HEMANGIOMA

HEMANGIOENDOTHELIOMA

The terms arteriovenous malformation, infantile hemangioma (capillary or cavernous), and hemangioendothelioma are used synonymously to describe vascular hepatic tumors described before 6 months of age (1). It is the most common symptomatic vascular tumor of infancy, with 85% presenting in the first 6 months of life.  There is a female predominance 967%). They are considered benign tumors of vascular origin, but they do have a high frequency of malignant degeneration (sarcomas). Cutaneous hemangiomas may be present in 45% of cases and the alpha fetoprotein may occasionally be increased. The main complication is congestive heart failure due to arteriovenous shunting.
 

Ultrasound

Prenatal detection of an arteriovenous malformation is important intrauterine steroid therapy and careful prenatal planning is required, as about 50% of infants have high output congestive cardiac failure as the presenting feature (2).

Hypoechoic mass and usually well circumscribed. Solitary lesions are more common than multiple lesions.

It may less commonly be isoechoic or hyperechoic (this generally occurs as the tumor fibrosis and involutes).

 

 

 

  • ± Polyhydramnios (3).
  • ± Non-immune hydrops(4).

·         Congestive cardiac failure (4).

Color doppler usually demonstrates a large vessel with bidirectional flow feeding into a complex hypoechoic mass.

Power doppler demonstrates a vascular tumor that drains into the middle hepatic vein.

Arteriovenous lakes demonstrate high velocity flow patterns with a mixed arterial and venous pattern. High velocity waveforms have been reported in the hepatic veins (5).

Post-natal abdominal ultrasound:

Vascular mass in liver.

Post-natal CT scan through the liver:

Mass seen on non-contrast enhanced scan (upper panel).

Marked vascular enhancement on the post contrast scans (lower panels).

 

Differential diagnosis:

1.      Mesenchymal hamartoma.

2.      Cavernous hemangioma.

3.      Hepatoocelluar carcinoma.

4.      Hepatoblastoma.

5.      Metastatic neuroblastoma.

 

 

 

REFERENCES
  1. Paltiel HJ, Patriquin HB, Keller MS et.al. Infantile hepatic hemangioma: Doppler ultrasound. Radiology 1992;182:735-742.
  2. Stanley P, Geer GD, Miller JH et.al. Infantile hepatic hemangiomas: clinical features, radiologic investigations, and treatment of 20 patients. Cancer 1985;64:936.
  3. Petrovic O, Haller H, Rukavina B et.al. Prenatal diagnosis of a large liver cavernous hemangioma associated with polyhydramnios. Prenat Diagn 1992;12:70.
  4. Gonen R, Fong K, Chiasson DA. Prenatal sonographic diagnosis of hepatic hemangioendothelioma with secondary non-immune hydrops. Obstet Gynecol 1989;73:485-487.
  5. Abuhamad AZ, Lewis D, Inati M et.al. The use of color doppler in the diagnosis of fetal hepatic hemangioma. J Ultrasound Med 1993;4:223-226.
  6. Berger TM, Berger MF, Hoffman AD et.al. Imaging diagnosis and follow-up of infantile hemangioendothelioma: a case report. Eur J Pediatr 1994;156:100-102.
  7. Selby DM, Stocker JT, Waclawiw WA et.al. Infantile hemangioendothelioma of the liver. Hepatology 1994;20:39-45.