AJR 2005; 185:815-816
© American Roentgen Ray Society
Spontaneous Rapid Regression of a Giant Hemangioma Mimicking a Liver Abscess
Yu-Fen Chiu,
Jeon-Hor Chen,
Yung-Fang Chen,
Yung-Jen Ho and
Iuan-Hung Tzeng
China Medical University Hospital
Taichung, Taiwan
A 52-year-old woman with diabetes mellitus and uremia was admitted because
of an intermittent low-grade fever after amputation of her forearm, where an
arteriovenous shunt had been created for hemodialysis, and cyanosis and
gangrene developed thereafter. Laboratory examination showed elevated WBC and
high C-reactive protein levels.
Abdominal sonography revealed a heterogeneously echoic mass in the right
lobe of the liver. With the suspicion of a hepatic abscess, we performed
abdominal CT. The CT images showed a 5-cm multiloculated cystic lesion that
was suggestive of an abscess (Fig.
1A); however, when reviewing CT studies that had been performed 1
year earlier, we found that a giant hemangioma of approximately 11 cm in
diameter with characteristic features of peripheral nodular enhancement had
been noted in the same location (Figs.
1B and
1C). Results from laboratory
examinations during these two hospital courses revealed normal liver function
and normal 
-fetoprotein levels. No therapeutic procedure for the
hemangioma had been performed during the previous year, and the patient had
not taken oral contraceptives.
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Fig. 1A —52-year-old woman with rapid regression of giant hepatic
hemangioma. Enhanced abdominal CT scan shows multiloculated cystic lesion in
right lobe liver. CT features suggested liver abscess. Note filling defect in
right portal vein.
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Fig. 1B —52-year-old woman with rapid regression of giant hepatic
hemangioma. Dynamic CT scan in arterial phase obtained 1 year before A
reveals huge peripherally nodular enhanced lesion, which is typical for
hemangioma, in same location. Note geographic low-density region
(arrow) in central portion of tumor indicating possibility of
fibrosis.
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Fig. 1D —52-year-old woman with rapid regression of giant hepatic
hemangioma. Unenhanced spoiled gradient-recalled echo T1-weighted MR image
(TR/TE, 150/4.2) shows spotty regions of high signal within
low-signal-intensity lesion.
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MRI was arranged for further evaluation of this lesion and showed some high
signal intensities in the lesion on both T1- and T2-weighted images,
indicating hemorrhage or proteinaceous fluid. After the administration of
gadolinium, T1-weighted imaging showed no enhancement (Figs.
1D and
1E). Stone-hard texture of this
lesion was noted during the biopsy procedure, and no obvious fluid could be
aspirated. With the combination of these findings, spontaneous rapid
regression of a giant hemangioma with hemorrhage and fibrosis was highly
suggested.
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Fig. 1E —52-year-old woman with rapid regression of giant hepatic
hemangioma. Gadolinium-enhanced spoiled gradient-recalled echo T1-weighted MR
image (150/4.2) in arterial phase shows no marked enhancement of lesion. Note
patch of enhanced region (arrows) adjacent to lesion, which is
suggestive of perfusion disorder due to portal vein thrombosis or
hyperemia.
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Hemangioma is the most common benign hepatic tumor, whereas giant hepatic
hemangioma is markedly less common. Giant hepatic hemangioma usually appears
as a central area of hypoattenuation on CT. On dynamic CT studies, complete
filling of the lesion is rarely shown. The central area usually presents with
hypointensity on T1-weighted MR images and hyperintensity on T2-weighted MR
images [1]. MRI findings of
giant hemangioma are closely correlated with its macroscopic appearance, which
shows changes such as hemorrhage, thrombosis, extensive hyalinization,
liquefaction, and fibrosis [2].
Other relatively uncommon findings include calcification and multilocular
appearance, possibly due to cystic degeneration caused by central thrombosis
and hemorrhage.
Complications caused by giant hepatic hemangioma include inflammation,
coagulation (Kasabach-Merritt syndrome), spontaneous rupture, and compression
of adjacent structures such as bile ducts
[1,
2]. Inflammatory process
complicating giant hepatic hemangioma might evoke low-grade fever, accelerated
erythrocyte sedimentation rate, anemia, thrombocytosis, and increased
fibrinogen level [2,
3]. Very rarely, giant
cavernous hemangioma also might be complicated by abscess formation
[4].
Most hepatic hemangiomas remain stable in size or show minimal increase in
diameter over time. Spontaneous regression of hepatic hemangioma is very rare
[5], although most infantile
cutaneous hemangiomas regress completely on their own. Unlike infantile
hepatic hemangioma, which can be treated with steroids, interferon, and
vincristine, no medical therapy is known to reduce the size or eliminate
adult-type hepatic hemangiomas. In a few cases, enlargement of a hemangioma
has been reported, most of which were due to pregnancy or to estrogen
administration [2].
Rapid regression of a giant hemangioma mimicking an abscess is extremely
rare. In our patient, extensive central thrombosis with hemorrhage or fibrosis
might account for the rapid tumor regression and the CT features of
multiloculation mimicking an abscess. It would have been difficult to make a
correct diagnosis if the patient had clinical findings suggestive of an
infectious process and no previous images had been available.
References
- Coumbaras M, Wendum D, Monnier-Cholley L, Dahan H, Tubiana JM,
Arrive L. CT and MR imaging features of pathologically proven atypical giant
hemangiomas of the liver. AJR 2002;179
: 1457-1463[Free Full Text]
- Vilgrain V, Boulos L, Vullierme MP, Denys A, Terris B, Menu Y.
Imaging of atypical hemangiomas of the liver with pathologic correlation.
RadioGraphics 2000;20
: 379-397[Abstract/Free Full Text]
- Pol B, Disdier P, Le Treut YP, Campan P, Hardwigsen J, Weiller PJ.
Inflammatory process complicating giant hemangioma of the liver: report of
three cases. Liver Transpl Surg 1998;4
: 204-207[CrossRef][Medline]
- Berliner L, el Ferzli G, Gianvito L, et al. Giant cavernous
hemangioma of the liver complicated by abscess and thrombosis. Am J
Gastroenterol 1983; 78:835
-840[Medline]
- Okano H, Shiraki K, Inoue H, et al. Natural course of cavernous
hepatic hemangioma. Oncol Rep 2001;8
: 411-414[Medline]
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