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Liver hemangioma

Posted Tue, 06/30/2009 - 07:54 by Shweta Bhatt
Images

Fig 1. Contrast enhanced CT showing a hypervascular lesion .

Figure 2. Axial SPECT image from tagged RBC scan .


Clinical History:

61-year-old female with history of breast cancer, abnormal lesion in the liver seen on CT scan. Evaluation for hemangioma is requested.


Findings:

Figure 1. Contrast enhanced CT of the liver in a patient with known breast cancer shows a hypervascular lesion (arrow) with peripheral enhancement.

Figure 2. Axial SPECT image of the liver from a tagged Red Blood Cell (RBC) scan shows a single abnormal focus of increased radiotracer uptake in the right liver lobe posteriorly corresponding to an enhancing liver lesion seen on recent CT scan, consistent with hemangiomna .
(The patient's blood was drawn and labeled with the Ultra Tag RBC Labeling Kit with 21.5 mCi of technetium 99 sodium pertechnetate, and then administered intravenously. Subsequently, abdominal planar images were acquired in anterior, posterior, RPO, RAO, LAO, LPO, right lateral, and left lateral projection. Next, SPECT images were acquired in axial, coronal, and sagittal plane of the abdomen ).


Diagnosis:

Hemangioma


Discussion:

Cavernous hepatic hemangiomas are the most common primary liver tumors ranging from 0.4-20%. These tumors are typically asymptomatic and incidentally discovered at imaging, surgery, or autopsy. They may be solitary or multiple in upto 50% patients. They are typically smaller than 4-5cm , and if larger are referred to as the giant hemangiomas.

Hemangiomas have typical imaging features on ultrasound (US), CT and nuclear scinitgraphy. On US, they appear as uniformly hyperechoic , well defined lesions. They do not demonstrate any color flow within them , and if present , an alternate diagnosis such as metastasis or primary malignancy should be considered. Interestingly, the hemangiomas may appear as ‘hypoechoic’ lesions in fatty livers.

Hemangiomas have characteristic features on contrast enhanced CT. They demonstrate a peripheral, interrupted , intense , nodular enhancement during the arterial phase with progressive centripetal fill-in on subsequent imaging . This appearance is considered pathognomonic for hemangiomas. Hemangiomas which do not demonstrate these typical features may need further confirmation with nuclear scinitigraphy.
MRI is considered superior to CT in the diagnosis of hemangiomas. They demonstrate low intensity on T1 weighted sequence , and hyperintense to the liver on T2 weighted images, and remain bright on increased TE (echo time). Contrast enhancement features are similar to CT.
Red blood cell-tagged technetium-99m (99m Tc) scintigraphy with single photon emission CT (SPECT) scanning permits a specific diagnosis of hemangiomas (1). The lesions characteristically show decreased activity on early dynamic images and delayed filling from the periphery of the lesion.

Most hemangiomas are managed conservatively.


References / Suggested Reading:

1. el-Desouki M, Mohamadiyeh M, al-Rashed R, Othman S, al-Mofleh I. Features of hepatic cavernous hemangioma on planar and SPECT Tc-99m-labeled red blood cell scintigraphy. Clin Nucl Med. Aug 1999;24(8):583-9.


Author

Shweta Bhatt, MD and Vikram S Dogra, MD

Assistant Professor (SB) and Professor (VSD) of Radiology

University of Rochester , Rochester, NY

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