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1.  Emergent Orthotopic Liver Transplantation for Hemorrhage from a Giant Cavernous Hepatic Hemangioma: Case Report and Review 
Introduction
Cavernous hemangiomas represent the most common benign primary hepatic neoplasm, often being incidentally detected. Although the majority of hepatic hemangiomas remain asymptomatic, symptomatic hepatic hemangiomas can present with abdominal pain, hemorrhage, biliary compression, or a consumptive coagulopathy. The optimal surgical management of symptomatic hepatic hemangiomas remains controversial, with resection, enucleation, and both deceased donor and living donor liver transplantation having been reported.
Case Report
We report the case of a patient found to have a unique syndrome of multiorgan cavernous hemangiomatosis involving the liver, lung, omentum, and spleen without cutaneous involvement. Sixteen years following her initial diagnosis, the patient suffered from intra-abdominal hemorrhage due to her giant cavernous hepatic hemangioma. Evidence of continued bleeding, in the setting of Kasabach-Merritt Syndrome and worsening abdominal compartment syndrome, prompted MELD exemption listing. The patient subsequently underwent emergent liver transplantation without complication.
Conclusion
Although cavernous hemangiomas represent the most common benign primary hepatic neoplasm, hepatic hemangioma rupture remains a rare presentation in these patients. Management at a center with expertise in liver transplantation is warranted for those patients presenting with worsening DIC or hemorrhage, given the potential for rapid clinical decompensation.
doi:10.1007/s11605-010-1248-1
PMCID: PMC3023038  PMID: 20549381
Hepatic hemangioma; Kasabach-Merritt syndrome; Liver transplantation
2.  Right hepatectomy for giant cavernous hemangioma with diffuse hemangiomatosis around Glisson’s capsule 
Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson’s capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn’t diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavernous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.
doi:10.3748/wjg.v20.i25.8312
PMCID: PMC4081710  PMID: 25009410
Giant cavernous hemangioma; Hemangiomatosis; Right hepatectomy; Around Glisson’s capsule; Surgery
3.  Spontaneous rupture of hepatic hemangiomas: A review of the literature 
World Journal of Hepatology  2010;2(12):428-433.
Hepatic hemangiomas are congenital vascular malformations, considered the most common benign mesenchymal hepatic tumors, composed of masses of blood vessels that are atypical or irregular in arrangement and size. Hepatic hemangiomas can be divided into two major groups: capillary hemangiomas and cavernous hemangiomas These tumors most frequently affect females (80%) and adults in their fourth and fifth decades of life. Most cases are asymptomatic although a few patients may present with a wide variety of clinical symptoms, with spontaneous or traumatic rupture being the most severe complication. In cases of spontaneous rupture, clinical manifestations consist of sudden abdominal pain, and anemia secondary to a haemoperitoneum. Disseminated intravascular coagulopathy can also occur. Haemodynamic instability and signs of hypovolemic shock appear in about one third of cases. As the size of the hemangioma increases, so does the chance of rupture. Imaging studies used in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic contrast-enchanced computed tomography scanning, magnetic resonance imaging, hepatic arteriography, digital subtraction angiography, and nuclear medicine studies. In most cases hepatic hemangiomas are asymptomatic and should be followed up by means of periodic radiological examination. Surgery should be restricted to specific situations. Absolute indications for surgery are spontaneous or traumatic rupture with hemoperitoneum, intratumoral bleeding and consumptive coagulopathy (Kassabach-Merrit syndrome). In a patient presenting with acute abdominal pain due to unknown abdominal disease, spontaneous rupture of a hepatic tumor such as a hemangioma should be considered as a rare differential diagnosis.
doi:10.4254/wjh.v2.i12.428
PMCID: PMC3010512  PMID: 21191518
Hepatic hemangioma; Giant hepatic hemangioma; Liver tumor; Spontaneous rupture; Surgery
4.  Co-existence of a giant splenic hemangioma and multiple hepatic hemangiomas and the potential association with the use of oral contraceptives: a case report 
Introduction
Hepatic and splenic hemangiomas are common benign tumors that mainly affect female patients. Giant splenic hemangiomas are extremely rare, especially when correlated with multiple hepatic hemangiomas. Pathogenetic mechanisms between hemangiomas and oral contraceptives, as well as therapeutic approaches, are analyzed in this case report, in particular for the management of synchronous splenic and hepatic hemangiomas.
Case presentation
We report here a 42-year-old woman with a giant splenic hemangioma, multiple hepatic hemangiomas and a history of oral estrogen intake for many years. At first it was difficult to determine the organ from which the giant hemangioma originated. Angiography proved extremely helpful in tracing its origin in the spleen. Hematomas in the giant hemangioma posed a significant threat of rupture and catastrophic hemorrhage. We left the small hepatic hemangiomas in place, and removed the spleen along with the giant splenic hemangioma.
Conclusion
Diagnostic pitfalls in the determination of the origin of this giant hemangioma, attribution of its origin to the spleen angiographically, the unusual co-existence of the giant splenic hemangioma with multiple hepatic ones, and the potential threat of rupture of the giant hemangioma are some of the highlights of this case report. Estrogen administration represents a pathogenic factor that has been associated with hemangiomas in solid organs of the abdominal cavity. The therapeutic dilemma between resection and embolization of giant hemangiomas is another point of discussion in this case report. Splenectomy for the giant splenic hemangioma eliminates the risk of rupture and malignant degeneration, whereas observation for the small hepatic ones (<4 cm) was the preferable therapeutic strategy in our patient.
doi:10.1186/1752-1947-2-147
PMCID: PMC2394533  PMID: 18462497
5.  Successful liver resection in a giant hemangioma with intestinal obstruction after embolization 
Hepatic hemangiomas are the most common benign tumor of the liver. Most hepatic hemangiomas remain asymptomatic and require no treatment. Giant hepatic hemangiomas with established complications, diagnostic uncertainty and incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. We present a case of a giant hemangioma with intestinal obstruction following transcatheter arterial embolization, by which the volume of the hemangioma was significantly reduced, and it was completely resected by a left hepatectomy. A 21-year-old Asian man visited our hospital for left upper quadrant pain. Examinations at the first visit revealed a left liver hemangioma occupying the abdominal cavity, with a maximum diameter of 31.5 cm. Embolization of the left hepatic artery was performed and confirmed a decrease in its size. However, the patient was readmitted to our hospital one month after embolization for intestinal obstruction. A left hepatectomy was completed through a herringbone incision, and safely removed a giant hemangioma of 26.5 cm × 19.5 cm × 12.0 cm in size and 3690 g in weight. Pre-operative arterial embolization is effective for reducing tumor size, but a close follow-up to decide the time for hepatectomy is important.
doi:10.3748/wjg.v19.i19.2974
PMCID: PMC3660824  PMID: 23704832
Hepatic hemangioma; Transcatheter arterial embolization; Intestinal obstruction; Complications; Hepatectomy
6.  Recurrent giant hemangiomas of liver: Report of two rare cases with literature review 
Most hepatic hemangiomas (HHs) are small, asymptomatic and do not require clinical intervention. Surgical resection is only indicated for symptomatic hemangiomas. We report here cases of recurrent HHs in 2 women of 37 and 40 years old, who initially presented with abdominal pain and mass. Radiological examination of each tumor revealed a solitary tumor of 14 and 20 cm in diameter, respectively. Surgical liver segmental resections were performed in both, and the diagnosis of cavernous hemangioma was confirmed. Both patients had recurrent tumor on subsequent radiological examination 4-5 years after the initial surgery. In the first patient, a 15 cm recurrent hemangioma was resected, but multiple hemangiomas were again detected 8 years later occupying the other hepatic lobe, which was not amendable for resection. In the second patient, a 16 cm hemangioma was seen on radiogram, and because the lesion was not symptomatic, conservative observation was offered. Recurrence after liver resection of giant hemangioma is extremely rare. The pathogenesis of tumor progression and recurrence is unknown, as is the management of these patients with recurrent hemangioma, particularly when it is extensive and unresectable.
doi:10.4240/wjgs.v4.i11.262
PMCID: PMC3596508  PMID: 23494295
Liver; Giant hemangioma; Recurrent hemangioma
7.  Surgical Management for Giant liver Hemangiomas Greater Than 20 cm in Size 
Gut and Liver  2011;5(2):228-233.
Background/Aims
The aim of this study was to investigate the primary management experience for giant liver hemangiomas greater than 20 cm in size.
Methods
Records of patients referred for evaluation of radiologically and/or histopathologically proven giant liver hemangiomas between January 2007 and March 2010 were retrospectively analyzed. The reasons for referral, results of imaging studies, preoperative and surgical treatments, and outcome were reviewed.
Results
A retrospective analysis was performed for 14 patients diagnosed with a giant hemangioma on the basis of an imaging study and/or a histopathological examination. All cases were diagnosed as giant liver hemangioma with at least one lesion greater than 20 cm in size. Abdominal discomfort was the main presenting complaint for the referral in 9 patients (64.2%). Abdominal ultrasound established the diagnosis in 12 patients (85.7%). Twelve patients underwent liver resection, 2 of whom underwent staged resection. Enucleation was performed in 2 patients. Selective transcatheter arterial embolization was implemented in 9 patients. Postoperative morbidity occurred in 3 patients (21.4%). No complications related to the hemangiomas occurred during follow up.
Conclusions
Liver resection is indicated for giant liver hemangiomas with abdominal discomfort, especially for lesions greater than 20 cm in size. Staged operations are performed for patients with multiple lesions. Preoperative selective transcatheter arterial embolization alleviates progressive abdominal pain.
doi:10.5009/gnl.2011.5.2.228
PMCID: PMC3140671  PMID: 21814606
Liver hemangioma; Liver resection; Transcatheter arterial embolization
8.  Liver hemangioma and vascular liver diseases in patients with systemic lupus erythematosus 
AIM: To investigate whether systemic lupus erythematosus (SLE) is associated with benign focal liver lesions and vascular liver diseases, since these have been occasionally reported in SLE patients.
METHODS: Thirty-five consecutive adult patients with SLE and 35 age- and sex-matched healthy controls were evaluated. Hepatic and portal vein patency and presence of focal liver lesions were studied by colour-Doppler ultrasound, computerized tomography and magnetic resonance were used to refine the diagnosis, clinical data of SLE patients were reviewed.
RESULTS: Benign hepatic lesions were common in SLE patients (54% vs 14% controls, P < 0.0001), with hemangioma being the most commonly observed lesion in the two groups. SLE was associated with the presence of single hemangioma [odds ratios (OR) 5.05; 95% confidence interval (CI) 1.91-13.38] and multiple hemangiomas (OR 4.13; 95% CI 1.03-16.55). Multiple hemangiomas were associated with a longer duration of SLE (9.9 ± 6.5 vs 5.5 ± 6.4 years; P = 0.04). Imaging prior to SLE onset was available in 9 patients with SLE and hemangioma, showing absence of lesions in 7/9. The clinical data of our patients suggest that SLE possibly plays a role in the development of hemangioma. In addition, a Budd-Chiari syndrome associated with nodular regenerative hyperplasia (NRH), and a NRH associated with hepatic hemangioma were observed, both in patients hospitalized for abdominal symptoms, suggesting that vascular liver diseases should be specifically investigated in this population.
CONCLUSION: SLE is associated with 5-fold increased odds of liver hemangiomas, suggesting that these might be considered among the hepatic manifestations of SLE.
doi:10.3748/wjg.v17.i40.4503
PMCID: PMC3218141  PMID: 22110281
Colour-Doppler ultrasound; Portal hypertension; Rheumatic diseases; Portal vein; Hepatic vein thrombosis
9.  A case of pedunculated hepatic hemangioma mimicking submucosal tumor of the stomach 
Hepatic hemangioma is the most common benign tumor of the liver. Most such hemangiomas are small, asymptomatic, and have an excellent prognosis. Giant hepatic hemangioma has been reported in the literature, but the exophytic and pedunculated forms of hepatic hemangioma are rare. A 56-year-old woman was referred to our hospital under the suspicion of having a gastric submucosal tumor. Abdominal computer tomography (CT) scans showed a pedunculated mass from the left lateral segment of the liver into the gastric fundus, exhibiting the atypical CT findings of hepatic hemangioma. We therefore decided to perform laparoscopic resection based on the symptoms, relatively large diameter, inability to exclude malignancy, and risk of rupture of the exophytic lesion. The pathology indicated it to be a cavernous hemangioma of the liver. Herein we report a case of pedunculated hepatic hemangioma mimicking a submucosal tumor of the stomach due to extrinsic compression of the gastric fundus.
doi:10.3350/kjhep.2011.17.1.66
PMCID: PMC3304623  PMID: 21494080
Hemangioma; Liver; Laparoscopy; Stomach neoplasm
10.  Hepatic Cavernous Hemangioma in Cirrhotic Liver: Imaging Findings 
Korean Journal of Radiology  2000;1(4):185-190.
Objective
To document the imaging findings of hepatic cavernous hemangioma detected in cirrhotic liver.
Materials and Methods
The imaging findings of 14 hepatic cavernous hemangiomas in ten patients with liver cirrhosis were retrospectively analyzed. A diagnosis of hepatic cavernous hemangioma was based on the findings of two or more of the following imaging studies: MR, including contrast-enhanced dynamic imaging (n = 10), dynamic CT (n = 4), hepatic arteriography (n = 9), and US (n = 10).
Results
The mean size of the 14 hepatic hemangiomas was 0.9 (range, 0.5-1.5) cm in the longest dimension. In 11 of these (79%), contrast-enhanced dynamic CT and MR imaging showed rapid contrast enhancement of the entire lesion during the early phase, and hepatic arteriography revealed globular enhancement and rapid filling-in. On contrast-enhanced MR images, three lesions (21%) showed partial enhancement until the 5-min delayed phases. US indicated that while three slowly enhancing lesions were homogeneously hyperechoic, 9 (82%) of 11 showing rapid enhancement were not delineated.
Conclusion
The majority of hepatic cavernous hemangiomas detected in cirrhotic liver are small in size, and in many, hepatic arteriography and/or contrast-enhanced dynamic CT and MR imaging demonstrates rapid enhancement. US, however, fails to distinguish a lesion of this kind from its cirrhotic background.
doi:10.3348/kjr.2000.1.4.185
PMCID: PMC2718199  PMID: 11752953
Liver, cirrhosis; Liver neoplasms, angiography; Liver neoplasms, MR; Liver neoplasms, US
11.  Giant liver hemangioma resected by trisectorectomy after efficient volume reduction by transcatheter arterial embolization: a case report 
Introduction
Liver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.
Case presentation
A 38-year-old Asian man was referred to our hospital with complaints of severe abdominal distension and pancytopenia. Examinations at the first visit revealed a right liver hemangioma occupying the abdominal cavity, protruding into the right diaphragm up to the right thoracic cavity and extending down to the pelvic cavity, with a maximum diameter of 43 cm, complicated with "asymptomatic" Kasabach-Merritt syndrome. Based on the tumor size and the anatomic relationship between the tumor and hepatic vena cava, primary resection seemed difficult and dangerous, leading us to first perform transcatheter arterial embolization to reduce the tumor volume and to ensure the safety of future resection. The tumor volume was significantly decreased by two successive transcatheter arterial embolizations, and a conventional right trisectorectomy was then performed without difficulty to resect the tumor.
Conclusions
To date, there have been several reports of aggressive surgical treatments, including extra-corporeal hepatic resection and liver transplantation, for huge hemangiomas like the present case, but because of its benign nature, every effort should be made to avoid life-threatening surgical stress for patients. Our experience demonstrates that a pre-operative arterial embolization may effectively enable the resection of large hemangiomas.
doi:10.1186/1752-1947-4-283
PMCID: PMC2936318  PMID: 20731839
12.  A hepatic sclerosed hemangioma with significant morphological change over a period of 10 years: a case report 
Introduction
Liver cavernous hemangioma is the most common noncystic hepatic lesion, and a hemangioma that undergoes degeneration and fibrous replacement is called a hepatic sclerosed hemangioma.
Case presentation
A 63-year-old Japanese man was admitted for detailed investigation of a liver tumor. Tumor markers carcinoembryonic antigen, alpha-fetoprotein, and CA19-9 levels in the peripheral blood were not elevated at any time. Plain computed tomography showed an approximately 1.5cm low density mass in the periphery of segment 8, which was marginally enhanced on contrast-enhanced dynamic computed tomography. On magnetic resonance imaging, the tumor was hypointense on T1-weighted image and hyperintense on T2-weighted image. The tumor was suspected to be an atypical hemangioma, metastatic, hepatocellular carcinoma, or cholangiocellular carcinoma. Segmental hepatectomy was performed. Histological examination of the resected tumor specimen revealed a sclerosed hemangioma with marked hyalinization and sparse stromal fibrosis. Immunochemically, the tumor cells were positive for CD34 and alpha smooth muscle actin. Electron microscopically, the residual hemangioma consisted of numerous caveolae and vesicles in endothelial cells in irregular shapes and sizes. Immunostaining for caveolin-1 showed decreased or no caveolin-1 reactivity in the hyalinized lesions of the sclerosed hemangioma, but abundant caveolin-1 reactivity in the residual cavernous hemangioma. Of interest, computed tomography images of the tumor obtained 10 years earlier at our hospital depicted a 3cm typical cavernous hemangioma.
Conclusions
Hepatic sclerosed hemangioma is a rare condition. Comparison of radiological findings of the lesion over a period of 10 years was valuable in providing insight for the evolutional process from liver cavernous hemangioma to hepatic sclerosed hemangioma.
doi:10.1186/1752-1947-7-139
PMCID: PMC3750244  PMID: 23714181
Caveolae; Caveolin-1; Electron microscopy; Hepatic sclerosed hemangioma; Immunohistochemistry; Liver cavernous hemangioma
13.  Cavernous hemangioma of the parietal bone 
Patient: Male, 38
Final Diagnosis: Cavernous hemangioma
Symptoms: Headache • parietal mass
Medication: —
Clinical Procedure: —
Specialty: Neurosurgery
Objective:
A rare disease
Background:
Bone hemangioma is a vascular hemartoma of bone structures. In general, this pathology is detected on incidentally investigated patients’ films. Bone hemangioma is most commonly seen in 4th decade of life and the male/female ratio is 1/1.5. The locations of these lesions are commonly long bones of the vertebral column and the skull.
Primary bone hemangiomas constitute less than 1% of all bone tumors, and they are seen at 0.2% in the calvarial region.
Case Report:
Cases with this pathology are seen on incidental radiological evaluations. We report the case of a 38-year-old man with localized headache and a palpable mass in the left parietal region, admitted and operated on after cranial CT and MRI. Pathology investigation revealed a cavernous hemangioma.
Conclusions:
We suspected that in our case head trauma may have been the cause of cavernous hemangioma in the calvarial region, because cavernous hemangiomas are rarely located there. Localized headache and minor discomfort can be seen with this pathology. The best treatment for cavernous hemangiomas is the removal of the mass within the limits of safe surgery.
doi:10.12659/AJCR.889388
PMCID: PMC3795520  PMID: 24133611
headache; trauma; cavernous hemangioma
14.  Is hepatotropic contrast enhanced MR a more effective method in differential diagnosis of hemangioma than multi-phase CT and unenhanced MR? 
BMC Gastroenterology  2011;11:43.
Background
Cavernous hemangiomas are the most frequent neoplasms of the liver and in routine clinical practice they often need to be differentiated from malignant tumors and other benign focal lesions. The purpose of this study is to evaluate whether diagnostic accuracy of magnetic resonance imaging (MRI) of hepatic hemangiomas, showing atypical pattern on US, improves with the use of Gd-BOPTA in comparison with contrast-enhanced multi-phase computed tomography (CT).
Methods
178 consecutive patients with ambiguous hepatic masses showing atypical hyperechoic pattern on grey-scale US, underwent unenhanced and contrast-enhanced multi-phase multi-detector CT and MR (1.5T) with the use of liver-specific contrast medium gadobenate dimeglumine (Gd-BOPTA). After intravenous contrast administration arterial (HAP), venous-portal (PVP), equilibrium phases (EP) both in CT and MR and additionally hepatobiliary phase (HBP) in MR were obtained. 398 lesions have been detected including 99 hemangiomas and 299 other lesions.
Results
In non-enhanced MDCT examination detection of hemangiomas was characterized by sensitivity of 76%, specificity of 90%, PPV of 71%, NPV of 92% and accuracy of 86%.
Non-enhanced MR examination showed sensitivity of 98%, specificity of 99%, PPV of 99%, NPV of 99% and accuracy of 99%.
After intravenous administration of contrast medium in MR the mentioned above parameters did not increase significantly.
Conclusion
Gd-BOPTA-enhanced MR in comparison with unenhanced MRI does not improve diagnostic accuracy in discriminating hemangiomas that show non-specific appearance in ultrasound examination. Unenhanced MR as a method of choice should directly follow US in course of diagnostic algorithm in differentiation of hemangiomas from other liver tumors.
doi:10.1186/1471-230X-11-43
PMCID: PMC3110140  PMID: 21504593
15.  A rare cavernous hemangioma of the adrenal gland☆ 
INTRODUCTION
Cavernous hemangiomas of the adrenal gland are rare. We report a case of a cavernous hemangioma of the adrenal gland presenting as an adrenal incidentaloma suspicious for adrenal cortical carcinoma (ACC).
PRESENTATION OF CASE
A 78 year old woman was admitted after a fall. Abdominal computed tomography revealed a large right adrenal lesion with features suspicious for adrenal cortical carcinoma (5.4 cm × 3.3 cm, unilateral, tumor calcifications, average Hounsfield units 55). The tumor was removed intact by a laparoscopic approach and pathology revealed a cavernous hemangioma of the adrenal gland.
DISCUSSION
Adrenal incidentalomas are found in up to 10% of patients undergoing abdominal imaging. Differential diagnosis includes both benign and malignant lesions. Guidelines for removal of adrenal incidentalomas recommend surgery based on functional status, size, and presence of concerning features on diagnostic imaging. Cavernous hemangiomas are rare, benign vascular malformations which can be challenging to distinguish pre-operatively from malignant lesions such as ACC.
CONCLUSION
Cavernous hemangiomas of the adrenal gland are exceedingly rare. These benign tumors have imaging features which may be suggestive of adrenal cortical carcinoma. The treatment of choice is surgical excision due the difficulty of excluding malignancy.
doi:10.1016/j.ijscr.2013.11.003
PMCID: PMC3921650  PMID: 24441435
Adrenal; Cavernous hemangioma; Adrenal cortical carcinoma
16.  Pulmonary embolism due to compression of the inferior vena cava by a hepatic hemangioma. 
Texas Heart Institute Journal  1993;20(1):66-68.
We describe a 35-year-old man who had a pulmonary embolism with thrombosis of the inferior vena cava, apparently resulting from compression by a hepatic hemangioma. The diagnosis of pulmonary embolism was confirmed by pulmonary angiography; however, the hemangioma was detected only incidentally, as a hyperechoic mass, during an echocardiogram for intracardiac thrombosis. Abdominal sonography, computed tomography, celiac angiography, technetium 99m-labeled red blood cell scintigraphy, and ultrasound-guided liver biopsy all assisted in the diagnosis of hepatic hemangioma and its compression of the inferior vena cava. Because of the multisegmental and perihilar involvement of the tumor, surgery was not performed. For dissolution of the clots, the patient was given thrombolytic therapy followed by heparin administration. He was then placed on long-term warfarin therapy and is well after 5 years; the size of the hemangioma is unchanged. Cases of pulmonary embolism due to diseases of the upper abdominal organs are rare and probably underestimated. This case stresses the need for a systematic investigation of the abdomen when a pulmonary embolism is present without evidence of deep vein thrombosis.
Images
PMCID: PMC325057  PMID: 8508068
17.  Surgical treatment of giant cavernous hemangiomas of the liver--analysis of 7 patients. 
Seven patients with giant cavernous hemangioma of the liver were treated surgically with success at Pusan Gospel Hospital, Kosin Medical College, Pusan, from 1980 through 1989. They were 3 males and 4 females, and their ages ranged from 6 to 59 years. The tumors were located on the right lobe of the liver in 5 patients and on the left lobe in 2. The lesions were solitary in all patients, and their sizes varied from 4cm to 15cm in diameter. All patients underwent hepatic resection: 1 right hepatic lobectomy and 4 partial resections for tumors on the right lobe, and 1 left lobectomy and 1 left lateral segmentectomy for tumors on the left lobe. There was no surgical death, but 1 patient had a postoperative complication: multiple stress ulcers on the stomach and ileum. The pathologic diagnosis was cavernous hemangioma in all cases. In the long-term follow-up, there was no recurrence of preoperative symptoms in any patient.
PMCID: PMC3049686  PMID: 1751017
18.  Stereotactically-guided craniotomy for resection of cerebral cavernous hemangioma: a series case report of 8 cases in Rasoul-e-Akram hospital (Tehran, Iran) 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 23.
Abstract:
Background:
In line with recent advances in magnetic resonance imaging (MRI), cavernous hemangioma (cavernoma) can be detected efficiently and reliably in patients with intractable epilepsy that surgical resection is a common treatment for them. Because these lesions are usually small and may be located near the eloquent areas, stereotactically-guided resection should be considered. This study aims to report the surgical features and outcomes of 6 patients underwent the stereotactically-guided craniotomy for excision of cavernoma.
Methods:
A total of six patients (1 male and 5 female, aged 10-42 years, mean age of 29 years) with cavernoma underwent stereotactically-guided craniotomy surgery in the Rasoul-e-Akram Hospital, affiliated to Tehran University of Medical Sciences (Tehran, Iran) for resection of cerebral cavernous hemangioma during September 2007 to May 2012. Clinical presentations were seizures, headache and hemorrhage. Two patients had a previous history of intracranial hemorrhage. Diagnosis was made using MRI and digital subtraction angiography. Locations of the lesions were parietal, frontal and temporoparietal. Size of lesion ranged from 0.7 to 3.1 cm (mean 1.7 cm). All those lesions were deep-seated or located near or within eloquent areas. Stereotactically-guided craniotomy was performed for excision of lesion. Clinical follow-up period ranged 5-48 months (mean 28 months). In all patients, complete surgical resection was achieved as demonstrated by postoperative image studies.
Results:
There was no associated morbidity or mortality. Histological diagnosis was consistent with cavernoma in all cases. Clinical follow-up revealed that all patients had complete recovery from preoperative symptoms and patients with seizures showed marked improvement.
Conclusions:
In conclusion, stereotactic guided craniotomy in surgery of eloquent or deep-seated cerebral cavernous malformations represents a very accurate and safe approach.
Keywords:
Stereotactically-guided craniotomy, Cavernous hemangioma, Magnetic resonance imaging
PMCID: PMC3571549
19.  Giant pedunculated hepatocellular carcinoma with hemangioma mimicking intestinal obstruction 
BMC Gastroenterology  2011;11:99.
Background
Pedunculated hepatocellular carcinoma (P-HCC) has rarely been reported and is characteristically large and encapsulated. Only sporadic cases have been published, in which P-HCC was combined with other liver tumors (mostly benign), making the diagnosis difficult.
Case presentation
We report a patient who was admitted to our hospital with clinical features of intestinal obstruction and a palpable mass in the right iliac fossa. Ultrasound, computed tomography and magnetic resonance imaging demonstrated an encapsulated mass of unclear origin and characteristics of liver hemangioma. Laboratory tests revealed elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (> 51.2 U/ml). With a possible diagnosis of giant liver hemangioma, we proceeded to surgery. During surgery, a giant pedunculated tumor was discovered on the inferior surface of the right lobe of the liver, hanging free in the right abdominal cavity towards the right iliac fossa. The macroscopic appearance of the tumor was compatible with liver hemangioma. Tumor resection was performed at a safe distance, including the pedicle. The rest of the liver appeared normal. Histopathological examination revealed grade II and III HCC (according to Edmondson-Steiner's classification) with nodular configuration, central necrosis, and infiltration of the capsule. Underneath the tumor capsule, residual tissue of a cavernous hemangioma was recognized. The resection margins were free of neoplastic tissue.
Conclusion
This rare presentation of a giant P-HCC combined with a hemangioma with features of intestinal obstruction confirmed the diagnostic difficulties of similar cases, and required prompt surgical treatment. Therefore, patients benefit from surgical resection because both the capsule and the pedicle prevent vascular invasion, therefore improving prognosis.
doi:10.1186/1471-230X-11-99
PMCID: PMC3187738  PMID: 21939543
20.  Giant Hepatic Hemangioma Presenting as Gastric Outlet Obstruction 
International Surgery  2013;98(1):19-23.
Hemangioma, a most frequently encountered primary benign tumor of the liver, is generally determined incidentally during the course of radiologic tests for other reasons. Most lesions are less than 3 cm and a significant proportion of patients are asymptomatic, although the size and location of the lesion in some patients may be associated with the onset of symptoms. Pressure on the stomach and duodenum of giant hemagiomas developing in the left lobe of the liver, in particular, may result in the development of abdominal pain, nausea, vomiting, and feeling bloated, which are characteristic of a gastric outlet obstruction. A 42-year-old man presented with findings of gastric outlet obstruction and weight loss as a result of a giant hepatic hemangioma.
doi:10.9738/CC170.1
PMCID: PMC3723163  PMID: 23438272
Liver; Giant; Cavernous hemangioma; Gastric outlet obstruction; Enucleation
21.  Pain pattern in multiple vertebral hemangiomas involving non-adjacent levels: report of two cases 
European Spine Journal  2000;9(3):256-260.
Hemangioma of the bone is a benign tumor usually involving the spine and the bones of the skull and pelvis. It may be either a single lesion or part of a generalized multifocal disease. Multiple lesions involving non-adjacent vertebrae are rare. Two cases of multiple vertebral hemangiomas at non-adjacent levels with different pain patterns are presented at various stages of follow-up in order to emphasize the fact that multiple vertebral hemangiomas may present with different clinical characteristics over a long period of time. The change in the location and pattern of the initially presented pain in both patients suggested the possibility of multiple level involvement. Investigation revealed multiple hemangiomas involving three non-adjacent vertebrae in the first patient and four in the second. We stress the fact that the existence of multiple non-adjacent lesions may remain undiagnosed for a considerable period of time and may be responsible for even longer-term recurrent episodes of pain. Multifocal location of back pain in patients with a known vertebral hemangioma may be considered a relative indication for the presence of multiple non-adjacent level lesions.
doi:10.1007/s005860000152
PMCID: PMC3611405  PMID: 10905446
Key words Adult; Case report; Spinal neoplasms; Hemangioma; Spine
22.  Sacroplasty for Symptomatic Sacral Hemangioma: A Novel Treatment Approach 
Interventional Neuroradiology  2013;19(2):245-249.
Summary
Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty.
A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma.
Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.
PMCID: PMC3670066  PMID: 23693051
sacral hemangioma, sacroplasty
23.  Giant Hepatic Hemangioma With Kasabach–Merritt Syndrome: Is the Appropriate Treatment Enucleation or Liver Transplantation? 
HPB Surgery  2000;11(6):413-419.
We present a case of giant cavernous hemangioma of the liver with disseminated intravascular coagulopathy (Kasabach–Merritt syndrome) which was cured by enucleation. The 51 year old woman presented with increased abdominal girth and easy bruisability. Workup elsewhere revealed a massive hepatic hemangioma and she was started on radiation therapy to the lesion and offered an orthotopic liver transplant. After careful preoperative preparation, we felt that resection was possible and she underwent a successful enucleation. The operation and postoperative course were complicated by bleeding but she recovered and remains well in followup after 6 months. All coagulation parameters have returned to normal. Enucleation should be considered the treatment of choice for hepatic hemangiomas, including those presenting with Kasabach–Merritt syndrome. The benefits of enucleation as compared to liver transplantation for these lesions are discussed.
doi:10.1155/2000/25954
PMCID: PMC2424000  PMID: 10977121
24.  Bilateral Lower Limb Edema Caused by Compression of the Retrohepatic Inferior Vena Cava by a Giant Hepatic Hemangioma 
International Surgery  2013;98(3):229-233.
Hemangiomas are the most common benign primary tumors of the liver and their prevalence ranges from 0.4% to 20%. Approximately 85% of hemangiomas are clinically asymptomatic and are incidentally detected in imaging studies performed for other causes. In a very small minority of patients, nausea, vomiting, abdominal pain, distension, palpable mass, obstructive jaundice, bleeding, and signs and symptoms of Budd-Chiari syndrome may develop due to compression of bile duct, hepatic vein, portal vein, and adjacent organs. Occasionally, external compression of inferior vena cava may lead to edema and/or indirect symptoms such as deep vein thrombosis of the lower limbs. In this report, we present a case of giant hepatic hemangioma that completely filled the right lobe of the liver. The patient presented with bilateral lower limb edema and pain. A computed tomography scan detected a 9 × 11 × 12 cm mass indicative of a hemangioma in the right lobe of the liver that compressed the inferior vena cava. The patient refused treatment initially but returned 6 months later presenting with the same symptoms. At that time, the mass had increased in size and a hepatectomy was performed, preserving the middle hepatic vein. By postoperative month 13, the swelling in the lower extremities had decreased significantly and the inferior vena cava appeared normal.
doi:10.9738/INTSURG-D-13-00046.1
PMCID: PMC3756845  PMID: 23971776
Liver; Giant hemangioma; Venous obstruction; Lower limb edema
25.  Multiple cavernous hemangiomas of the skull with dural tail sign: a case report and literature review 
BMC Neurology  2013;13:155.
Background
Primary intraosseous cavernous hemangioma is a rare bony tumor. To date, only 9 cases of multiple lesions and 2 cases with a dural tail sign have been reported.
Case presentation
Here, we present a case of multiple cavernous hemangiomas of the skull with dural tail sign in a 24-year-old man. No abnormalities were observed in the right orbit by craniography, but frontal bone destruction was unintentionally discovered. Computed tomography and magnetic resonance imaging demonstrated multiple intraosseous lesions that destroyed the surrounding bone and intracranial extension. Total resection of the two lesions and cranioplasty were performed. Histological examination confirmed the lesions as a cavernous hemangioma.
Conclusion
Cavernous hemangioma is a rare bony tumor that should be considered in the differential diagnosis of skull tumors. Resection of all lesions should be performed on patients with multiple cavernous hemangiomas, and these patients should have regular follow-up examinations. Based on this case, and our literature review, we found that outcomes are usually very good.
doi:10.1186/1471-2377-13-155
PMCID: PMC3835445  PMID: 24161077
Cavernous hemangiomas; Skull; Orbit

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