Diagnosis and management of giant hepatic hemangioma: the usefulness of contrast-enhanced ultrasonography

Abstract

Giant hepatic hemangiomas, though often asymptomatic, may require intervention if rapid growth occurs. The imaging studies including the computed tomography, magnetic resonance imaging, and ultrasonography, and so on are effective for the diagnosis and the management of this tumor; however, due to its size and various patterns of these studies, we need to carefully consider the therapeutic methods. Compared to the cost needed for these modalities, recently developed and approved Perflubutane- (Sonazoid-) based contrast agent enhanced ultrasonography is reasonable and safe. The major advantage is the real-time observation of the vascular structure and function of the Kupffer cells. By this procedure, we can carefully follow the tumor growth or character change in a hemangioma and decide the timing of therapeutic intervention, since abdominal pain, abdominal mass, consumptive coagulopathy, and hemangioma growth are the signs for the therapeutic intervention. We reviewed recent reports about Sonazoid-based enhancement and also showed the representative images collected in our department. This is the first review showing the detailed findings of the giant hemangiomas using Perflubutane (Sonazoid). This review will help the physician in making the decision, and we hope that Sonazoid will gain widespread acceptance in the near future.

Figure 1

Multidetector computed tomography (MDCT) images. (a) Axial MDCT image shows a huge hypodense mass in the right lobe of the liver measuring about 17 cm, extending to the middle hepatic vein (MHV). (b) Vascular reconstruction image shows “cotton wool-like pooling” (arrowhead).

Figure 2

Ultrasonography (US) scan. (a) B-mode US scan shows a huge nonhomogeneously hypoechoic lesion in the right lobe of the liver. (b) Sonazoid contrast-enhanced US in the early vascular phase reveals “cotton wool-like pooling” (arrowhead). (c) Gradual fill-in through the late vascular phase. (d) The fill-in was completed in the Kupffer phase.

Figure 3

US, employing the “defect reperfusion US imaging” technique with Sonazoid, was performed on another hepatic hemangioma, in the left lobe of the liver, in tumor 1. (a) Preinjection image shows a hypoechoic mass measuring about 2 cm (arrowhead). (b) The lesion shows “peripheral-nodular enhancement” 30 s after reinjection of Sonazoid.

Figure 4

Intranodular dynamic image of the hepatic hemangioma in tumor 2. (a) B-mode US shows a nonhomogeneously hyperechoic lesion approximately 6 cm in size in the right lobe of the liver. (b) Sonazoid contrast-enhanced US in the early vascular phase reveals typical “peripheral globular enhancement” of the lesion. (c) The lesion shows progressive “partial centripetal filling-in” during the late vascular phase. (d) The tumor is visualized as a hypoperfusion image in the Kupffer phase. (e) The same pattern is apparent 20 s after reinjection of Sonazoid: typical “peripheral globular enhancement” of the lesion in the early vascular phase 20 s after the first injection of Sonazoid. (f) Parenchymal perfusion 13 min after reinjection results in a hypoperfusion image similar to that in the Kupffer phase after the first injection of Sonazoid.