Diagnostic Radiology
RPC 1 from the AFlp2 William W. Olmsted, Maj., USAF MC, and J. Thomas Stocker, Maj., USAFMC
44-YEAR-OLD man was found to have a mass in the right upper quadrant on routine physical examination. His only complaint was slight loss of weight in the previous 3 to 4 months. Celiac angiography was performed after routine studies confirmed the presence of the mass. What is your diagnosis?
A
=
RPC radiologic-pathologic correlation. From the Departments of Radiologic Pathology (W. W.O., Chief, Gastrointestinal Radiologic Pathology Branch) and Pediatric Pathology (J.T.S., Acting Chief), Armed Forces Institute of Pathology, Washington, D. C. Accepted for publication in June 1975. Supported in part by research grant CA 15413-02 from the National Cancer Institute. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Air Force or Defense at large. sjh 1
2
59
60
WILLIAM W. OLMSTED AND
J.
THOMAS STOCKER
October 1975
Fig. 1. A and B (AFIP Negs. 70-12132-1 and 70-12132-2). Arterial (A) and venous (B) phases of the celiac angiogram show displacement of the celiac, common hepatic, and proper hepatic arteries. The major hepatic radicles are displaced away from and stetched over a tumor mass. Note the very early appearance and persistence of multiple vascular lakes. No calcifications were present on the scout film.
RADIOGRAPHIC FINDINGS
Celiac angiography reveals displacement of the celiac axis to the left and elevation of the common and proper hepatic arteries (Fig. 1) as well as crowding of the hepatic branches supplying the superior aspect of the right lobe and stretching of vessels over the middle aspect of the liver. The caliber of the celiac axis, common and proper hepatic arteries, and smaller hepatic branches is normal. Multiple punctate areas of contrast material are seen, some of them conglomerate as noted on the venous phase; these areas appear very early in the arterial phase and persist late into the venous phase. There is no evidence of arteriovenous shunting. The portal vein is not seen well, although the splenic vein is easily noted in the left upper quadrant. DIFFERENTIAL DIAGNOSIS
In assessing hepatic neoplasia, the patient's age, vessel size and tapering, vessel displacement, arteriovenous shunting, vein narrowing and/or occlusion, and neovascularity must be evaluated. One may arbitrarily divide neoplasms affecting the liver into groups based on the age of the patient: those occurring primarily in adult life include hepatocellular carcinoma, hepatocellular adenoma, focal nodular hyperplasia, cholangiocarcinoma, cavernous hemangioma, and metastatic tumor, while hepatoblastoma and hemangioendothelioma affect children and hamartoma and mesenchymal sarcoma may occur in both age groups. Thus the diagnosis of hemangioendothelioma and hepatoblastoma should be excluded in this case on the basis of the patient's age. Cholangiocarcinoma and most metastatic lesions (ex-
cept for renal, thyroid, carcinoid, some pancreatic tumors, melanoma, and choriocarcinoma) are avascular. When metastatic lesions are hypervascular, contrast accumulation usually does not persist. In addition, metastatic tumors are generally multifocal. This case involves a single large mass containing multiple areas of neovascularity (laking); hence cholangiocarcinoma and metastatic disease would be unusual diagnoses. If the rare hamartoma or mesenchymal sarcoma and focal nodular hyperplasia are excluded, the most logical diagnoses are hepatocellular carcinoma (or adenoma, which frequently has the same angiographic picture) and cavernous hemangioma. Radiological differentiation requires evaluation of vessel size and tapering, vessel displacement, arteriovenous shunting, vein abnormalities, and the type of neovascularity; the presence and type of calcifications on the plain film are not helpful in the differential diagnosis (1). The arteries supplying hepatocellular carcinoma are usually large and do not taper normally; macroscopically, both of these parameters are normal in cavernous hemangioma. Pantoja stated that the arterial branches measuring more than" 1 mm in diameter are normal; the smaller vessels are more tortuous and opacify vascular spaces either singly or in clusters (2). Hepatocellular carcinoma generally stretches vessels, while carvernous hemangioma crowds vessels away from the center of the lesion. Arteriovenous shunting is fairly common in hepatocellular carcinoma but is seen only rarely in hemangioma. The portal vein may be displaced, narrowed, invaded, or occluded by hepatocellular carcinoma but is usually normal in hemangioma. The most distinguishing characteristic between hepa-
RPC FROM THE AFIP
Vol. 117
Fig. 2 (AFIP Neg. 75-3581). Large vascular channels filled with red blood cells are separated by loose fibrous connective tissue containing focal hyalinization. (H & E X35)
tocellular carcinoma and cavernous hemangioma, however, is the type of neovascularity. Suzuki et a/. have described a spectrum of vascularity graded from 1 to 4 in hepatocellular carcinoma (3). The angiographic pattern in cavernous hemangioma is markedly different: punctate lakes of contrast material, either single or multiple, appear very early in the arterial phase of the angiogram and remain opacified well into the venous phase (up to 18 seconds) (4). McLoughlin described ring- or C-shaped configurations of the vascular spaces resulting from fibrous obliteration of the centers (4). No other hepatic tumor exhibits this type of pattern. Although disseminated small nodular densities may be seen in hepatic venous occlusion, alcoholic hepatitis, nephrogenic hepatopathy, and peliosis hepatis, the accumulation of contrast material is not prolonged in these conditions.
61
Diagnostic Radiology
Fig. 3 (AFIP Neg. 75-3582). Delicate vessels partially filled with red blood cells form a complex maze-like pattern. A thick-walled artery is seen at upper right. (H & E X50)
most dramatic roentgenographic findings are numerous unifocal or conglomerate vascular lakes which are seen early in the arterial phase of the angiogram and persist well into the venous phase. It is this characteristic which distinguishes cavernous hemangioma from more ominous neoplasms. Pollard et a/. speculated that retention of contrast material in the vascular lakes is secondary to puddling with resultant slow flow (7); we feel that this puddling might be related to partial thrombosis, which is a frequent occurrence. These authors also raised the possibility that slow flow may be secondary to the lower metabolism of a benign lesion (7). The answer, however, may lie in the anatomical-physiological correlation noted in Figures 2 and 3. The retention of contrast material may be the result of blood (and therefore contrast material) cycling through tortuous vascular channels in addition to puddling in these thin-walled vascular spaces.
PATHOLOGIC CORRELATION
A section from the central portion of the tumor (Fig. 2) displays large, intercommunicating blood-filled spaces lined by a flattened layer of endothelium supported by partially hyalinized fibrous tissue. The intricate anastomosing nature of this tumor is evidenced by portions of the vessel wall that appear to float within a larger vascular channel (Fig. 3). The blood must negotiate this maze to flow through the tumor. Calcifications are not seen in this growth. The hepatic parenchyma (not seen in these photomicrographs) is adjacent to but separate from the tumor and is histologically normal. DISCUSSION
The diagnosis in our patient is hepatic cavernous hemangioma. It is the most frequent benign neoplasm of the liver, being found in 2-7 % of autopsies (5). It is found in older age groups and symptoms occur primarily in women, although autopsy series show an almost equal male-female ratio (6). Pain and abdominal enlargement are the usual presenting symptoms. The
ACKNOWLEDGMENTS: We wish to thank Drs. Elias G. Theros and Kamal G. Ishak for their helpful comments and editorial advice. Department of Radiologic Pathology Gastrointestinal Branch Armed Forces Institute of Pathology Washington, D. C. 20306
REFERENCES 1. Boijsen E, Abrams HL: Roentgenologic diagnosis of primary carcinoma of the liver. Acta Radiol [Diag] 3:257-277, May 1965 2. Pantoja E: Angiography in liver hemangioma. Am J RoentgenoI104:874-879, Dec 1968 3. Suzuki T, Sarumaru S, Kawabe K, et al: Study of vascularity of tumors of the liver. Surg Gynecol Obstet 134:27-34, Jan 1972 4. McLoughlin MJ: Angiography in cavernous hemangioma of the liver. Am J RoentgenoI113:50-55, Sep 1971 5. Mir MA, Mir AM: Hepatic haemangioma with report of a case. Br J Clin Pract 20: 137-142, Mar 1966 6. Edmondson HA: Tumors of the liver and intrahepatic bile ducts. Atlas of Tumor Pathology, Sect VII, Fasc 25. Washington DC, AFIP, 1958, P 113 7. Pollard JJ, Nebesar RA, Mattoso LF: Angiographic diagnosis of benign diseases of the liver. Radiology 86:276-283, Feb 1966
62
WILLIAM W. OLMSTED AND
•
J.
THOMAS STOCKER
Cavernous Hemangioma of the Liver
October 1975
•
RPC from the AFIP William W. Olmsted, Maj., USAF MC, and J. Thomas Stocker, Maj., USAF MC In the differential diagnosis of hepatic lesions, age, vessel size and tapering, vessel displacement, arteriovenous shunting, the status of the veins, and neovascularity must be evaluated. Cavernous hemangioma should be considered in an adult patient when the vessels are normal in size and displaced away from the lesion, arteriovenous shunting is absent, the portal vein is normal, and prominent vascular lakes containing contrast material, which persists well into the venous phase, are seen. The differential diagnosis and pathophysiological explanation are presented. Angioma· Armed Forces Institute of Pathology· Liver, blood supply. Liver Neoplasms, diagnosis
INDEX TERMS:
Radiology117:59-62, October 1975
•
•
RPC 1 from the AFlp2 William W. Olmsted, Maj., USAF MC, and J. Thomas Stocker, Maj., USAFMC
44-YEAR-OLD man was found to have a mass in the right upper quadrant on routine physical examination. His only complaint was slight loss of weight in the previous 3 to 4 months. Celiac angiography was performed after routine studies confirmed the presence of the mass. What is your diagnosis?
A
=
RPC radiologic-pathologic correlation. From the Departments of Radiologic Pathology (W. W.O., Chief, Gastrointestinal Radiologic Pathology Branch) and Pediatric Pathology (J.T.S., Acting Chief), Armed Forces Institute of Pathology, Washington, D. C. Accepted for publication in June 1975. Supported in part by research grant CA 15413-02 from the National Cancer Institute. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Air Force or Defense at large. sjh 1
2
59
60
WILLIAM W. OLMSTED AND
J.
THOMAS STOCKER
October 1975
Fig. 1. A and B (AFIP Negs. 70-12132-1 and 70-12132-2). Arterial (A) and venous (B) phases of the celiac angiogram show displacement of the celiac, common hepatic, and proper hepatic arteries. The major hepatic radicles are displaced away from and stetched over a tumor mass. Note the very early appearance and persistence of multiple vascular lakes. No calcifications were present on the scout film.
RADIOGRAPHIC FINDINGS
Celiac angiography reveals displacement of the celiac axis to the left and elevation of the common and proper hepatic arteries (Fig. 1) as well as crowding of the hepatic branches supplying the superior aspect of the right lobe and stretching of vessels over the middle aspect of the liver. The caliber of the celiac axis, common and proper hepatic arteries, and smaller hepatic branches is normal. Multiple punctate areas of contrast material are seen, some of them conglomerate as noted on the venous phase; these areas appear very early in the arterial phase and persist late into the venous phase. There is no evidence of arteriovenous shunting. The portal vein is not seen well, although the splenic vein is easily noted in the left upper quadrant. DIFFERENTIAL DIAGNOSIS
In assessing hepatic neoplasia, the patient's age, vessel size and tapering, vessel displacement, arteriovenous shunting, vein narrowing and/or occlusion, and neovascularity must be evaluated. One may arbitrarily divide neoplasms affecting the liver into groups based on the age of the patient: those occurring primarily in adult life include hepatocellular carcinoma, hepatocellular adenoma, focal nodular hyperplasia, cholangiocarcinoma, cavernous hemangioma, and metastatic tumor, while hepatoblastoma and hemangioendothelioma affect children and hamartoma and mesenchymal sarcoma may occur in both age groups. Thus the diagnosis of hemangioendothelioma and hepatoblastoma should be excluded in this case on the basis of the patient's age. Cholangiocarcinoma and most metastatic lesions (ex-
cept for renal, thyroid, carcinoid, some pancreatic tumors, melanoma, and choriocarcinoma) are avascular. When metastatic lesions are hypervascular, contrast accumulation usually does not persist. In addition, metastatic tumors are generally multifocal. This case involves a single large mass containing multiple areas of neovascularity (laking); hence cholangiocarcinoma and metastatic disease would be unusual diagnoses. If the rare hamartoma or mesenchymal sarcoma and focal nodular hyperplasia are excluded, the most logical diagnoses are hepatocellular carcinoma (or adenoma, which frequently has the same angiographic picture) and cavernous hemangioma. Radiological differentiation requires evaluation of vessel size and tapering, vessel displacement, arteriovenous shunting, vein abnormalities, and the type of neovascularity; the presence and type of calcifications on the plain film are not helpful in the differential diagnosis (1). The arteries supplying hepatocellular carcinoma are usually large and do not taper normally; macroscopically, both of these parameters are normal in cavernous hemangioma. Pantoja stated that the arterial branches measuring more than" 1 mm in diameter are normal; the smaller vessels are more tortuous and opacify vascular spaces either singly or in clusters (2). Hepatocellular carcinoma generally stretches vessels, while carvernous hemangioma crowds vessels away from the center of the lesion. Arteriovenous shunting is fairly common in hepatocellular carcinoma but is seen only rarely in hemangioma. The portal vein may be displaced, narrowed, invaded, or occluded by hepatocellular carcinoma but is usually normal in hemangioma. The most distinguishing characteristic between hepa-
RPC FROM THE AFIP
Vol. 117
Fig. 2 (AFIP Neg. 75-3581). Large vascular channels filled with red blood cells are separated by loose fibrous connective tissue containing focal hyalinization. (H & E X35)
tocellular carcinoma and cavernous hemangioma, however, is the type of neovascularity. Suzuki et a/. have described a spectrum of vascularity graded from 1 to 4 in hepatocellular carcinoma (3). The angiographic pattern in cavernous hemangioma is markedly different: punctate lakes of contrast material, either single or multiple, appear very early in the arterial phase of the angiogram and remain opacified well into the venous phase (up to 18 seconds) (4). McLoughlin described ring- or C-shaped configurations of the vascular spaces resulting from fibrous obliteration of the centers (4). No other hepatic tumor exhibits this type of pattern. Although disseminated small nodular densities may be seen in hepatic venous occlusion, alcoholic hepatitis, nephrogenic hepatopathy, and peliosis hepatis, the accumulation of contrast material is not prolonged in these conditions.
61
Diagnostic Radiology
Fig. 3 (AFIP Neg. 75-3582). Delicate vessels partially filled with red blood cells form a complex maze-like pattern. A thick-walled artery is seen at upper right. (H & E X50)
most dramatic roentgenographic findings are numerous unifocal or conglomerate vascular lakes which are seen early in the arterial phase of the angiogram and persist well into the venous phase. It is this characteristic which distinguishes cavernous hemangioma from more ominous neoplasms. Pollard et a/. speculated that retention of contrast material in the vascular lakes is secondary to puddling with resultant slow flow (7); we feel that this puddling might be related to partial thrombosis, which is a frequent occurrence. These authors also raised the possibility that slow flow may be secondary to the lower metabolism of a benign lesion (7). The answer, however, may lie in the anatomical-physiological correlation noted in Figures 2 and 3. The retention of contrast material may be the result of blood (and therefore contrast material) cycling through tortuous vascular channels in addition to puddling in these thin-walled vascular spaces.
PATHOLOGIC CORRELATION
A section from the central portion of the tumor (Fig. 2) displays large, intercommunicating blood-filled spaces lined by a flattened layer of endothelium supported by partially hyalinized fibrous tissue. The intricate anastomosing nature of this tumor is evidenced by portions of the vessel wall that appear to float within a larger vascular channel (Fig. 3). The blood must negotiate this maze to flow through the tumor. Calcifications are not seen in this growth. The hepatic parenchyma (not seen in these photomicrographs) is adjacent to but separate from the tumor and is histologically normal. DISCUSSION
The diagnosis in our patient is hepatic cavernous hemangioma. It is the most frequent benign neoplasm of the liver, being found in 2-7 % of autopsies (5). It is found in older age groups and symptoms occur primarily in women, although autopsy series show an almost equal male-female ratio (6). Pain and abdominal enlargement are the usual presenting symptoms. The
ACKNOWLEDGMENTS: We wish to thank Drs. Elias G. Theros and Kamal G. Ishak for their helpful comments and editorial advice. Department of Radiologic Pathology Gastrointestinal Branch Armed Forces Institute of Pathology Washington, D. C. 20306
REFERENCES 1. Boijsen E, Abrams HL: Roentgenologic diagnosis of primary carcinoma of the liver. Acta Radiol [Diag] 3:257-277, May 1965 2. Pantoja E: Angiography in liver hemangioma. Am J RoentgenoI104:874-879, Dec 1968 3. Suzuki T, Sarumaru S, Kawabe K, et al: Study of vascularity of tumors of the liver. Surg Gynecol Obstet 134:27-34, Jan 1972 4. McLoughlin MJ: Angiography in cavernous hemangioma of the liver. Am J RoentgenoI113:50-55, Sep 1971 5. Mir MA, Mir AM: Hepatic haemangioma with report of a case. Br J Clin Pract 20: 137-142, Mar 1966 6. Edmondson HA: Tumors of the liver and intrahepatic bile ducts. Atlas of Tumor Pathology, Sect VII, Fasc 25. Washington DC, AFIP, 1958, P 113 7. Pollard JJ, Nebesar RA, Mattoso LF: Angiographic diagnosis of benign diseases of the liver. Radiology 86:276-283, Feb 1966
62
WILLIAM W. OLMSTED AND
•
J.
THOMAS STOCKER
Cavernous Hemangioma of the Liver
October 1975
•
RPC from the AFIP William W. Olmsted, Maj., USAF MC, and J. Thomas Stocker, Maj., USAF MC In the differential diagnosis of hepatic lesions, age, vessel size and tapering, vessel displacement, arteriovenous shunting, the status of the veins, and neovascularity must be evaluated. Cavernous hemangioma should be considered in an adult patient when the vessels are normal in size and displaced away from the lesion, arteriovenous shunting is absent, the portal vein is normal, and prominent vascular lakes containing contrast material, which persists well into the venous phase, are seen. The differential diagnosis and pathophysiological explanation are presented. Angioma· Armed Forces Institute of Pathology· Liver, blood supply. Liver Neoplasms, diagnosis
INDEX TERMS:
Radiology117:59-62, October 1975
•
•
![[A ruptured cavernous hemangioma of the liver].](/assets/img/hold.png)
