Answer for BIR CoW 06 Feb 2022
Giant Hemangioma of liver
Findings
Evidence of T1 hypointense, T2 hyperintense large lesion of size 16.7 cm (mediolateralx9.17cm (anteroposterior) x 14.8 cm(craiocaudal) noted involving segment 4,5,8 2 ,of liver without restricted diffusion and with high ADC values Multiple T2 hyperintense lesion noted involving segment 6 and 7 of liver On contrast administration lesion shows peripheral nodular enhancement on late arterial phase with progressive filling in subsequent phase Smaller lesion measuring 3.4x 1.6 cm segment noted in 6 & another smaller lesion of size 1.9x1.4 cm segment 7 of liver they are showing peripheral nodular enhancement in late arterial phasecentripetal filling in delayed phases.
Discussion
The term giant hemangioma is reserved for lesions larger than 5 cm. Hemangiomas are the most common benign tumors of the liver, with a prevalence of upward of 20% . They have a female-to-male predominance of 2–5:1 . Although many patients are asymptomatic, patients can present with right upper quadrant symptoms of pain or fullness. MR imaging also has high sensitivity (98%–100%) and specificity (92%–98%) in the diagnosis of hemangiomas MR imaging findings of giant hemangiomas are closely correlated with the macroscopic appearance, which demonstrates changes such as hemorrhage, thrombosis, extensive hyalinization, liquefaction, and fibrosis. The central cleftlike area may be due to cystic degeneration or liquefaction Lesions demonstrate low signal intensity on T1-weighted images and markedly high signal intensity on T2-weighted images; these signal intensity characteristics are likely due to slow flow within the lesion . Hypointense internal septa are commonly seen in giant hemangiomas. Lesions have well-defined contours, which can be round or lobular. Many lesions have a central scar, which remains hypointense on contrast-enhanced images. It is not uncommon for giant hemangiomas to have central loculations or clefts of high signal intensity on T2-weighted images ; the high signal intensity is higher than that of the surrounding hemangioma parenchyma and can be as bright as cerebrospinal fluid. These clefts are thought to represent areas of cystic degeneration or liquefaction . Gadolinium-enhanced imaging demonstrates three patterns of enhancement, which are similar to those of CT. The first pattern is immediate homogeneous enhancement, which represents so-called flash-filling hemangiomas. The second pattern is the classic peripheral nodular enhancement with centripetal filling. The third pattern is similar to the second, with the exception of a persistent central area of low signal intensity . The central area of low signal intensity represents a central scar in many lesions. Complications : Inflammatory changes Intralesional hemorrhage Intraperitoneal hemorrhage Potential volvulus of a pedunculated lesion. Kasabach-Merritt syndrome is a consumptive coagulopathy with intravascular coagulation, clotting, and fibrinolysis within the hemangioma. This process can spread from the lesion systemically, resulting in death in 20%–30% of patients
REFERENCES:
Giant Cavernous Hemangioma Prasanth M. Prasanna , Scott E. Fredericks, Steven S. Winn, Robert A. Christman Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation Valérie Vilgrain, Leila Boulos, Marie-Pierre Vullierme, Alban Denys, Benoît Terris, Yves Menu
Findings
Evidence of T1 hypointense, T2 hyperintense large lesion of size 16.7 cm (mediolateralx9.17cm (anteroposterior) x 14.8 cm(craiocaudal) noted involving segment 4,5,8 2 ,of liver without restricted diffusion and with high ADC values Multiple T2 hyperintense lesion noted involving segment 6 and 7 of liver On contrast administration lesion shows peripheral nodular enhancement on late arterial phase with progressive filling in subsequent phase Smaller lesion measuring 3.4x 1.6 cm segment noted in 6 & another smaller lesion of size 1.9x1.4 cm segment 7 of liver they are showing peripheral nodular enhancement in late arterial phasecentripetal filling in delayed phases.
Discussion
The term giant hemangioma is reserved for lesions larger than 5 cm. Hemangiomas are the most common benign tumors of the liver, with a prevalence of upward of 20% . They have a female-to-male predominance of 2–5:1 . Although many patients are asymptomatic, patients can present with right upper quadrant symptoms of pain or fullness. MR imaging also has high sensitivity (98%–100%) and specificity (92%–98%) in the diagnosis of hemangiomas MR imaging findings of giant hemangiomas are closely correlated with the macroscopic appearance, which demonstrates changes such as hemorrhage, thrombosis, extensive hyalinization, liquefaction, and fibrosis. The central cleftlike area may be due to cystic degeneration or liquefaction Lesions demonstrate low signal intensity on T1-weighted images and markedly high signal intensity on T2-weighted images; these signal intensity characteristics are likely due to slow flow within the lesion . Hypointense internal septa are commonly seen in giant hemangiomas. Lesions have well-defined contours, which can be round or lobular. Many lesions have a central scar, which remains hypointense on contrast-enhanced images. It is not uncommon for giant hemangiomas to have central loculations or clefts of high signal intensity on T2-weighted images ; the high signal intensity is higher than that of the surrounding hemangioma parenchyma and can be as bright as cerebrospinal fluid. These clefts are thought to represent areas of cystic degeneration or liquefaction . Gadolinium-enhanced imaging demonstrates three patterns of enhancement, which are similar to those of CT. The first pattern is immediate homogeneous enhancement, which represents so-called flash-filling hemangiomas. The second pattern is the classic peripheral nodular enhancement with centripetal filling. The third pattern is similar to the second, with the exception of a persistent central area of low signal intensity . The central area of low signal intensity represents a central scar in many lesions. Complications : Inflammatory changes Intralesional hemorrhage Intraperitoneal hemorrhage Potential volvulus of a pedunculated lesion. Kasabach-Merritt syndrome is a consumptive coagulopathy with intravascular coagulation, clotting, and fibrinolysis within the hemangioma. This process can spread from the lesion systemically, resulting in death in 20%–30% of patients
REFERENCES:
Giant Cavernous Hemangioma Prasanth M. Prasanna , Scott E. Fredericks, Steven S. Winn, Robert A. Christman Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation Valérie Vilgrain, Leila Boulos, Marie-Pierre Vullierme, Alban Denys, Benoît Terris, Yves Menu
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!