Hepatic hemangioma is a relatively common benign liver tumors, cavernous hemangioma is the most common clinical, natural populations autopsy found that the rate of 0.35-7.3%, accounting for 5-20% of benign tumors of the liver. Recent years, with increased awareness of healthy and a variety of diagnostic imaging technology advances, the detection rate of asymptomatic hemangioma was significantly increased in most cases the clinical symptoms or mild symptoms, longer duration, slow growth, the prognosis is good.
Disease Introduction
Hepatic hemangioma is a relatively common benign liver tumors, cavernous hemangioma is the most common clinical, natural populations autopsy found that the rate of 0.35-7.3%, accounting for 5-20% of benign tumors of the liver. Recent years, with increased awareness of healthy and a variety of diagnostic imaging technology advances, the detection rate of asymptomatic hemangioma was significantly increased in most cases the clinical symptoms or mild symptoms, longer duration, slow growth, the prognosis is good. currently the basis of the disease not lack of mature and rigorous standards of diagnosis and treatment and clinical research, treatment programs, to adapt to the characteristics defined exist many fuzzy or even wrong understanding, the traditional surgical treatment with radiofrequency ablation, hepatic arterial embolization, radiation therapy, surgery microwave curing surgery, freezing and hardening agent injection therapy and other treatment coexist, treatment options has not yet formed a more uniform clinical pathway for the doctor-patient choice. [1] [2] Causes of morbidity
Exact exact causes of hepatic hemangioma is not clear, there are several theories: (a congenital anomaly: The Theory of the majority of scholars believe that hemangioma occur as a congenital liver, peripheral vascular malformation is generally believed that in during embryonic development due to hepatic vascular abnormalities caused by abnormal proliferation of vascular endothelial cells and formation of hepatic hemangioma (2 hormonal stimulation theory: the scholars observed in female puberty, pregnancy, oral contraceptives, which will enable the growth of the hemangioma faster that one of the pathogenic mechanisms of the female hormones may hemangioma (3 Other: such as the capillary tissue infections deformation, leading to telangiectasia, focal necrosis of liver tissue blood vessels to dilate to form the vacuole, and its surrounding vascular congestion expansion, intrahepatic regional blood circulation stagnant, causing blood vessels to form a sponge-like expansion. [3] [4] Classification of Diseases
Hepatic hemangioma based on the number of its fibrous tissue pathology can be divided into 4 types: (1 cavernous hemangioma is the most common type, (2 sclerosing hemangioma (3 vascular endothelial cell tumor (capillary hemangioma. such rare use of the classification according to diameter size: <5cm (small blood vessels in tumors, 5-10cm (hemangioma, 10cm-15cm (giant hemangioma,> 15 cm (large hemangioma, may have some guidance hepatic hemangioma in patients with the significance of the treatment program, to provide an effective reference for the diagnosis and treatment of hepatic hemangioma. [5] Disease hazards
Hepatic hemangioma can onset at any age, 30-50 years old, common, reported in the literature more women than men, male to female ratio of about 1:3-6. 53,859 cases of the healthy population medical data analysis shows that the occurrence of hepatic hemangioma rate of 3.11%, the incidence of men and women fairly (3.36% vs 2.88%, P> 0.05, this phenomenon is different from the results reported in the literature may be related to previous reports in the literature are outpatient or inpatient exposure cases. large sample of the population census, the majority of hemangioma is not the statistics included in-depth analysis of men and women the size of the hemangioma of the census cases, you can see the> 5cm of cases of hepatic hemangioma accounted for the proportion of all cases women is 2.56 times that of men (2.90% vs 1.26%, P> 0.05, this result supports the previously envisaged. further analysis of visible when the relationship between age and the incidence increases with age, increased incidence of 40-60 years of age and reached the peak and subsequent decline. possible explanation of this phenomenon with increasing age, the initial is more difficult to detect occult hemangioma due to the gradual growth checks, so that the increased incidence of after 40-60 years of age, some vascular tumors stop growing and even some of the hemangioma has subsided caused by the incidence of decline. this phenomenon in the analysis of 131 cases over 5 years of follow-up, with increasing age, hemangioma increased the proportion of cases decreased significantly, the extent of vascular tumor diameter increased also significantly reduced. found in the analysis of the relationship of gender, age, and hemangioma size women hemangioma hemangioma in all ages than men, and increases the size of the hemangioma with age and significantly increased to 40-60 years of age and reached the peak, after a slight narrowing from the above information is not difficult to come to hemangioma development may be subject to changes in hormone levels, the effects of estrogen may be more significant, which may also explain why women the incidence is much higher than men's reason in diameter> 5cm liver hemangioma, [6] [7] [8] Symptoms of the disease
Most hepatic hemangiomas without obvious symptoms, and more healthy routine B-ultrasound or abdominal surgery, there is no evidence that they have may be malignant, but even to be confused with other malignant tumors of the liver could result in misdiagnosis when hemangioma increased to more than 5cm, it may be non-specific abdominal symptoms, including: (1 abdominal mass: the mass capsule sexy, no tenderness, surface smooth or not smooth mass in the Ministry of auscultation can sometimes hear the conduction vascular murmur, (2 gastrointestinal symptoms: the right upper abdominal pain and discomfort, and loss of appetite, nausea, vomiting, belching, food inflation saturated indigestion, (3 compression symptoms: a huge hemangioma of the surrounding tissue pushing and oppression. oppression of the lower esophageal dysphagia, compression of the extrahepatic bile duct, obstructive jaundice and gallbladder effusion, compression of the portal venous system and organ, splenomegaly and ascites, the oppression of the lungs breathing difficulties and lung , the oppression of the stomach and duodenum, gastrointestinal symptoms, (4 hepatic hemangioma rupture, severe abdominal pain may occur, as well as bleeding and symptoms of shock, is one of the most serious complications, mostly growth leading to rupture due to external bleeding in the costal arch following a large hepatic hemangioma is extremely rare, (5Kasabach-Merritt syndrome, hemangioma accompanied by thrombocytopenia, a large number of clotting factor consumption coagulopathy caused its pathogenesis retention of blood within giant hemangiomas, consume a lot of red blood cells, platelets, clotting factors II, V, Ⅵ and fibrinogen, causing abnormal clotting mechanism can be further developed of DIC (6 Other: free vascular pedicle growth in the extrahepatic torsion, the tumor can occur in necrosis, severe abdominal pain, fever and prostration appears. individual patients because of the hemangioma, arteriovenous fistula formation, to lead the increased Rhodobryum and increase the burden on the heart, causing heart failure and death. another rare the hemobilia those in [9] Assistant examination
Lack of specific clinical manifestations of hepatic hemangioma, imaging studies (eg, B-ultrasound, CT, MRI diagnosis of hepatic hemangioma comprehensive literature reports suggest hepatic hemangioma B ultrasonic diagnosis rate of 57.0% -90.5%, ultrasound imaging 94%, CT 73.0% -92.2%, MRI was 84.0-92.7%, hepatic arteriography was 62.5%. B ultrasound
Ultrasonography cheap, simple, universal rate, non-invasive pain, safe and reliable, short-term repeated dynamic observation of lesions change to get more information, it is of CT, MRI is less than B-ultrasonography of the liver hemangioma mostly hyperechoic and hypoechoic more reticular, homogeneous density, morphological rules, clear boundaries and a large hemangioma section lobulated internal echo still increase mainly was pipe network, or irregular nodular or block section of low echo area, and sometimes also calcified hyperechoic and posterior shadowing, Department of endovascular thrombosis, due to machine or calcification. Imaging ultrasound
In recent years, the role of contrast ultrasound in differential diagnosis of liver placeholder gradually being recognized by the majority of doctors. Typical imaging findings of hepatic hemangioma cases could be considered selective liver contrast ultrasound. Typical hemangioma ultrasound contrast performance for the arterial phase in the peripheral nodular or ring enhancement with time and increasing the range gradually extended to the center, this extension is a slow process, portal and delayed phase lesions is still in the enhanced echo is equal to or higher than the surrounding liver tissue This 'slow-slow-out' enhanced features enhanced spiral CT is similar to the sensitivity, specificity and accuracy of the reported imaging ultrasound of small hepatic hemangiomas of 100%, 87%, 94%. Enhanced spiral CT
CT scan to check the performance of liver parenchyma within the realm of clear round or oval low-density lesion, a small number of irregular shape, the CT value of about 30HU dynamic CT or spiral CT contrast enhancement scanning the majority of specific typical performance: rapid injection of contrast agent after 20-30s, early arterial phase the lesion edge nodular enhancement, enhanced the enhanced density of the density is higher than the normal liver, with the time after contrast injection, 50-60s into the portal vein of enhanced contrast-enhanced mutual integration of the stove, gradually advancing to the lesion center, the strength decreased, delayed scanning after a few minutes, the entire tumor is homogeneous enhancement, enhanced density continues to decline, may be higher or equal to the surrounding normal liver parenchyma enhanced density, contrast enhanced the process of 'spare' features some of the cavernous hemangioma, irregular low-density areas, however, around the tumor, the Ministry of the tumor whether the center could be enhanced in the delayed scan still shows the characteristics of this 'spare'. MRI
Showed low signal on MRI, T1-weighted, T2-weighted high signal strength uniform, sharp edges, contrasting with the surrounding liver has been described as 'light bulb' sign, which is a vascular tumor in MRI specificity of MRI dynamic scanning enhanced mode with CT. When the characteristic findings of CT and MRI have made it clear diagnosis, you do not have to be OK other expensive or invasive, but also to avoid liver biopsy. Other
Liver biopsy as low accuracy and can lead to bleeding, hepatic arteriography is an invasive, no more need to appear in recent years, the whole body positron emission tomography (PET / CT, exclude metabolically active malignant. [10] [11] Differential diagnosis
Hepatic hemangioma main differential diagnosis: Primary or metastatic liver cancer
Primary liver cancer often have chronic hepatitis B, a history of cirrhosis of the liver, abnormal liver function and AFP increased metastatic liver cancer, multiple, and often the digestive system of primary lesions, Liver hydatid disease
Patients with pastoral areas of life history, sheep, dogs history of exposure to hepatic hydatid intradermal test (Casoni test was positive, eosinophil count increased, Hepatic non-parasitic cysts
Isolated single liver cyst with hepatic hemangioma identification, only a handful of polycystic liver sometimes may be associated with hepatic hemangioma confusion. Merger polycystic kidney disease polycystic liver 50%, lesions from the beginning is the multiple, mostly covered with liver ultrasound CT examination showed lesions of varying sizes, the boundary is smooth and complete cysts, there may be hereditary factors. Other
Hepatic adenoma, hepatic vascular endothelial cell sarcoma are rare. The slow development of the former, but hard lumps, like rubber, which developed rapidly, with malignant tumor characteristics more common in young people. [12] [13] Surgery
There is considerable controversy on the treatment of hepatic hemangioma, hemangioma resection hemangioma ligation, hepatic artery ligation, microwave curing technique, radiofrequency ablation, hepatic artery embolization and other diffuse hepatic vascular tumor or unresectable giant hemangiomas, such as liver function decompensation or merger of Kasabach-Merritt syndrome, but also feasible and liver transplantation in the treatment of hepatic hemangioma in need of treatment, should be a variety of factors to consider in order to benefit the patients. safe and effective principles, based on the doctor's technical capability and experience, the trade-off between a variety of factors, choose a different treatment. below only the different treatment: resection of hepatic hemangioma effect of surgical resection are reliable, secure, complete resection is the only cure. With the development of surgical techniques, surgery-related complications and mortality has been low. Nevertheless, surgery still strict indications. common surgical procedure included resection of hepatic segments. The hemangioma stripping surgery, laparoscopic liver resection of hemangioma ligation, and liver transplantation. Liver segment resection
With the improvement of the development of surgical techniques and liver surgery techniques, liver resection mortality and complications are greatly reduced, the application has been expanded to the benign lesions of the liver, hepatic hemangioma is the most common application of liver resection and liver benign lesions of hepatic hemangioma patients without a history of liver cirrhosis, the liver compensatory function can tolerate a wide range of liver resection for giant hepatic hemangioma or multiple hemangioma is usually possible rules hepatic segment, lobe of the liver liver resection, even half of the liver resection, liver resection should not exceed the 70% -75% of the total hepatic segmentectomy main problem is the treatment of hepatic hemangioma, control of bleeding due to vascular tumor blood supply, the tumor itself is easy bleeding , thereby increasing the difficulty of operation, and sometimes surgery can lead to improper operation is difficult to control bleeding, how to control bleeding is the key to the success of the procedure. Hepatic hemangioma cystectomy
Mostly hepatic hemangioma expansive growth, may compress the normal liver tissue and bile ducts, blood vessels form a thin fibrous capsule, the blood vessels of the interface is less obtuse line separation along the interface, stripping out the hemangioma, which is 'vascular cystectomy outside the tumor capsule can be achieved by less bleeding, the purpose of complete excision of the lesion 1988 Alper first reported surgical dissection of the liver resection and vascular tumors, clinical studies of multiple samples found that: dissection, operative time, blood loss and transfusion volume was significantly less than the liver resection, liver damage light and maximize the retention of normal liver tissue, faster postoperative recovery of liver function, reduce the important intrahepatic vascular and duct injury, reduce bleeding, reduced the incidence of biliary fistula, currently advocated by many scholars at home and abroad, has become the surgical treatment of hepatic hemangioma. rules hepatectomy only for suspected malignancy, or a lobe of the liver completely tumor occupied. However, some scholars believe that the gap between the hemangioma of the liver parenchyma is difficult to confirm in some cases, surgery, stripping may be more bleeding, especially near the hepatic vein, liver after inferior vena cava structure hemangioma, blunt dissection is easy to tear the large blood vessels or damage tumor, resulting in difficult to control bleeding. expert opinion: (1) tumor located in the outer leaves of the left hepatic liver resection should be selected due to the operation more simple. hemangiomatosis confined to a lobe of the liver, hepatic resection, such a case-by removal of the tumor, injury, bleeding and time-consuming, (2) the right hepatic resection technology is relatively complex, trauma, liver right lobe hemangioma cystectomy than liver resection have an advantage, (3) hemangioma of the liver the middle near the hepatic portal not only close to the liver with access to large vessels, may also invaded the left and right lobe hepatectomy for such the tumor is even more intractable, cystectomy can not only effectively prevent damage to the pipeline of the hepatic hilum, but also having to removal of excessive normal liver tissue and significantly reduced blood loss, (4) The volume of a huge hemangioma should hepatectomy surgery. giant hemangiomas occupy the left hepatic lobe or right lobe of a liver segment, the oppression of the liver tissue, normal liver tissue remaining lesions where the lobe of the liver or liver segment the same regularity lobe of the liver or liver segment resection Buzhi Yu lose a lot of normal liver tissue, but also to avoid the tumor capsule excision may lead to or larger blood vessels tear bleeding, can not be ruled out (5) preoperative liver metastasis of primary liver cancer or other parts of the malignancy is suspected, The rules should be OK hepatic resection or local excision of a certain 'safe surgical margin, (6) distributed in different lobe or multiple hemangiomas of the liver segment can be combined with the use of two surgical methods. Laparoscopic liver resection
Laparoscopic liver resection technology has become increasingly mature, their trauma, fewer complications, quicker recovery and minimally invasive advantages are clear, the application rate is increasing year by year. Postoperative complications of abdominal surgery and rapid postoperative recovery, hospital a short time. laparoscopic liver resection of the left lateral lobe and the left half is expected to become the standard surgical treatment of hepatic hemangioma. parts of the right hepatic posterior lobe of the liver and caudate lobe of liver hemangioma, due to a unique position, easy to major bleeding occurred, total laparoscopic liver resection is still a certain degree of difficulty. Although laparoscopic liver resection limited the scope of the treatment of hepatic hemangioma, however, with the development of laparoscopic techniques and breakthroughs, laparoscopic liver resection of hepatic vascular tumors of this surgical approach will have broad application prospects. Orthotopic liver transplantation
Hepatic hemangioma is a benign disease, liver transplantation is used only for unresectable giant hepatic hemangioma and serious complications such as Kasabach-Merritt syndrome is not yet extensive. Ligation
Hepatic hemangioma ligation of hepatic hemangioma ligation hemangioma ligation so that the tumor shrinking machine, and even disappear, in order to achieve the objective of the treatment of hemangioma. Due to previous lack of awareness of the anatomy of the liver, blood vessels the tumor banded gastroplasty, tumor smaller pro bundle the longer, the better, while the tumor the greater, bundling the shorter the period, the effect is worse. simple vascular aneurysm ligation recurrence rate is very high. now do not recommend routine use. Hepatic artery ligation
Hepatic hemangioma is usually by the hepatic artery, hepatic artery ligation temporarily shrink the tumor softened. Combined with postoperative radiotherapy can make tumor machine of hard to improve the symptoms, control of tumor growth, but because of the collateral circulation the presence, efficacy and more difficult to maintain long-term effects is limited. hepatic artery ligation for unresectable giant hemangiomas. the adoption of new technologies in recent years, previously considered unresectable hemangioma is now in a good position in the technical conditions hepatobiliary surgery center safe removal, it is simple to hepatic artery ligation treatment of hepatic hemangioma is rarely used. Complication
Postoperative abdominal bleeding mostly occurred in less than 24h, postoperative common and serious complications, the need to pay particular attention to hepatic hemangioma patients without cirrhosis the basis of preoperative liver function, postoperative coagulation disorders cause bleeding less, most caused by intraoperative hemostasis or vascular ligature. laparotomy for postoperative bleeding hemangioma, vascular suture tight suture suspicious bleeding, after close attention to the bleeding. bile leakage after hepatic hemangioma stripped postoperative wound, surgery failed to find and ligation of a branch of the small bile duct is the main cause of bile leakage after hepatic hemangioma bile leakage need to keep the drainage open. generally self-healing when required percutaneous catheter drainage, postoperative liver dysfunction or failure is often associated with preoperative failure to fully assess the residual liver volume, associated with other underlying liver disease, massive hemorrhage, long time, hypotension, intraoperative injury to retain the lobe of the liver's hepatic or liver blood vessels, postoperative portal vein thrombosis, residual liver to reverse the impact of hepatic blood flow. hepatic hemangioma in patients undergoing hepatic portal occlusion control of hepatic artery and the majority of patients with postoperative transaminase elevation, reached a peak 2-3 days after surgery, usually in about one week to the normal range, some patients may also bilirubin slightly elevated, and more able gradually improved by protecting liver support treatment if difficult to reverse the liver failure, the only way to emergency liver transplant. [14] [15] [16] Non-surgical treatment
Hepatic arterial embolization (TAE
TAE treatment of hepatic hemangioma is borrowed from the experience of TAE treatment of liver cancer, the theory is based on the Hepatic Hemangioma with intratumoral hepatic artery embolization, arterial thrombosis, thrombotic mechanisms of fibrosis to tumor formation fibroma-like structure to achieve the narrowing, hardening of the purpose of the hemangioma. TAE treatment of hepatic hemangioma is still controversial, the reason is the long-term effects of a large hemangioma, it is difficult to make tumor regression machine of embolic agents to patients in the hemangioma from embolization at the same time, often involving the normal blood supply of the hilar and intrahepatic bile ducts, can cause serious complications such as biloma, hepatic necrosis, hepatic abscess, biliary cirrhosis, biliary stenosis and ischemic bile duct artery fistula. at the same time, the hardening of the arteries agent Pingyangmycin side effects, though small, but caused side effects of pulmonary fibrosis and high-dose intra-arterial damage artery intima can not be underestimated. Surgery and radiofrequency treatment of hepatic hemangioma microwave curing
Microwave coagulation of liver hemangioma surgery and radiofrequency treatment of microwave can be converted to heat energy leaving the surrounding tissue condensation tumor local shrink, harden, to achieve the purpose of curing the tumor using this method must block the first hepatic portal in order to reduce intratumor blood flow. large hepatic hemangioma, microwave treatment is difficult to be tumor completely cured, the recurrence rate is higher. RF principles and microwave, small hemangioma treatment effect can still> 8cm treatment ineffective, or even will lead to bleeding. organization of the aneurysm wall was thin, less fibrous tissue tumor puncture prone to uncontrollable bleeding, microwave coagulation or radiofrequency treatment contraindications. microwave coagulation and radiofrequency ablation of hepatic hemangioma can cause a large number of red blood cell destruction release large amounts of hemoglobin can cause acute renal failure and blood-red once white urine. Therefore, B ultrasound-guided percutaneous microwave coagulation or radiofrequency treatment of hemangioma should be very careful near the large vessels of the tumor in the liver center and near the gallbladder gastrointestinal and other organs as well as near the diaphragm could easily cause damage adjacent organs lead to serious complications, not suitable for radiofrequency ablation. [17] [18] Expert opinion
With in-depth understanding of the natural history of hepatic hemangiomas, right time of their surgery and indications of a new and different perceptions. Hemangioma treatment focuses on how to relieve symptoms and preventive control giant multiple hemangioma caused by concurrent disease and bleeding possible, should also give full consideration to the complications may be brought about by the different treatment options, especially on controversial in patients with clinical symptoms and signs, do not over-treatment, lead to unnecessary complications of hepatic hemangioma the treatment to testify in the current confusion, to determine the diameter, that the> 4-5cm should be treated surgically, to determine the symptoms and complications from the information available, the majority of hemangioma symptoms are not specific , difficult to be differentiated from the gastrointestinal tract and biliary symptoms, vascular tumor diameter less than 5cm less likely to cause symptoms, the left hepatic and caudate lobe in diameter greater than 6cm when clear symptoms of hemangioma, while the right hepatic The hemangioma appeared to 8cm above the surgical indications are that: (1) right hepatic> 8cm, the left liver and caudate lobe> 6cm, there are clear symptoms or exogenous growth rate of> 1-2cm / year (2) vascular tumor diameter greater than 10cm, (3) complications such as infection, fever, bleeding and significant hematologic abnormalities, (4) age greater than 60-year-old patient, the hemangioma may no longer grow or growth slow, so the indications should be made more stringent. (5) In view of the hepatic hemangioma may be accelerated increase during pregnancy tumor rupture can be caused by childbirth bleeding, so the young women of giant hepatic hemangioma should be positive surgical resection. ( 6) engaged in strenuous exercise, such as boxers, football players may consider surgical resection follow-up (7) found that tumor growth is faster, can not except other lesions may clear clinical symptoms, exogenous, fast growth and hair with hematological abnormalities should these patients the indication for surgery in the treatment of hepatic hemangioma, hemangioma stripping operation on security, thoroughness, bleeding, blood transfusion, and hospital stay were significantly better than resection of the hemangioma located on the edge exogenous and the left hepatic lobe can be applied to laparoscopic resection in order to achieve the trauma, quicker recovery purposes. TAE and certain efficacy and minimally invasive advantages of small blood vessels in tumor therapy, <5cm hemangioma often do not have treatment, but poor long-term effects of TAE treatment of hemangioma, serious complications can occur and increase the surgical treatment more difficult. suggested that even if the physical findings of hepatic hemangioma, but also with reference to the indications for surgery treatment decisions , interventional treatment in selective cases, such as old age, systemic complications, surgical contraindications, giant hemangioma inoperable, and the strong demand of patients. In short, the diagnosis and treatment of hepatic hemangioma in progress, as the liver common diseases and frequently-occurring disease, the clinical attention, the attitude of the treatment should be cautious and strict attention and other liver lesions, especially malignant disease identification.
