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32
Table 3.2 Hepatic hemangioma treatment
Author (year) N Age Size (cm) Operation Complication rate Other
Study type
(QOE
a
)
Özden et al.
(2000) [
22 ]
42 50 10 Enucleation 12 % Retrospective
cohort-low
Terkivatan
et al. (2001)
[
18 ]
Total cohort: 208 48 9.0 Segmentectomy, Lobectomy,
wedge resection
24 % Includes other benign
liver tumors
Retrospective
cohort-low
103: Hemangiomas
(25 operative, 78
observation)
Kammula
et al. (2001)
[
23 ]
Total: 28 35 7 Enucleation 10.7 % Includes other benign
liver tumors
Retrospective
cohort-low
Hemangiomas: 10
Reddy et al.
(2001) [
3 ]
Total: 130 49 6.9 Segmentectomy, Lobectomy
trisegmentectomy
5 % Includes other benign
liver tumors
Retrospective
cohort-low
Hemangiomas: 71
(35 operative, 36
observation)
1.2 % mortality (pt
with FNH) One unresectable
hemangioma
Charny et al.
(2001) [
25 ]
Total: 155 52 12.1 Enucleation. Segmentectomy,
lobectomy
21 % (whole series) Includes other benign
liver tumors
Retrospective
cohort-low
Hemangioma :97 (39
operative)
Popescu et al.
(2001) [
24 ]
57 44.2 9 Enucleation, segmentectomy
and hepatectomy
10.3 Retrospective
cohort-low
Yoon et al.
(2003) [
5 ]
115 (52 operative,
63 observation)
52 6 Enucleation, Segmentectomy 25 % 96 % symptom
resolution
Retrospective
cohort-low
Median ebl 400 cc
Descottes
et al. (2003)
[
31 ]
Total: 87 41 6 Laparoscopic resection 5 % (whole series) Includes other benign
liver tumors . One
conversion to open
Retrospective
cohort-low
Hemangiomas: 13
Tsai et al.
(2003) [
14 ]
43 Symptomatic vs
suspicious diagnosis
Retrospective
cohort. Low
J.M. Millis and D.C. Molina
33
Author (year) N Age Size (cm) Operation Complication rate Other
Study type
(QOE
a
)
Liu et al.
(2004) [
37 ]
Total : 107 43 2.8 (whole
series)
Lobectomy,Segmentectomy,
wedge
16 % Includes benign and
malignant pathology
Retrospective
cohort-low
Hemangiomas: 12
Kim et al.
(2004) [
17 ]
Total: 71 41 NA Lobectomy, wedge
segementectomy
27 % (whole series) Retrospective
cohort-low
Hemangioma: 21
Lerner et al.
(2004) [
31 ]
52 (27 lobectomy,
25 enucleation)
48 10.9 Enucleation vs Lobectomy 27 % Only giant
hemangiomas ,
compared resection vs
enucleation
Case series
Hamaloglu
et al. (2005)
[
27 ]
22 46 9 Hepatectomy vs enucleation 14.2 Only giant
hemangiomas
compared enucleation
vs resection
Herman et al.
(2005) [
19 ]
249 (only 8
underwent surgery)
49 3.7 Lobectomy, segmentectomy None Surgical treatment
granted to lesions
>14 cm
Retrospective
cohort-low
Fan (2005) 27 41 5.5 Laparoscopic RFA (50 lesions
treated)
None Complete necrosis
achieved in 100 %
Retrospective
cohort-low
Ibrahim et al.
(2007) [
38 ]
Total: 84 43.6 8.2 Lobectomy, segmentectomy,
wedge
8.3 (whole series) Included patients with
Hep-B
Retrospective
cohort-low
Hemangiomas: 46
Erdogan
et al. et al.
(2007) [
20 ]
34 (14 operative) 48.5 12.9 Bisegmentectomy, lobectomy,
segmentectomy
21 % Retrospective
cohort-low
Singh et al.
(2007) [
28 ]
21 42.5 9.5 Enucleation vs Hepatectomy 23 % (all in the
resected group
Belli et al.
(2009) [
33 ]
180 (12 surgical
treatment
NA NA Enucleation Enucleation using
ultrasonically
activated device in 4
cases
Retrospective
cohort-low
(continued)
3 What Is the Best Surgical Method of Addressing Hepatic Hemangiomas?
34
Table 3.2 (continued)
Author (year) N Age Size (cm) Operation Complication rate Other
Study type
(QOE
a
)
Fu Xiao-Hui
et al. (2009)
[
8 ]
172 (96 peripheral,
76 central)
46/42 10/11 Enucleation 2.6 Centrally vs
peripherally, impact of
location
Retrospective
cohort-low
Schnelldorfer
et al. (2010)
[
6 ]
289 (233 non-
operative,
56-operative)
51 8.4 Partial
hepatectomy/ enucleation/ RFA
7.1 % Retrospective
cohort-low
Giuliante
et al. (2011)
[
29 ]
74 (34 non-
operative, 40 op
46.3 6/ 11.9 Partial
hepatectomy/ enucleation
10 % Retrospective
cohort-low
Ho et al
(2012) [
34 ]
61 47.3 10 Enucleation/lobectomy 13.1 % Only giant
hemangiomas
Retrospective
cohort-low
Yedibela
et al. (2013)
[
21 ]
246 (103 operative,
143 non operative)
52 9.1 hepatectomy, segmentectomy 17 %
Yang Y et al.
(2014) [
35 ]
273 45/41 14.2/12.9 Lobectomy/Segmentectomy 26 %, 1.3 %
mortality
Compares selective
vascular exclusion vs
Pringle maneuver
Retrospective
cohort-low
Miura et al.
(2014) [
36 ]
241 46 8.5 Enucleation/ hepatectomy/ seg
mentectomy-
5.7 %, 0.8 %
mortality
Retrospective
cohort-low
a
Quality of evidence
J.M. Millis and D.C. Molina
35
Recommendations
• The indication for the resection of hepatic hemangiomas has to be based on
symptoms, suspicion of malignancy or growth, although no size increment or
specifi c time interval is known (Evidence quality Moderate, strong
recommendation)
• When feasible, enucleation is the method of choice to allow preservation of
parenchyma, decreased blood loss and need for outfl ow control (Evidence qual-
ity Moderate, strong recommendation)
• Laparoscopic resection of hemangiomas is a safe procedure when patients are
appropriately selected and the procedure is performed by an experienced sur-
geon. (Evidence quality low: weak recommendation)
• Alternative procedures like Radiation, Chemotherapy and TAE should be used as
second line agents or for palliation purposes (Evidence quality low: weak
recommendation)
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3 What Is the Best Surgical Method of Addressing Hepatic Hemangiomas?
39© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_4
Chapter 4
Which Diagnostic Modality is best to Assess
Benign Hepatic Tumors?
Stephen Thomas and Aytekin Oto
Abstract Benign hepatic lesions are relatively common in the general population.
The majority of these lesions are incidentally detected at imaging and don’t pose
any risk to the patient. Some of these lesions have characteristic imaging features
while others can have atypical imaging features and can pose a diagnostic challenge. Utilizing the proper imaging modality and intravenous contrast agents can
help better characterize them and minimize unnecessary workup of these lesions.
Benign hepatic lesions are classifi ed according to their cell of origin. This article
discusses common and uncommon benign hepatic tumors, their different imaging
features, and the diagnostic modality that can best characterize them.
Keywords Hemangioma • Focal nodular hyperplasia • Hepatocellular adenoma •
Biliary hamartoma • Medical imaging • Benign liver lesions
Introduction
There is high prevalence of benign hepatic lesions in the general population. While
most of these lesions are usually asymptomatic and incidentally detected, they may
pose a clinical dilemma in patients with systemic disease, chronic liver disease or in
patients with a malignancy undergoing staging. These lesions may require additional imaging to prove benignity or in some cases may need resection due to their
size or risk of hemorrhage. The benign hepatic neoplasms include hemangiomas,
which are of mesenchymal origin; focal nodular hyperplasia (FNH), hepatocellular
adenoma (HCA), and nodular regenerative hyperplasia (NRH) which are of hepatocellular origin; hepatic cysts, bile duct hamartoma which are of cholangiocellular
origin.
S. Thomas (*) • A. Oto
Department of Radiology , The University of Chicago Medicine ,
5841 S. Maryland Avenue, MC 2026 , Chicago , IL 60637 , USA
e-mail:
sthomas@hotmail.com
40
Imaging modalities commonly used for non-invasive liver lesion work-up and
characterization includes ultrasonography (US), computed tomography ( CT ), magnetic resonance (MR) imaging. The tumor features being evaluated include their
cystic or solid appearance; calcifi cations, fat and hemorrhage within the lesion;
lesion border and capsule. The use of intravenous contrast agents allows evaluation
of lesion vascularity, perfusion, hepatocyte function and biliary excretion.
There is a paucity of prospective studies comparing all modalities and their performance in detection and diagnosis of benign hepatic tumors in the literature.
Imaging technologies were introduced at different decades with each modality
undergoing signifi cant technological advances over time leading to improved lesion
conspicuity and characterization. In many cases, studies comparing the imaging
fi ndings of a particular modality with lesion histology have not been performed.
Comparison with either another modality or following lesion stability over time
would be considered the “gold-standard”. Modalities such as US, CT and MR have
improved lesion detection and characterization with the introduction of intravascular contrast agents, including selective hepatobiliary MR contrast agents, which
have improved liver lesion characterization. Sonographic contrast agents have provided additional diagnostic capability to conventional ultrasonography. However,
although these are widely available in Europe, their availability is limited in the US.
In this chapter, we will discuss the imaging features of cavernous hemangioma ,
focal nodular hyperplasia, hepatic adenoma, biliary hamartoma, and provide a preferred modality imaging in diffi cult cases.
Cavernous Hemangioma
Ultrasonography The ‘typical’ imaging features of a small hemangioma (<2 cm)
on ultrasound is uniform hyperechogenicity (66 %), well defi ned margin and posterior acoustic enhancement [ 1 ]. Between 20 and 40 % (mostly larger lesions) can
have an ‘atypical’ pattern with an echogenic border either as a thick rind or thin rim
with a hypoechoic internal echo pattern or an anechoic/cystic pattern (Fig. 4.1 ) [ 2 ,
3 ]. Hemangiomas detected by ultrasound tend to be stable over time with 82 %
having similar imaging characteristics. 18 % can show change in their sonographic
appearance and they can also grow in size over the time [ 4 ]. The ultrasound appear-
ance of hemangiomas can overlap with those of hepatocellular carcinoma (HCC)
and some hypervascular hepatic metastases [ 5 , 6 ]. As a result, patients with chronic
liver disease or with a known or suspected extra-hepatic malignancy should undergo
a confi rmatory examination such as a contrast enhanced CT or MRI.
Computed Tomography Hemangiomas are well demarcated masses that are
hypo-attenuating to liver parenchyma and are iso-attenuating to blood pool on noncontrast CT . Dystrophic calcifi cations can be present in approximately 10 % of
lesions. With contrast administration, hemangiomas have a typical enhancement
S. Thomas and A. Oto
41
pattern with peripheral nodular discontinuous enhancement on the arterial and early
portal venous phase with gradual centripetal fi lling on delayed phase images. This
enhancement pattern is present in approximately 60 % of all hemangiomas, more
commonly present in larger lesions and varies by size: >2 cm (85 %), 1–2 cm (55 %)
and <1 cm (23 %) [ 7 ]. Smaller lesions can show diffuse hyper-enhancement, a pat-
tern that can be seen in metastasis.
Magnetic Resonance Imaging A typical hemangioma is a well-demarcated
homogenous mass that is hypointense on T1-weighted images and hyperintense on
T2-weighted images (T2–WI) (Fig. 4.2 ). The very long T2 relaxation of hemangio-
mas is useful in distinguishing them from malignant hepatic neoplasms.
Hemangiomas demonstrate a relative increase in signal intensity on heavily T2–WI
sequences compared to moderately T2–WI sequences. In contradistinction, other
solid hepatic masses show a relative decrease in signal intensity on more heavily
T2–WI [ 8 – 11 ]. Using a 1.5 Tesla MR unit, MRI can characterize lesions as heman-
giomas with an accuracy of 84–97 % based on T2 values, morphologic features and
tissue homogeneity [ 8 , 10 , 11 ]. However, hypervascular metastasis from pheochro-
mocytoma, carcinoid, and pancreatic islet-cell tumor can also be hyperintense on
T2–WI and is a pitfall of this technique [ 12 , 13 ]. Therefore, intravenous adminis-
tered contrast agent is usually required to make a defi nitive diagnosis of hemangioma. Hemangiomas >4 cm can be heterogeneous in signal due to fi brosis,
hemorrhage, thrombosis, hyalinization and cystic degeneration [ 14 , 15 ].
Use of an intravenous gadolinium based contrast agent (GBCA) results in similar
enhancement patterns as CT with arterial peripheral nodular or globular enhancement and progressive centripetal enhancement (Figs. 4.3 and 4.4 ). This pattern is
seen in hemangiomas >2 cm; small lesions <2 cm may have a homogenous enhancement on early phase and may be indistinguishable from small hypervascular
metastasis. Metastasis tends to have a continuous rim enhancement on later phases
of imaging [ 12 , 13 , 16 ]. Contrast enhanced MRI is able to distinguish hemangioma
from metastasis with an accuracy of 96 % [ 17 ].
Fig. 4.1 Ultrasound of the
liver shows a hypoechoic
heterogeneous mass within
the left lobe of the liver
with a hyperechoic rim
( arrow )
4 Which Diagnostic Modality is best to Assess Benign Hepatic Tumors?
42
Strategy for Diffi cult Cases
MRI is the modality of choice in cases where the diagnosis is not certain. The use
of heavily weighted T2–WI, multi-phasic contrast sequences with the ability to
obtain multiple delayed phases without any ionizing radiation can help confi rm
the diagnosis of hemangioma. MRI can identify atypical features of hemangiomas,
Fig. 4.2 Axial fat
saturated T2-weighted
MRI shows a welldemarcated T2
hyperintense mass in the
left lobe of the liver
( arrow )
Fig. 4.3 Axial fat
saturated T1-FSPGR post
contrast MRI shows the
classic peripheral nodular
discontinuous
enhancement on early
arterial phase of imaging
( arrow )
S. Thomas and A. Oto