Giant liver hemangioma resected by trisectorectomy after efficient volume reduction by transcatheter arterial embolization: a case report

Abstract

IntroductionLiver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.Case presentationA 38-year-old Asian man was referred to our hospital with complaints of severe abdominal distension and pancytopenia. Examinations at the first visit revealed a right liver hemangioma occupying the abdominal cavity, protruding into the right diaphragm up to the right thoracic cavity and extending down to the pelvic cavity, with a maximum diameter of 43 cm, complicated with "asymptomatic" Kasabach-Merritt syndrome. Based on the tumor size and the anatomic relationship between the tumor and hepatic vena cava, primary resection seemed difficult and dangerous, leading us to first perform transcatheter arterial embolization to reduce the tumor volume and to ensure the safety of future resection. The tumor volume was significantly decreased by two successive transcatheter arterial embolizations, and a conventional right trisectorectomy was then performed without difficulty to resect the tumor.ConclusionsTo date, there have been several reports of aggressive surgical treatments, including extra-corporeal hepatic resection and liver transplantation, for huge hemangiomas like the present case, but because of its benign nature, every effort should be made to avoid life-threatening surgical stress for patients. Our experience demonstrates that a pre-operative arterial embolization may effectively enable the resection of large hemangiomas.

Enucleation versus hepatectomy for giant hepatic haemangiomas: a meta-analysis

“…22 Some authors have reported cases of huge haemangiomas that were successfully resected following effective TAE. 23 The results indicate the importance of preoperative management to reduce tumour size by TAE. This study had a number of limitations that should be acknowledged.…”

Successful liver resection in a giant hemangioma with intestinal obstruction after embolization

“…Although some authors reported that symptomatic giant liver hemangiomas can be managed successfully and non-invasively by TAE with a satisfactory decrease in symptoms and tumor volume [22] , the effect of TAE generally seems to be variable and sometimes even results in a volume increase [14,15] . However, there were reports that TAE for giant hemangiomas, performed prior to surgical resection, facilitated the mobilization of the liver by shrinking the hemangioma and, consequently, decreased intraoperative hemorrhage [9,23] . We also performed TAE before surgery to ensure the safety of the future radical resection of the tumor, which resulted in a decrease in the size of hemangioma, as shown in the previous report.…”

Diagnosis and Management of Giant Hepatic Hemangioma: The Usefulness of Contrast-Enhanced Ultrasonography

“…Giant hepatic hemangiomas greater than 20 cm in maximum diameter are often reported [24]. In a case with a giant hepatic hemangioma, since the image pick-up range of an ultrasonic probe is narrow, it is difficult to obtain an overall picture of the tumor.…”

“…On the other hand, large unresectable hemangiomas have been treated with transcatheter arterial embolization (TAE) [21] and liver transplantation [22, 23]. TAE is reportedly useful for reducing the tumor volume, which could potentially facilitate radical resection [24, 25]. A case of hepatic hemangioma with consumptive coagulopathy was also reported, and TAE appeared to ameliorate the coagulopathy and increase the safety of surgery [26].…”