Cavernous hemangioma of liverBy mahyarHistory: 40 Y/O female Findings:
:: CT 1 ::CT
:: CT 2 ::CT
:: CT 3 ::CT
:: CT 4 ::CT
:: CT 5 ::CT
:: CT 6 ::CT
:: Fluoroscopy 1 ::Angiography Discussion: 1. Best diagnostic clue: Peripheral nodular enhancement on arterial phase (AP) scan with slow progressive centripetal enhancement isodense to vessels. 2. Location: Common in subcapsular area in posterior right lobe of liver Size 1. Vary from few millimeters to more than 20 cm 2. Giant hemangiomas: Larger than 10 cm (arbitrary) Morphology: 1. Most common benign tumor of liver 2. Second most common liver tumor after metastases 3. More commonly seen in postmenopausal women 4. Usually solitary & grow slowly 5. May be multiple in up to 50% of cases 6. Calcification is rare (less than 10%) " Usually in scar of giant hemangioma " CT Findings NECT: - Small (1-2 cm) & typical hemangioma (2-10 cm) - Well-circumscribed, spherical to ovoid mass isodense to blood - Giant hemangioma (more than 10 cm) - Heterogeneous hypodense mass - Central decreased attenuation (scar) CECT: Small hemangiomas ("capillary"): Less than 2 cm - Arterial & venous phases: Show homogeneous enhancement ("flash filling") 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 Giant hemangioma: More than 10 cm in diameter - Arterial phase: Typical peripheral nodular or globular enhancement - Venous & delayed phases: Incomplete centripetal filling of lesion (scar does not enhance) Atypical hemangioma: Inside to outside pattern - Arterial phase: No significant enhancement - Venous & delayed phases: Gradual enhancement from center to periphery (centrifugal filling) - Hyalinized (sclerosed) hemangioma - Shows minimal enhancement - Cannot be diagnosed with confidence by imaging - Hemangioma in cirrhotic liver - Flash-filling of small lesions - May lose characteristic enhancement pattern - Capsular retraction - Decrease in size over time MR Findings TlWI : - Small & typical hemangiomas - Well marginated - Isointense to blood or hypointense - Giant hemangioma - Hypointense mass - Central cleft like area of marked decreased intensity (scar or fibrous tissue) T2WI: - Small & typical hemangiomas - Hyperintense, similar to CSF - Giant hemangioma - Hyperintense mass - Marked hyperintense center (scar or fibrosis) - Hypointense internal septa T1 C+ - Small hemangiomas (less than 2 cm) : Homogeneous enhancement in arterial & portal phases . - Typical & giant hemangiomas : Arterial phase: Peripheral, nodular discontinuous enhancement, Venous phase: Progressive centripetal filling, In both phases: Isointense to blood, Central scar: No enhancement & remains hypointense Ultrasonographic Findings: - Real Time: Small hemangioma : - Well-defined, hyperechoic lesion - Size: Less than 2 cm Typical hemangioma: - Homogeneous hyperechoic mass with acoustic enhancement - Size: 2-10 cm Giant hemangioma: - Lobulated heterogeneous mass with echoic border - Size: More than 10 cm - Atypical hemangioma - Well-defined - Iso-/hypoechoic mass with echoic rim - - Color Doppler: - Show filling vessels in periphery of tumor - No significant color Doppler flow in center of lesion - Power Doppler: - May detect flow within hemangiomas - Flow pattern is nonspecific - Similar flow pattern may be seen in hepatocellular carcinoma & metastases Angiographic Findings: - Dense opacification of lesion - "Cotton wool" appearance - Pooling of contrast medium within hemangioma - Normal-sized feeders - No neovascularity - No arteriovenous shunting - Typically retain contrast beyond venous phase Nuclear Medicine Findings: - Tc-99m labeled RBC scan with SPECT (95% accuracy) - Early dynamic scan: Focal defect or less uptake - Delayed scans (over 30-50 min): Persistent filling - Vascular tumors (adenoma, HCC & FNH) - All exhibit early uptake rather than a defect - May have persistent uptake on delayed scan - Rarely angiosarcomas exhibit hemangioma pattern - Early defect & late uptake of isotope Imaging Recommendations: - Best imaging tool: Helical NE + CECT or MR - Protocol advice: Arterial, venous & delayed scans Demographics: - Age: all age groups, more common in postmenopausal age group, uncommonly diagnosed in children, gender: M:F = 1:5. Natural History & Prognosis: 1. Complications (extremely rare). 2. Spontaneous rupture 3. Abscess formation 4. Prognosis: Usually good 5. Often show slow growth Differential diagnosis: 1. Peripheral (intrahepatic) cholangiocarcinoma: - Delayed persistent enhancement, "fill in" may mimic hemangioma. - Often heterogeneous, not isodense with vessels on CT. - Not bright on T2WI. - Often invades/obstructs vessels & bile ducts. 2. Hypervascular metastases: - Usually multiple. - Hyperdense in late arterial phase images. - Hypo-or isodense on NECT & portal venous phase. - Treated metastases may mimic hemangioma on imaging (e.g., breast). - Not isodense to vessels on NECT or CECT : Examples: Islet cell, carcinoid, thyroid, renal carcinomas, heochromocytoma & some breast cancers. Diagnosis confirmation: Surgery / Histo Category: Gastrointestinal Region / Organ: Abdomen-Liver Etiology: neoplastic References: Diagnostic imaging. Abdomen / Michael P. Federle ... let al. 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