Giant cavernous haemangioma with “flame-shaped” enhancement in female patient

Clinical History

Female 46-year-old patient arrived at the emergency department with complaints of abdominal pain in right upper quadrant and abdominal distension. Laboratory tests were normal except PCR of 8.1. After hospitalization both MDCT and MRI were performed.

Imaging Findings

MDCT was performed with intravenous injection of iodinated contrast. During the native phase an ovoid hypodense lesion in SVI-VII of the liver (Couinaud classification) with 82x60x89mm was found. During the early arterial phase there was an extensive peripheral enhancement in the structure of the lesion (297, 9HU), which was close to the attenuation of abdominal aorta and had a “flame-shaped” appearance (Fig. 1). Feeding arteries are also identified supplying the lesion from its periphery during early arterial phase. During portal-venous phase the “flame-shaped” peripheral enhancement area increased in size with clearly defined, irregular rim of hypodense peritumoral oedema around the lesion (Fig. 2). The lesion was incompletely opacified during the delayed phase (Fig. 3).
On MRI the lesion is characterized by well-defined margins, low signal intensity on T1-weighted images (Fig. 4) and high signal intensity onT2-weighted images, surrounded by less hyperintense rim, consistent with peritumoral oedema (Fig. 5). Note the identity of high signal intensity of the lesion to that of cerebrospinal fluid onT2-weighted images. On dynamic gadolinium-enhanced T1-weighted gradient-echo sequences the peripheral intake of gadolinium is “flame-shaped” and similar to the enhancement on MDCT (Fig. 6).

Discussion

Though haemangioma is the most common benign neoplasm of the liver, giant haemangiomas which reach a size of > 4 cm are rare [1, 2]. Nevertheless, some authors point out the size of giant hemangioma to be over 6 cm [3]. Giant haemangiomas come into attention of physicians when they become symptomatic and cause various symptoms from slight abdominal discomfort to spontaneous rupture, a life-threatening complication [4]. Hepatic haemangiomas are diagnosed mainly by using non-invasive diagnostic procedures such as US, CT and MRI [5].
Radiologic findings for typical hepatic haemangioma are well known. On CT it’s a hypodense lesion with peripheral, globular enhancement during arterial phase, centripetal progression of enhancement during venous phase, which continues during delayed phase. Small hepatic haemangiomas can enhance homogeneously. On MRI it’s a well-defined lesion that has high signal intensity on T2-weighted images and gadolinium intake similar to the intake of iodinated contrast material during enhanced CT [6].
In certain patients the case is significant clinically due to the presence of abdominal pain in the right upper quadrant and is interesting because of the size of the tumour (about 9 cm), extensive “flame-shaped” peripheral enhancement, feeding arteries, incomplete opacification during delayed phase and rim of peritumoral oedema. Whereas “flame-shaped” enhancement is described in the literature, it is mostly grouped up with globular enhancement pattern and is not presented with discrete illustrations, which along with incomplete opacification due to thrombosis during delayed phase can lead to uncertainty in diagnosis. A presence of feeding vessels, peritumoral oedema and high signal intensity on T2-weighted images should be differentiated from hepatic adenoma [7]. Differential diagnosis with hepatic capillary haemangioma lies in the angiographic pattern of enhancement, when pooling, which is characteristic of cavernous haemangioma, is not seen [8].

Differential Diagnosis List

Final Diagnosis

Giant cavernous haemangioma

URL:	https://eurorad.org/case/14498
DOI:	10.1594/EURORAD/CASE.14498
ISSN:	1563-4086