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Management of Giant Hepatic Haemangioma By Dr. Hung Shun Tak Department of Surgery Princess Margaret Hospital.

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Presentation on theme: "Management of Giant Hepatic Haemangioma By Dr. Hung Shun Tak Department of Surgery Princess Margaret Hospital."— Presentation transcript:

1 Management of Giant Hepatic Haemangioma By Dr. Hung Shun Tak Department of Surgery Princess Margaret Hospital

2 Introduction First described by Ambroise Pare in 1570 Most common benign tumors of liver Incidence in autopsy ranging from 0.4% to 7.3%* Age: third & sixth decade, with predominance in the fourth decades Women to men ratio: 4:1 to 6:1** Giant haemangioma** is defined as haemangioma with size > 4cm*** *Ishak KG, Rabin L. Benign tumors of the liver.Med Clin North Am 1975;59:995–1013. **Adam YG, Huvos AG, Forrter JG. Giant hemangiomas of the liver. Ann. Surg. 1970;172:239–245 ***Kawarada Y, Mizumoto R. Surgical treatment of giant hemangioma of the liver. Am J Surg 1984; 148:287–91

3 Management of Giant Hepatic Haemangioma Presentation Imaging Indications Treatment Modalities

4 Presentation Asymtpomatic; uncomplicated Pain: unclear mechanism, ? Increasing size or intratumoral thrombosis or haemorrhage secondary distension of liver capsule Pressure symptoms: nauseas, vomiting, early satiety, or weight loss

5 Presentation Complication: Spontaneous or traumatic rupture 33 case reports of spontaneous rupture in adult, but the mortality rate is about 75%* Kasabach Merritt Syndrome Malignant transformation has not been reported *Ribeiro AF M., et al. Spontaneous rupture of hepatic hemangiomas: A review of the literature. World Journal of Hepatology 2010 December 27; 2(12)

6 Management of Giant Hepatic Haemangioma Presentation Imaging Indications Treatment Modalities

7 Diagnosis Incidental findings of abdominal imagings Majority of haemangioma would be managed non- operatively due to its benign course Accurate diagnosis of haemangioma is essential

8 Imaging UltrasonographyContrast Computed Tomography Magnetic Resonance ImagingRed Cell Scan Imaging Source: Google picture

9 Ultrasonography Heterogenous area interspersed within an hyperechoic mass Source: Márcio Martins MachadoI; Ana Cláudia Ferreira Rosa. Liver hemangiomas: ultrasound and clinical features. Radiol Bras vol.39 no.6 São Paulo Nov./Dec. 2006

10 Contrast Computed Tomography Source: Dario Ariel TiferesI; Giuseppe D'Ippolito. Liver neoplasms: imaging characterization. Radiol Bras vol.41 no.2 São Paulo Mar./Apr. 2008

11 Magnetic Resonance Imaging Source: Dario Ariel TiferesI; Giuseppe D'Ippolito. Liver neoplasms: imaging characterization. Radiol Bras vol.41 no.2 São Paulo Mar./Apr. 2008

12 MRI : Centripetal Enhancement Post-contrast Source: Learning radiology.com

13 Certainty of Diagnosis Uncertain diagnosis due to atypical features of imagings Diagnosis of haemangioma was established by USG in 57%, by CT scan 73% of patients* Red blood cell ( RBC ) or MRI scans regarded as the most accurate imaging tools *Yoon SS, Charny CK, Fong Y, Jarnagin WR, Schwartz LH, Blumgart LH, et al: Diagnosis, management, and outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg 2003; 197: 392–402. **Book: Surgical Management of Hepatobiliary And Pancreatic Disorders, Chapter 10: Diagnosis and management of haemangiomas of liver **SensitivitySpecificity Contrast CT MRI9095 RBC scan ( SPECT )90100

14 Percutaneous Biopsy Indicated in suspected malignant tumor Risks: tumor rupture, intratumoral bleeding; seeding along the tract, intraperitoneal spread

15 Management of Giant Hepatic Haemangioma Presentation Imaging Indications Treatment Modalities

16 Does size matter? Benign natural course/ uncomplicated Only 33 case reports of spontaneous rupture* No malignant transformation Follow up in 63 patients with giant haemangioma for 33 months**: no one develop new symptom or complication, 2 haemangioma increase in size; one by 1.1cm another by 3.6cm *Ribeiro AF M., et al. Spontaneous rupture of hepatic hemangiomas: A review of the literature. World Journal of Hepatology 2010 December 27; 2(12) **Yoon SS, Charny CK, Fong Y, Jarnagin WR, Schwartz LH, Blumgart LH, et al: Diagnosis, management, and outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg 2003; 197: 392–402.

17 Indications for Intervention 1. Incapacitating symptoms 2. Complications 3. Uncertain diagnosis 4. +/- Increase in size */** 5. +/- Size>5cm with high risk for trauma*** *Rajneesh Kumar Singh, Sorabh Kapoor, Peush Sahni, and Tushar K Chattopadhyay: Giant Haemangioma of the Liver: Is Enucleation Better than Resection? Ann R Coll Surg Engl July; 89(5): 490–493 **Yoon SS, Charny CK, Fong Y, Jarnagin WR, Schwartz LH, Blumgart LH, et al: Diagnosis, management, and outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg 2003; 197: 392–402 ***Yamagata M, Kanematsu T, Matsumata T, Utsunomiya T, Ikeda Y, Sugimachi K Management of haemangioma of the liver: comparison of results between surgery and Observation. Br J Surg. 1991;78(10):1223

18 Incapacitating Symptoms 54% of patients were ultimately found to have other causes for their symptoms* Causes: peptic ulcer disease, ischemic heart disease, gallstones or acidic reflux *Yoon SS, Charny CK, Fong Y, Jarnagin WR, Schwartz LH, Blumgart LH, et al: Diagnosis, management, and outcomes of 115 patients with hepatic hemangioma. J Am Coll Surg 2003; 197: 392–402.

19 Complications Spontaneous or traumatic rupture 33 case reports of spontaneous rupture in adult, but the mortality rate is about 75%* Kasabach Merritt Syndrome: consumptive coagulopathy Malignant transformation has not been reported *Ribeiro AF M., et al. Spontaneous rupture of hepatic hemangiomas: A review of the literature. World Journal of Hepatology 2010 December 27; 2(12)

20 Uncertain Diagnosis Imaging: atypical appearance High risks patients: History of colorectal cancer, HBV / HCV carrier Resection is indicated in case of suspicion

21 Management of Giant Hepatic Haemangioma Presentation Imaging Indications Treatment Modalities

22 Treatment Modalities 1. Surgery (Resection / Enucleation) 2. Radiation therapy 3. Embolization 4. Radiofrequency Ablation

23 1. Surgery: Low Morbidity & Mortality

24 1. Surgery Resection vs Enucleation

25 Resection: Anatomaical & non-anatomatical In 1988, Alper et al * described a new technique : Enucleation= dissect along the fibrous cleavage plane between the capsule of haemangioma and surrounding normal liver tissue Avoid the need to resect normal liver parenchyma and minimize damage to blood vessels and bile ducts *Aydin Alper, MD; Orhan Ariogul, MD; Ali Emre, MD; Ali Uras, MD; Attila Okten, MD. Treatment of Liver Hemangiomas by Enucleation. Arch Surg. 1988;123(5):

26 Resection vs Enucleation Choice depends on certainty of diagnosis and anatomical considerations

27 Resection vs Enucleation Indications for Resection: potentially malignant lesions lesions that totally replace an anatomical section of liver Deep seated lesions Expectant difficulty to enucleate Indications for Enucleation: indicated in anterior and peripheral haemangioma

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30 Resection vs Enucleation *Susan M. Lerner, MD; Jonathan R. Hiatt, MD; Johanna Salamandra, RN, BSN. Giant Cavernous Liver Hemangiomas: Effect of Operative Approach on Outcome. Arch Surg. 2004;139: **Erhan Hamaloglu, Hasan Altun, Arif Ozdemir and Ahmet Ozenc. Giant Liver Hemangioma: Therapy by Enucleation or Liver Resection. World J Surg Jul;29(7):890-3 ***Rajneesh Kumar Singh, Sorabh Kapoor, Peush Sahni, and Tushar K Chattopadhyay: Giant Haemangioma of the Liver: Is Enucleation Better than Resection? Ann R Coll Surg Engl July; 89(5): 490–493

31 Resection vs Enucleation (Conclusion) Enucleation is preferred when feasible, as it preserves hepatic parenchyma and minimizes complications. Resection is reserved for lesions that cannot be enucleated safely.

32 2. Radiation Therapy Indication: Diffuse, multiple, massive unresectable haemangioma with symptom or progression in size Reductions in volume from 20-40%, with 30% improvement in symptomatology Mechanism: provoke sclerosis of tumor parenchyma with subsequent reduction in size Complication: hepatitis, centrilobular thrombosis, tumor rupture, malignant transformation*, SCC in kidney* *Michael J. McKay, Peter J. Carr2, Allan O. Langlands. Treatment of hepatic cavernous haemangioma with radiation therapy: case report and literature review. Aust N Z J Surg Dec;59(12):965-8.

33 3. Embolisation Indication: - symptomatic giant haemangioma - complicated with coagulopathy - preoperative embolization * Result: reduction in tumor size**, symptomatology** correction of coagulopathy*** *Akamatsu N, Sugawara Y, Komagome M, Ishida T, Shin N, Cho N, Ozawa F, Hashimoto D. Giant liver hemangioma resected by trisectorectomy after efficient volume reduction by transcatheter arterial embolization: a case report. J Med Case Reports Aug 23;4:283. **Giavroglou C, Economou H, Ioannidis I. Arterial embolization of giant hepatic hemangiomas. Cardiovasc Intervent Radiol Jan-Feb;26(1):92-6. ***EPY Fung, WH Luk, TK Loke, JCS Chan. Kasaback-Merritt Syndrome Treated by Transarterial Embolisation of Giant Cavernous Haemangioma. Transarterial Embolisation of Cavernous

34 Complications Post-embolisation pain, fever, leukocytosis Serious complications like infarction, intrahepatic abscess, sepsis are uncommon

35 4. Radiofrequency Ablation Case reports of single or multiple electrode RF technology. Mechanism: thrombogenic effect by damaging the layer of endothelial lining cause thrombosis Complications*: ~2%, include infection, bleeding, injury to blood vessels, bile ducts, diaphragm, other abdominal organ * Ronald J. Zagoria1, Todd J. Roth1, Edward A. Levine2 and Peter V. Kavanagh. Radiofrequency Ablation of a Symptomatic Hepatic Cavernous Hemangioma. AJR 2004; 182:

36 Summary Hepatic hemangiomas : Most common benign tumors of the liver Mostly asymptomatic and uncomplicated High accuracy of diagnosis by present imaging modalities Asymptomatic or minimally symptomatic patients can be safely observed Indications for resection of hepatic hemangiomas include severe symptoms, inability to exclude malignancy, and complications Enucleation, when feasible, is the technique of choice for resection, and resection can be performed with minimal morbidity and rare mortality Other treatment modalities need further studies to support its validity

37 THANK YOU!


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