hepatic cavernous hemangioma
Introduction
Introduction to hepatic cavernous hemangioma Hepatic cavernous hemangioma is a relatively common benign tumor of the liver. In addition to skin and mucous membranes, the liver is the best site for cavernous hemangioma. It can be single or multiple, with or without pedicles. Its volume is from the tip of the needle to the size of the walnut or the head. In severe cases, it can occupy the entire liver and bulge obviously toward the abdomen. The tumor is soft in texture, the cut surface is honeycomb-shaped, filled with blood, elastic and compressible. When the tumor first occurs, it does not produce any symptoms. When it grows up, it will cause a series of symptoms due to compression of the surrounding organs. It can also lead to complications such as heart failure. As the tumor gradually enlarges, if it is not treated, it may cause massive bleeding due to rupture. danger. basic knowledge The proportion of illness: 0.023% Susceptible people: no specific population Mode of infection: non-infectious Complications: shock heart failure
Cause
Cause of hepatic cavernous hemangioma
(1) Causes of the disease
The exact cause of hepatic cavernous hemangioma is unknown, and there are several theories.
1. Developmental abnormality theory It is generally believed that during embryonic development, vascular anomalies cause tumor-like hyperplasia to form hemangioma, some exist at birth, or can be seen shortly after birth, which is also indicated as congenital development. abnormal.
2. Others say that the capillary tissue is deformed after infection, leading to capillary dilatation; after local necrosis of liver tissue, the blood vessels dilate to form a vacuole, and the surrounding blood vessels are congested and dilated; the regional blood circulation in the liver is stagnant, causing the blood vessels to form a spongy dilatation; After internal hemorrhage, the hematoma is mechanized, and blood vessels are dilated to form a vasodilatation.
(two) pathogenesis
Hepatic cavernous hemangioma expands in a vasodilating form, not a malignant enlargement of neovascularization. The change of endocrine factors has an effect on the growth of hemangioma. Estrogen during pregnancy or oral administration may cause hemangioma. Rapidly increase and develop symptoms.
Hepatic cavernous hemangioma varies in size from small to needle-like, with a large weight of more than 10 kg. The naked eye is purple-red or blue-violet. It can be irregularly lobulated, with clear boundaries and irregular fibrous packets. Membrane, soft texture, smooth surface, elastic and compression filling, can also be hard due to fibrosis, most hemangioma often seen degenerative pathological changes, such as fibrous fibrosis, old thrombosis, glass It is accompanied by collagen increase and even calcification. The cavernous hemangioma is usually located under the liver capsule, and can also be deeply in the liver parenchyma. At this time, the liver surface may be depressed or bulged, and the liver parenchyma is clearly demarcated. The hepatic cavernous hemangioma may be Combined with hepatic cysts and hepatic adenomas, rarely coincide with cirrhosis. So far, no reports of malignant transformation of hepatic cavernous hemangioma have been reported in the literature.
The hepatic hemangioma has a mesh-like shape and can be classified into the following four types according to its fibrous tissue.
Cavernous hemangioma: the most common, generally referred to as hepatic hemangioma refers to cavernous hemangioma, the cut surface is honeycomb-shaped, filled with blood, visible cystic sinusoids of different sizes under the light microscope, lining the sinusoidal wall Layer endothelial cells, the sinusoids are often filled with red blood cells, sometimes with thrombosis, separated by fibrous tissue between the sinusoids, occasionally with compressed cell cords, large fibers separated by blood vessels and small bile ducts, fiber separation and tubes Calcification or venous stone formation may occur in the cavity, and a fibrous envelope is often formed around the tumor to demarcate from normal liver tissue.
Sclerosing hemangioma: The vascular cavity collapses or closes, the fibrous tissue is extremely rich, and the hemangioma is degenerative.
Vascular endothelial cell tumor: vascular endothelial cells proliferate actively, easily malignant, often confused with vascular endothelial cell sarcoma.
Capillary hemangioma: rare, characterized by narrowing of the vascular lumen and abundant fibrous tissue.
Prevention
Hepatic cavernous hemangioma prevention
Cavernous hemangioma is more common in adults, mostly single, slow growth, small tumors without any symptoms, and no treatment. Larger tumors show hepatomegaly, which can oppress adjacent organs, causing discomfort such as abdominal pain and bloating. The most dangerous complication of hepatic cavernous hemangioma is acute massive bleeding.
Complication
Hepatic cavernous hemangioma complications Complications, shock heart failure
Tumor rupture and hemorrhage, there may be severe pain in the upper abdomen and symptoms of hemorrhage and shock; when the pedicled tumor that grows outside the liver is twisted, tumor necrosis may occur, abdominal pain, fever and collapse may occur, and some cases have huge hemangioma. Arteriovenous fistula formation, resulting in increased blood flow and increased heart burden, leading to heart failure and death.
Symptom
Symptoms of hepatic cavernous hemangioma Common symptoms Loss of appetite, slow growth, difficulty swallowing, dyspnea, nausea, calcification, hernia, obstructive jaundice, ascites
The tumor grows slowly and has a long course of disease. The medical history can be traced back to many years ago. According to the clinical manifestations, it is divided into:
1. Asymptomatic type This type accounts for the vast majority (more than 80%), and has no feeling for life. It is unexpectedly found in B-ultrasound or abdominal surgery during normal physical examination.
2. Symptomatic type Usually, when the tumor diameter exceeds 4cm, symptoms may occur. Common symptoms are:
(1) Abdominal mass: more than half of the patients have this sign, the mass of the mass is sac sexy; no tenderness, the surface is smooth or not smooth, soft and hard, moving up and down with the breath, and some can hear the conduction in the mass of the mass. Vascular murmur.
(2) Gastrointestinal symptoms: There may be pain and discomfort in the right upper quadrant, as well as loss of appetite, nausea, vomiting, belching, postprandial swelling and indigestion.
(3) compression symptoms: tumor compression of the lower end of the esophagus, dysphagia can occur; compression of the extrahepatic biliary tract, obstructive jaundice and gallbladder effusion; compression of the portal system, splenomegaly and ascites can occur; oppression of the lungs, dyspnea and lungs No Zhang; oppression of the stomach and duodenum, gastrointestinal symptoms can occur; and so on.
The diagnosis of hepatic cavernous hemangioma is generally not difficult, and the vast majority can be diagnosed by asymptomatic, no history of hepatitis, AFP (-), combined with two or more typical imaging findings.
Examine
Examination of hepatic cavernous hemangioma
The diagnosis of this disease is not helpful, the general liver function is normal, the enzyme activity is not high, a few patients have red, white blood cells and thrombocytopenia, can return to normal after resection of hemangioma, blood changes in the case of giant hepatic cavernous hemangioma are more common In the 1980s, a group of 40 patients with giant hepatic cavernous hemangioma with a diameter of more than 15cm reported in the 1980s, half of the hemoglobin was below 1.55mmol/L (10g), and the lowest was only 0.96mmol/L (6.2g). There are 3/4 cases with white blood cell count below 5.0×109/L, and the lowest is only 2.2×109/L; one third of patients have platelet count below 100×109/L, and the lowest is only 40×109/L. After surgery, the hemangioma is restored to normal, and anemia and thrombocytopenia may be related to intratumoral thrombosis, which destroys red blood cells and consumes a large number of platelets.
The diagnosis of hepatic cavernous hemangioma depends mainly on imaging examination:
1. Ultrasound examination nearly 70% of hemangioma is strong echo, and the internal echo is even, the rest can be hypoechoic, echo or mixed echo, if there is calcification visible strong echo with sound shadow, color Doppler ultrasonography shows The blood flow signal in the hemangioma is rare, and some hemangioma may have a blood pool-like filling in the central part.
2. CT scan of cavernous hemangioma showed a low density and uniform density. The central part of the large hemangiomas showed a lower density zone, which was star-shaped, fissed or irregular, and occasionally calcified in the tumor. Circular or amorphous strong echo, the edge of the lesion is usually clear and smooth, and the typical enhanced scan is characterized by high density enhancement at the edge of the early lesion, and then the enhancement zone is progressively extended to the center, and the delayed scan lesion is filled with equal density, indicating "fast forward and slow The performance of hemangioma with a diameter less than 3cm is more complicated. It can be characterized by high density enhancement in the early stage of the lesion, and intensification of the lesion is not significant. It is lower than normal liver tissue, and all lesions in the delayed scan are filled with equal density. There are no enhancements in individual cases, and there is no filling in delayed scans. The wall of such hemangioma is very thick, the lumen is narrow, and the contrast agent is difficult to enter.
3. The radionuclide hepatic blood pool scan has a high diagnostic value for hepatic cavernous hemangioma. The red blood cells are labeled with 99mTc, and the blood flow can be visualized. The blood flow is rich or the stasis is concentrated. The cavernous blood vessels of the liver The tumor showed a concentration of radionuclide in the hemangioma at 5 min, gradually thickened, and did not dissipate after 1 h. This slow radioactive overfilling phenomenon is a characteristic basis for the diagnosis of hepatic cavernous hemangioma.
4. The MRI examination showed a long T1 long T2 signal, and the T2 image showed a relatively high signal, showing a "bulb sign".
5. Hepatic artery angiography is an invasive examination method. It has high sensitivity and specificity for hemangioma. It is stained around 2~3s after early injection. The contrast agent is cleared slowly and can be filled for more than 18s. This fast-forwarding phenomenon of contrast agents is a typical feature of hemangioma, which is called "early and late return".
It has been suggested that for the diagnosis of hepatic cavernous hemangioma, any ultrasonographic examination of focal lesions with a diameter of about 3 cm in the liver should be verified by CT or MRI. If the results are not consistent, hepatic blood pool scan or hepatic artery should be performed. Contrast examination, it is feasible to identify ultrasound-guided needle biopsy. In the past, fine needles were emphasized for suspicious hepatic cavernous hemangioma biopsy. However, fine needle biopsy results showed that it is difficult to observe typical tumors under 50% hepatic cavernous hemangioma. The structure of hemangioma is based on the diagnosis of hepatic cavernous hemangioma based on smear and no tumor cells. In the past 5 years, Dong Baozhen and other liver sponges have a safe approach (the needle passes through at least 1cm of normal liver parenchyma and then enters the mass). The hemangioma is 18G thick needle puncture, which can get larger tissue specimens, the diagnosis rate can reach 90%. Because the puncture process uses the cutting type automatic ejection biopsy device, the cutting speed is fast, so compared with the 20G fine puncture needle, The incidence of complications such as bleeding has not improved significantly. It is recommended to use 18G needle biopsy in the case of good indications.
Diagnosis
Diagnosis and diagnosis of hepatic cavernous hemangioma
The diagnosis of hepatic cavernous hemangioma is generally not difficult, and the vast majority can be diagnosed by asymptomatic, no history of hepatitis, AFP (-), combined with two or more typical imaging findings.
Differential diagnosis
Hepatic cavernous hemangioma is mainly differentiated from liver cancer or other benign lesions of the liver. Primary liver cancer is the most common hepatic malignant tumor. The incidence rate in China is very high. Therefore, it is clear that in the physical examination, the diagnosis of liver occupancy is helpful in ultrasound. Choose the right treatment in time.
1. Primary or metastatic liver cancer Primary liver cancer has chronic hepatitis B, a history of cirrhosis, abnormal liver function and elevated AFP. For patients with primary liver cancer with low AFP, medical history, physical examination and Ultrasound, CT and other examinations to identify, such as CT plain scan for low-density lesions, no envelope boundary is unclear, enhanced scanning lesions are unevenly enhanced, all support primary liver cancer, such as large lesion center necrosis bleeding can also cause density unevenness Metastatic liver cancer, mostly multiple, has a primary digestive system.
2. Patients with hepatic hydatid disease have a pastoral life history, with sheep, dog contact history, liver hydatid skin test (Casoni test) positive, eosinophil count increased.
3. Liver non-parasitic cysts Isolated single hepatic cysts are easy to distinguish from hepatic cavernous hemangioma. Only a few polycystic livers may be confused with hepatic cavernous hemangioma. Polycystic liver disease is more than 50% combined with polycystic kidney disease. It is multiple, mostly filled with liver, ultrasound, CT shows lesions of varying sizes, smooth borders, intact cystic cavity, may have family genetic factors.
4. Other hepatic adenomas, hepatic vascular endothelial cell sarcoma, are rare, although the former is also slow to develop, but the mass is hard like rubber; the latter develops faster, has malignant tumor characteristics, and is more common in adolescents.
