Photoclinic

 

	Fig 1		Fig 2
	Fig 3		Fig 4

 

 

A 41-year-old woman was admitted to the hospital because of abdominal pain. There was a three-month history of vague right upper quadrant abdominal pain, together with nausea, and early satiety. She didn’t complain of weight loss or jaundice. On abdominal examination, there was a palpable mass in the right upper quadrant. Her laboratory values including serum aminotransferase levels, serum alkaline phosphatase, and serum alpha fetoprotein were normal. A multi-phasic helical abdominal computed tumography scan (CT scan) was performed. A non-contrast-enhanced image revealed a  very  large  hypodense  mass  in the right

 

 

lobe of the liver (Figure 1). Arterial phase of contrast enhanced image as well as delayed phase image are shown in Figures 2 and 3, respectively. Surgical resection of the mass was performed, and subsequently her symptoms resolved completely. The histopathologic features of the mass lesion are shown in Figure 4.

 

 

 

Your Diagnosis?

 

See below for the diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Photoclinic Diagnosis:                    Giant Hepatic Hemangioma

 

An arterial phase of image (30 seconds after administration of intravenous contrast material) demonstrated peripheral enhancement of the mass (Figure 2). A delayed phase image (12 minutes after administration of contrast material) revealed an isodense lesion, but the center of the mass was not opacified completely (Figure 3). The above mentioned findings of CT scan are characteristic of hepatic hemangioma. Additionally, pathologic examination of the mass lesion revealed neoplastic proliferation of dilated vessels, indicative of cavernous hemangioma (Figure 4). Standard abdominal CT scans may fail to delineate cavernous hemangioma because the tumor becomes isodense with liver, depending on the timing of the imaging in relation to the administration of intravenous contrast.¹

The administration of contrast results in a peripheral enhancement in the arterial phase caused by the puddling of contrast in dilated, ectatic vascular spaces within the tumor, followed by a centripetal pattern or "filling in" during the late phase.²  The lesions classically opacify after a delay of three or more minutes and remain isodense or hyperdense on delayed scans. In large hemangiomas, the center of the lesion may not opacify completely, which is due to scar tissue or large cystic areas within the lesion.³

Most hemangiomas require no treatment; but enlarging lesions, those that become symptomatic, or massive hemangiomas with diameters greater than 15 cm on initial presentation, are best treated by resection.¹

 

REFERENCES

 

1. Trotter JF, Everson GT. Benign focal lesions of the liver. Clin Liver Dis. 2001; 5: 17 – 42.

 

2. Quinn SF, Benjamin GG. Hepatic cavernous hemangiomas: Simple diagnostic sign with dynamic bolus CT. Radiology. 1992; 182: 545 – 8.

 

3. Yamashita Y, Ogata I, Urata J, Takahashi M. Cavernous hemangioma of the liver: pathologic correlation with dynamic CT findings. Radiology. 1997; 203: 121 – 5.  

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Mehdi Mohamadnejad,* MD; Reza Malekzadeh,** MD; and Seyed Mohammad Tavangar,*** MD.

*GI and Liver Disease Research Center, Iran University of Medical Sciences, Tehran, Iran; ** Department of Internal Medicine, Digestive Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran; ***Department of Pathology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.