Male 48 years-old with central 12,5 cm hemangioma ( Segments IV a, V,VIII) that is growing since 2013 , respectivelly 6,5 to 8,5 to 12,5 cm of diameter very close as vena cava as right and medium hepatic veins. Hiv + but under control, oligosymptomatic (tenderness and palpable mass em rh). Left hepatic lobe is small to perform right trisegmentectomy. He was submitted to embolization without sucess by other colleague. Should we resect this giant hemangioma? If positive do we perform Enucleation or even mesohepatectomy? With or without total vascular exclusion? Do we need to reserve lung-heart machine? Is worthwhile right portal embolization to performe right trisegmentectomy? Is whorthwile to reserve autotransfusions like "cell saver"?
I would not consider surgery for him. I will keep following. Its a benign tumor with high-risk for surgical resection and extremely low risk if observation only.
The main apprehension of this patient is the necessity of liver transplantation on the future. He said me with him owner words "Doctor i know that my disease is benign but its behaviour is malign and it grows each year more and more. i am afraid of this growth.
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Well, anyway we must be afraid of a major operation for a benign tumor. If you follow him closely with the same type of study at the same place we may see the real growing rate of the hemangioma and decide for the optimal treatment. At the present date, the risk of surgery is still greater than the benefit.
Are you sure that his is actually an hemangioma or could be an hemangioendothelioma?
Tanks a lot for your attention prof. Marcel. This diferentiall diagnosis always worried me since first visit at my office , however there are no classical findings of hepatic hemangioendothelioma as capsular retraction, lollipop aspect or calcifications. However., we should remind this patient underwent embolization of this lesion that could modify radiological findings. Really, to confirm heh, we would need any type of biopsy and imunohistochemistry pannel. Would you indicate biopsy for this case? What via? Puncture by means fine-needle for example i am afraid because material could be insuficient for definitive analysis and there is risks too as chance of bleeding.
May be PET-CT could help us to evaluate HEH. But, we need to remind that inflammatories settings may also occur in hemangiomas due inflamation or infarct. These settings may leave a false -positive findings too.
Could you post some images of the MRI? It may help us..
I will try to post for you to aim we think together about best solution for this case. This patient should be realizing hepatic volumetry by means TC, i think that he will come back as soon as possible because he is very worried and desperate with him situation. Tanks a lot once more.
Both enucleation and liver resection are safe and effective surgical treatments for liver hemangiomas larger than 10 cm. The risk of intraoperative blood loss is related to adjacency to major vascular structures and the location of hemangioma.
hi
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Haemangioma is the most common liver tumour. Treatment is indicated for symptomatic tumours, rapid increase in size, rupture or doubt in diagnosis. There is continuing debate regarding the ideal method of surgical treatment for liver haemangiomas, with some surgeons favouring enucleation over liver resection.
Haemangioma is the most common liver tumour. Treatment is indicated for symptomatic tumours, rapid increase in size, rupture or doubt in diagnosis. There is continuing debate regarding the ideal method of surgical treatment for liver haemangiomas, with some surgeons favouring enucleation over liver resection.
I agree with yours comentaries. I think that enucleation is a very good option mainly by means laparoscopic approach. In fact, hemangioma generally presents a capsule. Nevertlhess, on this case the lesion is very large very close to major vital structures as vena cava as hepatic veins, and the worst this patient underwent hemangioma embolization. We have seen very inflamatory reaction in these cases that makes difficult enucleation.Therefore, i think two things about this case : first - to resect by means enucleation should be no easy and second enucleation should be dangerous. I would feel safe to perform an anatomic resection with total vascular exclusion and to reserve heart-lung machine if were necessary.
Choice for performing or enucleation either anatomic resection is only tactic. For example : giant hemangioma depply situated into right lobe is a case to perform righ hepatectomy, for the other hand giant hemagioma very superficial lesion on left lobe is a case to perform enucleation mainly for laparoscopic via.
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