Answer for BIR CoW 26 June 2022
Hepatic cavernous hemangioma
Findings
Well defined T1 hypointense/T2 hyperintense lobulated lesion noted in subcapsular region of segments VI and VII of right lobe of liver showing few areas of diffusion restriction. Markedly T2 hyperintense areas noted within the lesion. Another well defined subcapsular T1 hypointense/T2 hyperintense lesion noted in segment II of left lobe of liver. On contrast administration, the lesions show peripheral discontinous nodular enhancement on arterial phase and progressivew centripetal filling in on venous and delayed phases. Impression : Features suggestive of hepatic cavernous hemangiomas in segment VI, VII and II of liver.
Discussion
Detected by chance in most cases, the hepatic hemangioma is the most common non-cystic hepatic lesion. The incidence may reach 20% according to several autopsy series. In its typical form, the hemangioma is well known and does not raise diagnostic problems in imaging. However, certain “variants” and “atypias” may complicate the diagnosis. The hepatic hemangioma is a benign vascular lesion. In the vast majority of cases, it is non-evolving and does not require treatment or monitoring. Histologically, it is a mesenchymal lesion consisting of blood-filled vascular cavities of different size, surrounded by a simple layer of flat endothelial cells, supported by a fibrous connective tissue. This is a lesion consisting of large vascular spaces with a central cavernous zone, all the larger with a voluminous hemangioma, and not very extensive connective tissue. In general, this typical appearance is observed in lesions less than 3 cm in diameter. The outlines are sharp, well defined. In the sonograph, it is a hyperechogenic, homogenous lesion presenting a posterior acoustic enhancement. According to Yu et al., there is a correlation between the echogenicity of the lesion, its internal architecture and its hemodynamic behaviour. Therefore, the hyperechogenicity of cavernous hemangiomas seem to be related to the great many interfaces between the vascular spaces and the fibrous stoma as well as to the slower blood flow in the large vascular spaces. The majority of hepatic hemangiomas produced either no power Doppler signal or one that was minimal . In unenhanced CT, the density of the lesion is the same as that of the vessels. In MRI, the lesion presents an homogenous and high intensity signal on T2-weighted images (similar to that of the cerebrospinal fluid), a low intensity signal on T1-weighted images and the absence of restriction of the apparent diffusion coefficient (ADC). The enhancement kinetics is slow. Classically, a nodular peripheral enhancement is observed, as well as late, progressive, centripetal, full and persistent filling . This enhancement kinetics is also observed by contrast sonography and is reproducible and specific . At the arterial time, “bridged” contrast enhancement crossing the lesion may be associated with early peripheral contrast enhancement . According to Yamashita et al., the hemodynamic behaviour of hemangiomas depends on their inner structure and, in particular, on the size of the vascular spaces. Therefore, in cavernous hemangiomas, the diameters of the vascular spaces are significantly smaller in the early peripheral zones of enhancement in clusters compared with the central zone of progressive centripetal filling . Giant hemangiomas It consists of a cavernous hemangioma measuring over 4 cm in diameter . These hemangiomas may be the seat of thrombosis, liquefaction and fibrosis. A cystic cavity or central calcifications may appear. Internal septa are classically observed. The edges are regular without loss of parenchymatous volume or capsular retraction. In sonography, this lesion seems to be heterogeneous. In CT-scan, a heterogeneous, more hypodense central zone may be seen. In MRI, the hyperintensity on T2-weighted images may be modified by the presence of a hypointense central scar. The enhancement kinetics of giant hemangiomas is slow but identical to that of cavernous hemangiomas with nodular peripheral enhancement followed by centripetal filling that often remains incomplete. Flash filling hemangiomas Generally less than 2 cm in size. On CT, these lesions are normally iso- to hypodense on unenhanced scans. There is a quick, intense and homogeneous enhancement of the lesion in the arterial phase itself, hence the name "flash filling". In the rest of the phases, it retains the contrast and remains isodense to the adjacent vascular pool.
References
F. Caseiro-Alves, J. Brito, A.E. Araujo, P. Belo-Soares, H. Rodrigues, A. Cipriano, et al.Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis Eur Radiol, 17 (6) (2007), pp. 1544-1554 Y. Yamashita, I. Ogata, J. Urata, M. TakahashiCavernous hemangioma of the liver: pathologic correlation with dynamic CT findings Radiology, 203 (1) (1997), pp. 121-125
Findings
Well defined T1 hypointense/T2 hyperintense lobulated lesion noted in subcapsular region of segments VI and VII of right lobe of liver showing few areas of diffusion restriction. Markedly T2 hyperintense areas noted within the lesion. Another well defined subcapsular T1 hypointense/T2 hyperintense lesion noted in segment II of left lobe of liver. On contrast administration, the lesions show peripheral discontinous nodular enhancement on arterial phase and progressivew centripetal filling in on venous and delayed phases. Impression : Features suggestive of hepatic cavernous hemangiomas in segment VI, VII and II of liver.
Discussion
Detected by chance in most cases, the hepatic hemangioma is the most common non-cystic hepatic lesion. The incidence may reach 20% according to several autopsy series. In its typical form, the hemangioma is well known and does not raise diagnostic problems in imaging. However, certain “variants” and “atypias” may complicate the diagnosis. The hepatic hemangioma is a benign vascular lesion. In the vast majority of cases, it is non-evolving and does not require treatment or monitoring. Histologically, it is a mesenchymal lesion consisting of blood-filled vascular cavities of different size, surrounded by a simple layer of flat endothelial cells, supported by a fibrous connective tissue. This is a lesion consisting of large vascular spaces with a central cavernous zone, all the larger with a voluminous hemangioma, and not very extensive connective tissue. In general, this typical appearance is observed in lesions less than 3 cm in diameter. The outlines are sharp, well defined. In the sonograph, it is a hyperechogenic, homogenous lesion presenting a posterior acoustic enhancement. According to Yu et al., there is a correlation between the echogenicity of the lesion, its internal architecture and its hemodynamic behaviour. Therefore, the hyperechogenicity of cavernous hemangiomas seem to be related to the great many interfaces between the vascular spaces and the fibrous stoma as well as to the slower blood flow in the large vascular spaces. The majority of hepatic hemangiomas produced either no power Doppler signal or one that was minimal . In unenhanced CT, the density of the lesion is the same as that of the vessels. In MRI, the lesion presents an homogenous and high intensity signal on T2-weighted images (similar to that of the cerebrospinal fluid), a low intensity signal on T1-weighted images and the absence of restriction of the apparent diffusion coefficient (ADC). The enhancement kinetics is slow. Classically, a nodular peripheral enhancement is observed, as well as late, progressive, centripetal, full and persistent filling . This enhancement kinetics is also observed by contrast sonography and is reproducible and specific . At the arterial time, “bridged” contrast enhancement crossing the lesion may be associated with early peripheral contrast enhancement . According to Yamashita et al., the hemodynamic behaviour of hemangiomas depends on their inner structure and, in particular, on the size of the vascular spaces. Therefore, in cavernous hemangiomas, the diameters of the vascular spaces are significantly smaller in the early peripheral zones of enhancement in clusters compared with the central zone of progressive centripetal filling . Giant hemangiomas It consists of a cavernous hemangioma measuring over 4 cm in diameter . These hemangiomas may be the seat of thrombosis, liquefaction and fibrosis. A cystic cavity or central calcifications may appear. Internal septa are classically observed. The edges are regular without loss of parenchymatous volume or capsular retraction. In sonography, this lesion seems to be heterogeneous. In CT-scan, a heterogeneous, more hypodense central zone may be seen. In MRI, the hyperintensity on T2-weighted images may be modified by the presence of a hypointense central scar. The enhancement kinetics of giant hemangiomas is slow but identical to that of cavernous hemangiomas with nodular peripheral enhancement followed by centripetal filling that often remains incomplete. Flash filling hemangiomas Generally less than 2 cm in size. On CT, these lesions are normally iso- to hypodense on unenhanced scans. There is a quick, intense and homogeneous enhancement of the lesion in the arterial phase itself, hence the name "flash filling". In the rest of the phases, it retains the contrast and remains isodense to the adjacent vascular pool.
References
F. Caseiro-Alves, J. Brito, A.E. Araujo, P. Belo-Soares, H. Rodrigues, A. Cipriano, et al.Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis Eur Radiol, 17 (6) (2007), pp. 1544-1554 Y. Yamashita, I. Ogata, J. Urata, M. TakahashiCavernous hemangioma of the liver: pathologic correlation with dynamic CT findings Radiology, 203 (1) (1997), pp. 121-125
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!