AJR 2004; 182:210-212
© American Roentgen Ray Society
Radiofrequency Ablation of a Symptomatic Hepatic Cavernous Hemangioma
Ronald J. Zagoria1,
Todd J. Roth1,
Edward A. Levine2 and
Peter V. Kavanagh1
1 Department of Radiology, Wake Forest University School of Medicine, Medical
Center Blvd., Winston-Salem, NC 27157.
2 Department of Surgical Oncology, Wake Forest University School of Medicine,
Winston-Salem, NC 27157.
Received June 17, 2003;
accepted after revision July 30, 2003.
Address correspondence to R. J. Zagoria
(rzagoria{at}wfubmc.edu).
Introduction
Cavernous hemangioma is the most common benign neoplasm of the liver; its
incidence in autopsy studies ranges from 0.4% to 20%
[1,
2]. Most hemangiomas are
asymptomatic and therefore usually are discovered incidentally during
abdominal sonography or CT. Most have a benign course, but hemangiomas may
cause symptoms such as abdominal pain and swelling
[1]. Complications such as
hemorrhage, jaundice, thrombocytopenia (i.e., Kasabach-Merritt syndrome), and
hypofibrinogenemia have been reported, although these are rare
[1,
3]. Treatment of hemangiomas is
reserved for lesions that are symptomatic or cause complications. The primary
treatment is surgical resection, but transarterial embolization, steroid
treatment, radiation therapy, and hepatic arterial ligation have also been
reported [2,
4,
5]. We describe the successful
treatment of a symptomatic hepatic cavernous hemangioma using percutaneous
radiofrequency ablation.
Case Report
The patient was a 33-year-old woman who had experienced constant right
upper quadrant and epigastric pain for several weeks. Upper endoscopy showed a
small hiatal hernia, but findings were otherwise unremarkable. Abdominal
sonography revealed a 5-cm homogeneous hyperechoic lesion in the posterior
segment of the right hepatic lobe. The gallbladder, kidney, and other organs
were normal. Serum liver function test results were all normal. Abdominal MRI
showed the lesion to be homogeneously hypointense on T1-weighted images
(Fig. 1A) and hyperintense on
T2-weighted images. Dynamic gadolinium-enhanced images showed peripheral
nodular enhancement on the initial phase, with progressive increase in the
degree of enhancement on later phases (Fig.
1B). The imaging findings were characteristic of a cavernous
hemangioma.
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Fig. 1A. —33-year-old woman with liver hemangioma who presented with
right upper quadrant abdominal pain. T1-weighted (A) and dynamic
gadolinium-enhanced (B) MRIs show mass to be hypointense. Note
peripheral nodular enhancement of lesion in B.
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Fig. 1B. —33-year-old woman with liver hemangioma who presented with
right upper quadrant abdominal pain. T1-weighted (A) and dynamic
gadolinium-enhanced (B) MRIs show mass to be hypointense. Note
peripheral nodular enhancement of lesion in B.
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Because the patient continued to experience abdominal pain and no other
source was detected after a thorough evaluation, she was referred to our
institution for possible surgery. She was seen by an oncologic surgeon who
subsequently referred her to the department of radiology for percutaneous
radiofrequency ablation.
The patient was administered general anesthesia and given 1 g of cephazolin
IV immediately before preliminary unenhanced CT of the liver performed with
the patient in the supine position. Using a Cool-Tip radiofrequency cluster
electrode (Radionics, Burlington, MA), we treated the lesion in three
locations (Fig. 1C), attaining
temperatures greater than 50°C after each ablation. Care was taken to
place the electrode close to the margins of the lesion to ablate the
peripheral blood vessels. CT immediately after ablation showed complete
ablation of the lesion with no significant residual enhancement. The patient
tolerated the procedure well, developed no complications, and was discharged a
few hours after the procedure.
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Fig. 1C. —33-year-old woman with liver hemangioma who presented with
right upper quadrant abdominal pain. Unenhanced CT scan obtained with patient
in supine position shows radiofrequency electrode (arrow) positioned
in lesion before ablation. Two additional ablations (not shown) were performed
with electrode tip in other areas. Plus signs indicate areas where electrode
was positioned for additional ablations of lesion.
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Follow-up contrast-enhanced CT performed 3 months later showed a persistent
hypodense defect that corresponded to the ablation site and no enhancement in
the lesion (Fig. 1D). The
patient was interviewed by telephone 4 and 8 months after the procedure and
reported that she remained free of pain and of other symptoms.
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Fig. 1D. —33-year-old woman with liver hemangioma who presented with
right upper quadrant abdominal pain. Contrast-enhanced CT scan obtained 3
months after C shows focal nonenhancing defect (solid arrow)
corresponding to treated hemangioma. Absence of enhancement indicates no blood
flow in tumor. Unchanged patent right hepatic vein (open arrow) seen
in A–C abuts anterior edge of ablated hemangioma. Area of hepatic
hypoperfusion peripheral to treated tumor was transient hepatic attenuation
defect that was normalized on scan obtained 120 sec later and was attributed
to vascular compression caused by hemangioma.
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Discussion
Cavernous hemangioma is the most common neoplasm of the liver
[1,
2]. The lesions are
predominantly composed of endothelium-lined vascular spaces that are perfused
by slow-flowing blood [1].
Thrombosis in the vascular spaces may occur as a result of the relatively
static blood flow [1].
In most cases, a presumptive diagnosis of cavernous hemangioma can be made
on the basis of the imaging findings. Clinicians have been reluctant to biopsy
hemangiomas with percutaneous puncture because of the vascular nature of these
lesions. However, studies have shown that percutaneous needle puncture can be
performed safely and with little risk of hemorrhage or other complications
[6–8].
Cronan et al. [6] performed
biopsies on 15 cavernous hemangiomas using 20-gauge Franseen needles (Cook,
Bloomington, IN), and no patients had complications. Heilo and Stenwig
[8] performed core needle
biopsies on 47 hemangiomas using 18-gauge cutting needles, and no patients
experienced complications. Radiofrequency ablation cluster electrodes puncture
the liver simultaneously with three 17-gauge electrodes. Theoretically, the
risk of hepatic hemorrhage is higher with this technique than with a single
puncture or with finer-gauge needles, but the risk of clinically significant
hemorrhage probably is still quite low. No significant bleeding occurred in
our patient.
Treatment is rarely required for cavernous hemangioma lesions because most
have a benign course. The primary treatment for symptomatic lesions has
traditionally been surgical resection, with its associated morbidity and low
risk of mortality.
Radiofrequency ablation is a minimally invasive, safe, and effective
treatment for neoplasms of the lung, liver, kidney, and bone
[9–11].
Percutaneous radiofrequency ablation of primary and metastatic liver neoplasms
has been extensively studied and has a proven efficacy and low associated
morbidity and mortality rates
[10]. Clinically relevant
complications occur at a rate of approximately 2% and include infection;
bleeding; and injury to blood vessels, bile ducts, diaphragm, or other
abdominal organs [11,
12]. This complication rate
compares favorably with risks accompanying hepatic resection, particularly if
resection of more than one liver segment is required for complete lesion
extirpation.
Little has been published on the treatment of benign liver tumors such as
hemangiomas with radiofrequency ablation. However, because the risks of
hemangioma puncture and liver tumor ablation are low, this minimally invasive
technique is a reasonable treatment option before resorting to surgery for
symptomatic liver hemangiomas. Our experience in this patient supports this
assumption because the patient tolerated the procedure without any
complications and remains pain-free 8 months later.
The mechanism of action of radiofrequency ablation in treating liver
hemangiomas has yet to be determined, but it may involve its thrombogenic
effect. Damage to the layer of the endothelial lining in the vascular
structures promotes thrombosis. This effect is already used for its
therapeutic benefit in other areas— for example, in the treatment of
varicose veins with radiofrequency ablation.
In conclusion, percutaneous radiofrequency ablation is a promising
technique for the treatment of symptomatic cavernous hemangiomas. The low risk
of complications and the significant likelihood of complete ablation suggest
that percutaneous radiofrequency ablation should be considered an alternative
to surgical resection for the treatment of selected symptomatic cavernous
hemangiomas of the liver.
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