typical and giant hemangiomas

– Arterial phase: Peripheral, nodular, discontinuous enhancement
– Venous phase: Progressive centripetal filling
– In both phases: Isointense to blood
– Central scar: No enhancement and remains hypointense

Ultrasonographic Findings

• Grayscale ultrasound

image Small hemangioma (< 2 cm)

– Well-defined hyperechoic lesion
image Typical hemangioma (2-10 cm)

– Homogeneous hyperechoic mass with acoustic enhancement
image Giant hemangioma (> 10 cm)

– Lobulated heterogeneous mass with hyperechoic border
image Atypical hemangioma

– Well defined
– Iso-/hypoechoic mass with hyperechoic rim
• Color Doppler

image Shows filling vessels in periphery of tumor
image No significant color Doppler flow in center of lesion
• Power Doppler

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