Fifteen patients had hepatic hemangiomas removed with liver resections that ranged in extent from local excision to right trisegmentectomy. There was no mortality and little morbidity. The propriety and feasibility of extirpative treatment of such liver tumors has been emphasized by this experience

Fennell, RH

Iwatsuki, S

Johnson, ML

Kano, T

Koep, LJ

Starzl, TE

Weil, R

English

D-Scholarship@Pitt

Reprinted from ANNALS of SURGERY, Vol. 192, No.1, July 1980. Copyright, © 1980, by J. B. Lippincott Company. Printed in U.S.A. Excisional Treatment of Cavernous Hemangioma of the Liver THOMAS E. STARZL, M.D., PH.D., LAWRENCE J. KOEP, M.D., RICHARD WElL, III, M.D., ROBERT H. FENNELL, M.D." SHUNZABURO IWATSUKI, M.D., TAD KANO, M.D., MICHAEL L. JOHNSON, M.D.t Fifteen patients had hepatic hemangiomas removed with liver resections that ranged in extent from local excision to right trisegmentectomy. There was no mortality and little morbidity. The propriety and feasibility of extirpative treatment of such liver tumors has been emphasized by this experience. A LTHOUGH HEMANGIOMAS ARE the most common benign tumors of the liver,1.4 the role of surgical excision in their treatment has not been well defined. We report here 15 patients who had resections of hepatic hemangiomas. The cases illustrate the value and safety of such surgical treatment in carefully screened patients. Case Material The 15 patients ranged in age from 40 to 65 years old (Table 1). Eight patients were female and seven were male. In 9 patients, the diagnosis of cavernous hemangioma was strongly suspected from x-ray studies or definitely diagnosed from prior biopsy specimens. In the other six patients, the decision to proceed was reached during operations on hepatic masses that were suspected to be malignant before operation. The principal symptoms are listed in Table 1. Four patients were asymptomatic with liver masses that had been detected at physical examination or by radionu-clide scanning in the course of general medical evalua-tion. Three patients had abdominal masses which were self-diagnosed. Three patients had pain. Six patients * Department of Pathology, the School of Medicine, University of Colorado Health Sciences Center. t Department of Radiology, the School of Medicine, University of Colorado Health Sciences Center. Reprint requests: Thomas E. Starzl, M.D., Ph.D., Department of Surgery (C-305), School of Medicine, University of Colorado, Health Sciences Center, 4200 East Ninth Avenue, Denver, Colorado 80262. Supported by research grants from the Veterans Administration; by grant numbers AM-17260 and AM-07772 from the National In-stitutes of Health; and by grant numbers RR-00051 and RR-00069 from the General Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health. Submitted for pUblication: December 27, 1979. From the Departments of Surgery, Pathology, and Radiology, the School of Medicine of the University of Colorado Health Sciences Center, and the Denver Veterans Administration Medical Center, Denver, Colorado had gastrointestinal distress, apparently caused by pressure from large tumors. Three patients with intra-abdominal hemorrhage (one spontaneous, 2 after biopsy) were referred to us for definitive resection. All of the patients were examined by one or more of the radiologic techniques of radionuclide scanning, ultrasonography, computerized axial tomography or arteriography (Table 2). The diagnosis of hemangioma was most commonly suspected after arteriography, a procedure which we often have omitted in recent years because of its significant inconvenience and morbidity. Liver functions preoperatively were normal or nearly normal in all patients, as were hematologic measures, including platelet counts. Operative Procedures The hemangiomas were localized and resection was possible in each patient. Blood loss in each patient is given in Table 1. Ten patients had hepatic lobectomy or segmentectomy (Table 1), using techniques described elsewhere. 13.14 The other five patients had local excision. In the latter cases, the tumors tended to be superficial and with a base which was either narrow enough or accessible enough to permit cross clamping with one or more standard vascular clamps. After local excision of the vascular tumor, the clamped base was oversewn with two layers of 2-0 continuous catgut suture. Result All 15 patients are alive and have normal liver func-tion after follow-ups of two months to seven months (Table 1). There were no postoperative hemorrhages 0003-4932/80/0700/0025 $00.65 © J. B. Lippincott Company 25 26 ST ARZL AND OTHERS Ann. Surg .• July 1980 TABLE 1. Fifieen Cases of Cavernous Hemangioma of the Liver Case Blood Loss No. Age/Sex Size in cm and Location of Tumor Principal Symptoms Procedures (m!) 1 43 F 8 x 5 plus small lesions in rt. lobe Mass felt at time of hysterectomy Local excision in rt. lobe 1000 2 62 F 2.5 x 2 in rt. lobe Nausea and vomiting Local excision in rt. lobe 300 3 61 F 15 x 6 in rt. lobe RUQ and epigastric pain, Rt. hepatic lobectomy 1500 spontaneous hemorrhage 4 51 M 22.5 x 14 in It. lateral segment Epigastric distress, nausea and Lt. lateral segmentectomy 1100 vomiting 5 45 F 14 x 12 in rt. lobe Mass felt by patient Local excision in rt. lobe 700 6 44 M 16 x 15 in rt. lobe Abdominal fullness, stippling Rt. hepatic lobectomy 3000 calcification on x-ray 7 58 F 4.3 x 2.9 in rt. lobe RUQ pain, gastrointestinal Local excision in rt. lobe 200 bleeding* 8 61 M 15 x 11.5 plus mUltiple small Asymptomatic mass felt by Rt. hepatic lobectomy 1900 lesions in rt. lobe physician 9 65 M 17 x 9 in rt. lobe Asymptomatic mass found by scan Rt. hepatic lobectomy 3000 \0 41 M 13 x 7.5 in rt. lobe Mass felt by patient Rt. hepatic lobectomy 2500 11 53 F 4 x 2 in median segment It. lobe; RUQ pain, radiating to rt. shoulder Rt. trisegmentectomy 3000 smaller lesions in rt. lobe 12 57 M \0 x 9.5 in It. lateral segment Asymptomatic mass found by scan Lt. lateral segmentectomy 200 13 40 F 16 x 10 in rt. lobe Weakness, massive hemorrhage Rt. hepatic lobectomy 1850 from open biopsy 14 45 M 17 x 20 plus smaller lesions Mass, weight loss and anorexia Lt. hepatic lobectomy 3000 in It. lobe 15 44 F 16 x 13 in It. lateral segment Mass, epigastric fullness; Local excision in It. lobe 2000 massive hemorrhage after closed needle biopsy * Small bowel lymphosarcoma also found and resected. The lymphoma had caused the bleeding. Patient well 19 months. nor any intra-abdominal abscesses. Two patients de-veloped wound hernias which were repaired later. After they were cut, the tumors ranged in size from 2.5 to 20 cm in diameter (Table 1). By measuring them after evacuation of their blood contents, their size was systematically underestimated. The tumors were soft and red, and often had firm gray-white streaks or areas. Four tumors were multifocal. Microscopically the tu-mors were cavernous hemangiomas and were composed of vessels of varying size. Rarely, capillary patterns were in the same tumor. Organizing thrombi, some recent and some old, were common and focally obliterated vessels in parts of one tumor. The thickness of the vessels in several tumors was attributed to organization of thrombi. The adjacent liver was normal except for mild lymphocytic infiltration of sinusoids adjacent to the tumor. One liver (Case 1) showed severe fatty change. This patient had diabetes mellitus. TABLE 2. Radiologic Studies in 15 Patients Number of Number of Number of Hemangioma Studies Positive Strongly Performed for Mass Suspected Radionuciide scan 14 13 0 Ultrasonography 9 8 I Computed tomography 8 8 0 Arteriography 7 7 4 All symptoms were relieved. Amelioration of pain was particularly noteworthy. One patient (Case 11) was denied operation for many months because of the suspicion that her complaints were an excuse for non-employment plus drug abuse. After right trisegmentec-tomy she was immediately relieved of pain and did not ask for postoperative analgesics. Discussion The hemangiomas of this series were all of the cavernous variety, there being no examples of capillary hemangiomas. Cavernous hemangiomas are found in about 2% of autopsy livers,S but the great majority of these lesions are small and without medical or surgical significance. Adam, Huvos, and Fortner classified hemangiomas as . 'giant" if their diameter exceeded 4 cm.l The larger hemangiomas can be responsible for diverse complications including pain and hemor-rhage.1.4,8,ll,16 Until recently, the surgical literature about cavernous hemangiomas consisted mainly of periodic scholarly reviews3,5,lo,l5 for which the stimulus frequently was an unusual operative experience with one or two cases. The only significant series described in detail was that of Adam, Huvos, and Fortner. l They observed 22 pa-tients with hepatic cavernous hemangiomas exceeding 4 cm in diameter. In ten of these patients they attempted to remove the tumors with six local excisions, three Vol. 192. No.1 CAVERNOUS HEMANGIOMA 27 right lobectomies, and one left lobectomy. Two of the three patients submitted to right lobectomy died, but these deaths were attributable to ongoing hemorrhages that led to the attempts at emergency resection. The other eight patients who had elective operations survived. The true frequency with which hemangiomas are removed probably is not accurately reflected by the foregoing literature or lack thereof. In Smith's series of 78 hepatic resections, ten (13%) were for hemangio-mas. 12 Longmire et al. recorded eight hemangiomas among 75 partial hepatectomies.6 The 15 cases herein reported were culled from 87 liver resections at the University of Colorado. The inability to establish an unequivocal preopera-tive diagnosis may be one reason to carry out hepatic resection. To establish a diagnosis, resection may be the safest procedure. Needle biopsies of hemangiomas have been responsible for fatal hemorrhages and should not be done for suspicion of this diagnosis. !,R,ll In recent years, the radiologic diagnosis of hemangiomas has improved. Radionuclide scanning. ultrasonography, and computerized axial tomography can be helpful. The most distinctive findings are with arteriography whereby there is early arterial and persistent late venous puddling of the contrast material,2,7,9 In spite of the relative specificity of such findings, we have used he-patic arteriography less and less frequently. First, even arteriography cannot assure the diagnosis with cer-tainty; two of our other patients thought to have hem-angiomas actually had malignancies. Second, because a symptomatic hemangioma is a valid reason for partial hepatic resection, the establishment of this diagnosis at the time of operation instead of before should not alter therapy. The validity of the foregoing aggressive attitude about surgery depends on the safety with which the excision of hemangiomas can be offered. In our ex-perience, there was no mortality and little morbidity, and the experience of others has been the same.1,6,12 The surgical principles involved were simple and above all involved the avoidance of uncontrolled hemorrhage. Local (wedge) excision was the procedure of choice but this was performed only if the pedicle of the tumor could be clamped and oversewn. Failure to meet this condition could result in transection through vessels so large that lethal bleeding could result. When formal segmental or lobar resections were performed, the major vessels entering or leaving the specimen were controlled before starting the parenchymal transection. It must be emphasized that the compilations of this series and other large seriesl,6,12 of surgical resections of hemangiomas have been in specialized liver centers. The appropriate decision for occasional liver surgeons in many of our patients might well have been to close the incision without biopsy and to refer the patient to a specialty center. There would seem to be little justifica-tion to attempt "palliation" with hepatic artery ligation or arterial embolization or radiotherapy in patients whose lesions are susceptible to excision. At our center, most asymptomatic hemangiomas are not removed if the diagnosis is secure. On the other hand, ifthe hem-angiomas are symptomatic, they are excised unless the risks are deemed overwhelming from systemic disease or anatomic considerations. References 1. Adam YG, Huvos AG, Fornter JG. Giant hemangiomas of the liver. Ann Surg 1970; 172:239. 2. Freeny PC, Vimont TB, Barnett DC. Cavernous hemangioma of the liver: ultrasonography, arteriography, and computed tomography. Radiology 1979; 132:143. 3. Grieco MB, Miscall BG. Giant hemangiomas of the liver. Surg Gynecol Obstet 1978; 147:783. 4. Henson SW, Jr, Gray HK, Dockerty MB. Benign tumors of the liver. Surg Gynecol Obstet 1956; 103:23. 5. Ishak KG, Robin L. Benign tumors of the liver. Med Clin North Am 1975; 59:995. 6. Longmire WP, Jr, Trout HH, III, Greenfield J, et aI. Elective hepatic surgery. Ann Surg 1974; 179:712. 7. Neiman HL, Goldstein HM. Angiography of benign and malig-nant hepatic masses. Semin Roentgenol 1975; 10: 197. 8. Ochsner JL, Halrert B. Cavernous hemangioma of the liver. Surgery 1958; 43:577. 9. Pantoja E. Angiography in liver hemangioma. Am J Roentgenol 1968; 104:874. 10. Sewell JH, Weiss K. Spontaneous rupture of hemangioma of the liver. Arch Surg 1961; 83:729. 11. Shumacker HB, Jr. Hemangioma of the liver; discussion of symptomatology and report of patient treated by operation. Surgery 1942; 11:209. 12. Smith R. Tumours of the liver. Ann R Coli Surg Eng 1979; 61:87. 13. Starzl TE, Bell RH, Beart RW, et al. Hepatic trisegmentectomy and other liver resections. Surg Gynecol Obstet 1975; 141:430. 14. Starzl TE, Koep LJ, Weil R, III, et al. Right trisegmentectomy for hepatic neoplasms. Surg Gynecol Obstet 1980; 150:208. 15. Stayman JW, Jr, Polsky HS, Blaum L. Ruptured cavernous hemangioma of the liver. PA Med 1976; 2:62. 16. Wakeley CPG. A large cavernous haemangioma of the left lobe of the liver causing obstruction to the cardiac orifice of the stomach. Br J Surg 1925; 12:590. 

Excisional treatment of cavernous hemangioma of the liver

THOMAS E. STARZL

LAWRENCE J. KOEP

RICHARD WEIL

ROBERT H. FENNELL

SHUNZABURO IWATSUKI

TAD KANO

MICHAEL L. JOHNSON

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Excisional Treatment of Cavernous Hemangioma of the Liver

Weil III, R

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Excisional treatment of cavernous hemangioma of the liver

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