A 47-year-old male presented to his primary care physician with
persistent cough and epigastric discomfort. His chest radiograms
showed persistent infiltrates in the left lower lobe over several
months. He had been healthy prior to this presentation and had no
other complaints. A chest CT was performed to rule out pulmonary
neoplasm. In addition to showing left lower lobe pneumonia, several
hepatic masses, including a large space-occupying lesion in the
left lobe of the liver, were incidentally demonstrated (figure 1).
An abdominal MRI scan was performed on the same day to further
evaluate the hepatic masses (figures 2, 3).
Giant hepatic cavernous hemangioma.
Contrast-enhanced CT demonstrated a large complex soft-tissue
mass involving the left lobe of the liver, with peripheral nodular
enhancement and a central stellate zone of low density (figure lA).
There also are several foci of smaller low density lesions
involving the right hepatic lobe; one of these is shown in figure
1B. On MRI scans, there was a large mass (8.0 ¥ 10.5 cm) occupying
most of the left lobe of the liver (figure 2A), and three smaller
lesions in the right lobe of the liver (figure 2B). The largest
lesion demonstrated signal characteristics of giant hemangioma: a
large, well defined mass with heterogeneous low signal intensity on
T1-weighted images (figure 2) and heterogeneous high signal
intensity on T2-weighted images (figure 3). T2 calculations for
these lesions range from 104 to 150, consistent with hemangiomas.
No additional tests were performed. The patient's left lower lobe
pneumonia resolved with a second course of antibiotics, and he
remained asymptomatic and healthy.
Giant hepatic cavernous hemangioma (GHCH), defined as a
hemangioma in which at least one dimension exceeds 8 cm, is an
uncommon benign tumor of the liver.1-3 It rarely coexists with
multiple smaller hemangiomas. Scatarige et al2 reported that 1 out
of 8 GHCH cases (13%) had coexisting smaller (<5 cm in diameter)
hemangiomas. In contrast to smaller incidently discovered
hemangiomas, giant hemangiomas are more likely to produce
symptoms,3,4 such as right upper quadrant abdominal pain or
fullness or upper abdominal mass palpable on physical examination.
Therefore, they may often be confused with primary or metastatic
malignancy of the liver. The differential diagnosis for GHCH mainly
includes hepatic metastases, hepatocellular carcinoma, focal fatty
adenoma, focal nodular hyperplasia, and cholangiocarcinoma.
Hemangiomas are difficult to diagnose by means of needle biopsy
because of their relatively low cellularity, high vascularity, and
fibrous stromal component. Aspirations tend to be extremely bloody,
and the cytologic diagnosis of hemangioma often is one of
exclusion.5 Therefore, definitive, noninvasive imaging of GHCH is
important to make a correct diagnosis and to avoid biopsy and
Classically, hemangiomas were definitively diagnosed by hepatic
angiography, which was the "gold standard" for many years. In the
last decade, however, noninvasive imaging modalities have proved
just as useful. Currently CT, MRI, scintigraphy with
Technetium-99m- labelled red blood cells (Tc-RBC), and occasionally
angiography are used to make the diagnosis of hemangioma. Dynamic
CT scan is the most commonly used modality to make the initial
diagnosis. In most cases, diagnosis of GHCH should be considered
when the CT scan shows a large hepatic mass that contains irregular
areas of decreased density on the pre-contrast image, peripherally
enhancing on bolus dynamic study and exhibiting centripetal but
incomplete isodense fill-in on delayed images.1,2,6 Dynamic
enhancement patterns are related to the collective size of their
constituent vascular spaces, i.e., tumors with slow fill-in have
relatively larger spaces and tumors with rapid enhancement have
smaller vascular spaces and larger interstitium.7 More recent
studies1,2,6,7 reveal that CT features of hemangiomas include a
broad spectrum of morphologic patterns, thus raising questions
about the specificity of CT diagnosis.9 Hemangiomas examined by CT
after slow drip infusion of contrast material may be mistaken for
metastases or hepatocellular carcinoma.2,8 CT scans are not
sensitive in detecting lesions that measure less than 1 cm in
Single-photon emission computed tomography (SPECT) Tc-RBC
scinitgraphy also is a commonly used modality for diagnosis of
hepatic hemangiomas, with specificity approaching 100%.
Characteristic findings of hemangioma on Tc-RBC scintigrams include
the presence of photopenic defect on early imaging of the tumor,
which becomes gradually accumulating and prominently hyperintense
relative to the normal liver on 2-hour delayed imaging.
Unfortunately, SPECT Tc-RBC is not sensitive in detecting
hemangiomas of less than 2 cm in diameter, due to its limited
MRI is increasingly being used, demonstrating sensitivities
which aproach 100% in detection of hemangiomas. An advantage of MRI
over CT is its ability to resolve lesions smaller than 1 cm in
diameter due to its ability to portray high signal contrast between
normal and abnormal tissue for a given site of scanning parameters.
On MRI, a moderate sized cavernous hemangioma classically appears
as a well defined, smooth-bordered spherical or oval lesion having
a homogeneous hypointense-to-isointense signal relative to normal
liver on T1-weighted sequences, and a homogeneous hyperintense
signal on T2-weighted sequences. However, giant hepatic cavernous
hemangioma shows a large, well defined, heterogenous mass
containing areas of increased intensity ratio with prologation of
TR and TE, cleft-like zones of low signal intensity on T1-weighted
images, and higher intensity on T2-weighted images (figures 2,3).
Absolute T2 values of tissue have allowed the separation of
hemangiomas from malignant tumors.10,11 However, metastatic disease
can mimic the long T2 components of the signa and thus, specificity
remains to be determined.
Finally, when noninvasive modalities fail to diagnose
hemangioma, hepatic angiography should be considered. The typical
angiographic feature of hemangioma is a contrast "stain" that
arises from the slow flow of the contrast through the large blood
In summary, GHCH is an uncommon benign tumor of the liver and
often causes mild symptoms. Biopsy of the tumor is bloody and is
generally fruitless, thus it should be avoided. In the present
case, multiple hepatic masses were incidentally demonstrated on
chest CT. A repeat dynamic CT scan would not give definite
diagnosis because of multiple lesions with variable sizes. Because
SPECT Tc-RBC has limited sensitivity in detecting those small
lesions, and because the patient's unremarkable past medical
history makes such large hepatic metastases unlikely, we chose MRI
as the diagnostic tool.
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3. Cronan JJ, Esparza AR, Dorfman GS, et al: Cavernous
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cavernous hemangioma of liver. Radiology 137:149-155, 1980.
9. Krause T, Hausenstein K, Studier-Fisher B, et al: Improved
evaluation of technitium-99m-red blood cell SPECT in hemangioma of
the liver. J Nucl Med 34:375, 1993.
10. Beers BV, Demeure R, Pringot J, et al: Dynamic spin-echo
imaging with Gd-DTPA: Value in the differentiation of hepatic
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Prepared by Tom X.L. Tan, MD, William F. Bennett, MD, and
Charles F. Mueller, MD, Ohio State University Medical Center,
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