Embolization of benign hepatics tumours. When, How and Why?

Transcription

1 Embolization of benign hepatics tumours. When, How and Why? Poster No.: C-1116 Congress: ECR 2015 Type: Educational Exhibit Authors: M. D. Ferrer-Puchol, C. La Parra Casado, R. Ramiro, R. Sala, A. Cremades, E. Esteban, A. Cervera, P. Poves, F. Carbonell Castelló ; Alzira/ES, Algemesí/ES Keywords: Liver, Vascular, Interventional vascular, Catheter arteriography, CT-Angiography, Embolisation, Surgery, Neoplasia DOI: /ecr2015/C-1116 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 62

2 Learning objectives Benign liver tumours occur frequently, and often encountered incidentally. In most cases they are accurately diagnosed by non-invasive radiologic imaging techniques. Most are asymptomatic, but some cause hepatomegaly, right upper quadrant discomfort, or intraperitoneal haemorrhage. Treatment is necessary only in a few specific circumstances. 1. To describe the most common benign hepatic tumours. 2. To review the indication, describing technique, embolization material and possible complications. 3. To present our experience in 7 cases: Giant cavernous hemangiomas (2) Hepatic adenoma (3) Hepatic adenomatosis (1) Focal nodular hyperplasia (1) N Sex Age Clinical Localization Size Embolization Surgery Diagnosis presentation 1 F 34 Abdominalleft mass lobe. 12cm Gelfoam CompleteFNH resection 2 F 43 Abdominalright lobe pain 15cm 2 CompleteCAVERNOUS emboliz resection HEMANGIOMA (PVA +coils) 3 F 23 Abdominalright / left pain. lobes Bleeding 14cm PVA + coils NO 4 F 70 Abdominalleft lobe 11cm disconfort PVA CompleteCAVERNOUS ADENOMATOSIS resection HEMANGIOMA Page 2 of 62

3 5 F 35 Abdominalleft lobe 11cm pain PVA CompleteADENOMA resection PVA CompleteADENOMA resection PVA Surgery ADENOMA pending Vomits 6 F 31 growing left lobe 8.8cm mass SLE 7 F 74 abdominalleft lobe 9cm pain Images for this section: Fig. 1: CASE 1. FOCAL NODULAR HYPERPLASIA. A 34-year-old woman presented with right upper quadrant abdominal pain and asthenia. Laboratory blood tests revealed elevation of GGT. Abdominal ultrasound showed and iso-echogenic mass in in the left liver lobe. Page 3 of 62

4 Fig. 2: Liver MRI with Gd-EOB-DTPA (Primovist (R)) in the arterial phase depicted a huge mass in the left liver lobe with intense enhancement, except for a central foci, considered a scar. Page 4 of 62

5 Fig. 3: Liver MRI with Gd-EOB-DTPA in the hepatocellular phase showed persistent enhancement of the hepatobilliary agent, typical finding of FNH. Page 5 of 62

6 Fig. 4: It was decided to embolize the lesion previous surgery to reduce the risk of bleeding. Aortography demonstrated the hypervascular lesion supplied by left liver artery. Page 6 of 62

7 Fig. 5: Selective angiography of the left hepatic artery from a microcatheter also showed tumor hypervascularity. Page 7 of 62

8 Fig. 6: Angiogram obtained before embolization with gelfoam showed truncation of the left hepatica artery. Page 8 of 62

9 Page 9 of 62

10 Fig. 7: 24 hours later the patient was operated and the tumor was removed without bleeding complications. Fig. 8: Central area showing interphase between fibrotic scar and hepatocellular nodules Page 10 of 62

11 Fig. 9: Ductular proliferation Page 11 of 62

12 Background Hepatic cavernous hemangiomas are the most common benign tumours of the liver. They arise from the mesoderm and are composed of blood-filled cavernous spaces of varying size lined with a single layer of flat endothelial cells, which may be separated by fibrous septa of variable thickness. In infants, hemangiomas often regress spontaneously by age 2 yr. However, large hemangiomas occasionally cause arteriovenous shunting sufficient to cause heart failure and sometimes consumption coagulopathy. In these cases, treatment may include high-dose corticosteroids, sometimes diuretics and digoxin to improve heart function, interferon alfa, surgical removal, selective hepatic artery embolization, and, rarely, liver transplantation. In adults, when they are larger than 4 cm are classified as giant cavernous hemangiomas, these can be symptomatics and present with pain or abdominal mass. Intraabdominal haemorrhage is rarely described and the incidence of spontaneous bleeding is unknown, but large subcapsular lesions are thought to be at greater risk. Treatment for symptomatic hemangiomas includes steroids, radiation therapy, surgical resection, hepatic arterial ligation, and transcatheter arterial embolization. Interventional procedures should be performed only in cases of: symptomatic hemangiomas hemangiomas that grow progressively hemangiomas with high risk of bleeding Hepatic adenomas are uncommon benign epithelial liver tumours. At histopathologic analysis, hepatic adenomas contain well-differentiated hepatocytes lacking bile ducts or portal triads. Predisposing factors to adenoma formation include oral contraceptive use in female patients, anabolic steroid use in male patients, and glycogen storage disease. Adenomas due to contraceptive use often regress if the contraceptive is stopped. These lesions may present with complications such as spontaneous bleeding (especially, patients with lesions >5 cm). Another complication is the possibility of malignant degeneration, but it is difficult to ascertain from the literature, two small studies reported the development of malignant transformation in 8-13 % of patients. Page 12 of 62

13 Adenomatosis is characterized by the presence of more than 10 adenomas, lack of association with steroids use. The bleeding appears to be common, particularyin patients who have adenomas larger than 4 cm that are in subcapsular location. Management: asymptomatic with small adenoma.conservative approach woman contemplating pregnancy.surgical resection pregnant woman.resection in second trimester symptomatic patients with large adenomas.presurgical embolization adenomatosis..liver transplantation. Focal nodular hyperplasia is the second most common benign tumour of the liver. It is thought to be secondary to a proliferative response of hepatocytes. It is present in 3 % of the population and is often found in women years old., typically asymptomatic and has no malignant potential. Rarely can produce symptoms of pain or discomfort. Hepatic resection has been the traditional treatment in symptomatic patients, but surgical resection carries significant risks. In studies with open surgical resection of hepatic lesions, complications rates range from 17.1 %-25 %. Embolization in Focal Nodular Hyperplasia: Arterial embolization previous to surgery could decease the risk of bleeding It may be a suitable and affective alternative in cases when resection is very difficult Page 13 of 62

14 There is a desire to spare normal hepatic parenchyma. BENIGN SYMPTOMATIC LIVER TUMOURS: Recent advances now offer selective transcatheter arterial embolization. The aim to embolization could be: To control acute haemorrhage To decrease bleeding during surgery To treat unresectable tumours The most common complications of embolization are: Pain Pyrexia Leucocytosis Nausea These symptoms could appear for a few days. Postembolization pain is due to thrombosis and necrosis. Severe complications are rare and include infection, hepatic abscess and sepsis, and migration of embolization agent. Images for this section: Page 14 of 62

15 Fig. 10: CASE 2. GIANT HEPATIC HEMANGIOMA. A 43-year-old woman was admitted to our hospital for right upper quadrant discomfort. Ultrasonography of the abdomen (not shown) depicted a giant, inhomogeneous lesion 15 cm in diameter suggestive of an hemangioma. Liver MRI revealed the solid hyperintese mass in the T2 TSE, relative to normal liver, well defined, with a central cystic area. Page 15 of 62

16 Fig. 11: Liver MRI with Gd in the equilibrium phase showed the centripetal progression of the peripheral, nodular and discontinuous contrast enhancement, typical of hemangiomas. Page 16 of 62

17 Fig. 12: Arteriography was made in order to embolize prior to liver resection. Page 17 of 62

18 Fig. 13: Parenchymal phase of selective arteriography showed a larger mass with contrast containing vascular spaces and the contrast material persisted into the venous phase. Page 18 of 62

19 Fig. 14: Embolization was made using PVA particles ( mcm). The postembolization angiography showed almost complete occlusion oh the hemangioma s supplying artery and its main branches. Page 19 of 62

20 Fig. 15: Ultrasonnography 24 hours after embolization. Page 20 of 62

21 Fig. 16: Contrast-enhanced CT after embolization showed persistence of lesion vascularization Page 21 of 62

22 Fig. 17: Peripheral vascularization of lesion persisted and we decided to repeat the intraarterial embolization. Page 22 of 62

23 Fig. 18: Second embolization showed feeding of hemangioma from frenic artery and from right liver artery branches. Page 23 of 62

24 Fig. 19: We decided to perform intraarterial embolization using particles and coils in the origin of feeding arteries. Page 24 of 62

25 Fig. 20: Liver resection. The hemorrhage from the hepatic raw surfaces was minimal. There was no bleeding from the mobilization of the right liver lobe from the retroperitoneal space where collateral vessels were dissected. Page 25 of 62

26 Fig. 21: Hemangioma resected. Page 26 of 62

27 Fig. 22: Blood- filles spaces Page 27 of 62

28 Fig. 23: Blood-filled spaces with a single layer of flat endothelial cells separated by fibrous septa Page 28 of 62

29 Findings and procedure details We describe indication, technique and follow up of patients. Transcatheter arterial embolization(tae) should be as selective as possible, in branches feedings the lesions. The choice of embolic material depends on the angiographic appearance. Selective TAE is a safe procedure owing to its minimal invasivness compared to exploration and surgical treatment. The development of microcatheters has provided useful tools for selective embolization. The risk of concomitant ischemic damage of liver paremchyma remains low because of portal vein supply to the liver, but caution is necessary to not compromise branches of the major liver arteries. Materials available for embolization are: gelfoam steel coils polyvinyl particles Complications of TAE are rare and mostly consist of: complications of the angiographic procedure use of contrast medium postembolization syndrome: (pain, nausea and fever) Images for this section: Page 29 of 62

30 Fig. 24: CASE 3. LIVER CELL ADENOMATOSIS. A 23-year-old woman presented with acute onset of right upper abdominal pain combined with abdominal distension. No abdominal trauma was occurred. Abdominal ultrasound showed echogenic lesions in both lobes and a subcapsular hematoma in the right liver lobe. A presumptive diagnosis of multiple liver adenomas was made. Page 30 of 62

31 Fig. 25: Abdominal CT without contrast. Multiple focal liver lesions, well defined, with variable attenuation, containing areas of increased attenuation secondary to hemorrhage foci (arrows). Page 31 of 62

32 Fig. 26: Abdominal CT in arterial phase revealed variable enhancement of the mass (asterisks), with subcpasular feeding arteries (arrows). Page 32 of 62

33 Fig. 27: Selective angiogram of the common hepatic artery showed the large adenomas in both lobes. We decode to embolize the largest adenoma responsible of bleeding. Page 33 of 62

34 Fig. 28: PVA and coils were use to embolize the largest lesion. Page 34 of 62

35 Conclusion In some cases reduction in size post-embolization can control symptoms related to mass effect, before or, in selected cases, avoiding surgery. Images for this section: Fig. 29: CASE 4. CAVERNOUS HEMANGIOMA. A 70- year-old woman was admitted to our hospital for abdominal discomfort. Abdominal CT showed a hypodense well-defined Page 35 of 62

36 large mass with some coarse calcifications in the left hepatic lobe causing parenchymal compresion. Fig. 30: Contrast enhanced CT, in the arterial phase, showed a peripheral nodular and discontinous enhancement. Noteworthy is the greater prominence of the left gastric and left hepatic arteries feeding the mass. Page 36 of 62

37 Fig. 31: Abdominal CT in delayed phase depicted the progressive centripetal enhancement of the mass. Page 37 of 62

38 Fig. 32: Venous phase. Uniform enhancement of the mass with some attenuation areas which yielded a finding corresponding to fibrous scarring or fat. Page 38 of 62

39 Fig. 33: We performed intraarterial embolization previous to surgery. Aortography. Page 39 of 62

40 Fig. 34: Left gastric artery angiography showed how the mass is fed. Page 40 of 62

41 Fig. 35: No significant residual flow to the lesion. Embolization was made using PVA mc particles. Page 41 of 62

42 Fig. 36: The macroscopic view of the mass in the left hepatic lobe demonstrated the calcification inside the tumor. Page 42 of 62

43 Fig. 37: Hystological study of the mass revealed the anastomosed vessels of the haemangioma. Some polyvinyl alcohol spherical particles inside the calibre of the vessels. Page 43 of 62

44 Fig. 38: CASE 5. ADENOMA. A 35 years old woman, with a history of ovarian stimulation for assisted reproductive treatment presented with abdominal pain and vomits. Imaging techniques revealed a huge liver mass. MRI T1WI without contrast showed intratumoral blood products (arrows), and a big cystic central area. Page 44 of 62

45 Fig. 39: Liver MRI with Gd in the arterial phase revealed intense enhancement of the solid peripheral aspect, that appeared hyperintense on T2WI (not shown). Page 45 of 62

46 Fig. 40: Liver MRI in the arterial phase showing the solid enhancing superior aspect. Page 46 of 62

47 Fig. 41: Liver MRI in the equilibrium phase showing wash out of the hiperenhancing foci, with a pseudocapsule formation (arrows). Page 47 of 62

48 Fig. 42: Angiogram previous embolization showed the hyperascularized peripheral aspect of the lesion, feeded by the left hepatic artery, and the central cystic area. Embolization was made using PVA particles. Page 48 of 62

49 Fig. 43: Control post-embolization showed complete cessation of blood flow to the adenoma. Page 49 of 62

50 Personal information MD Ferrer-Puchol, C La Parra, R Ramiro and E Esteban are members of staff in Radiology Department. R Sala, P Poves and F Carbonell Castelló are members of staff in Surgey Department. A Cremades is member of staff in Pathology Department. A Cervera is Resident in Radiology. Images for this section: Fig. 44: CASE 6. HEPATIC ADENOMA. A 31-year-old woman with medical history of systemic lupus erithematosus (SLE) and chronic renal failure that required peritoneal Page 50 of 62

51 dialysis. Ultrasonography performed during a SLE control detected a hypo-isoechoic lesion in left liver lobe (58 x 31 mm in diameter), that was studied with MRI (not shown) and considered an FNH. Fig. 45: 4 years later, new routine imagine examinations revealed a mass growth until 8.8 cm, and further examinations with liver MRI revealed hyperenhancement of the mass in the arterial phase, and realtive wash out in delayed pase, consistent with adenoma vs FNH). Page 51 of 62

52 Fig. 46: Liver MRI in the venous phase showed the relative wash out. Given the growth and the suspicious of adenoma surgical removal was recommended. Page 52 of 62

53 Fig. 47: Transarterial embolization previous surgery was performed. Patients had two left hepatic arteries. Left hepatic artery originated directly from the celiac trunk and the other from the left gastric artery This image shows the origin from left gastric artery (dominant artery). Page 53 of 62

54 Fig. 48: Irrigation from the left hepatic artery Page 54 of 62

55 Fig. 49: Left hepatic artery completely occluded using PVA particles ( mc). A left hepatectomy was safely conducted after ligation of left hepatic artery and left branch of portal vein. Page 55 of 62

56 Fig. 50: Pathology study showed well-differentiated hepatocytes lacking bile ducts or portal triad. Page 56 of 62

57 Fig. 51: The patient s postoperative course was uneventful. CT 6 month following surgery showed left hepatectomy. Liver function was normal. Page 57 of 62

58 Fig. 52: CASE 7. ADENOMA. A 74 years old woman was referred to the radiology department for abdominal pain, nausea and vomits. Liver MRI revealed a left liver lobe mass, hyperenhancing in the arterial phase with Gd, with central areas of fat, hemorrhage and necrotic foci, with subcapsular feeding arteries (arrow), consistent with adenoma. Page 58 of 62

59 Fig. 53: Liver MRI in the equilibrium phase depicted the pseudocapsule formation (arrow). Note the compression to the major gastric curvature (arrowheads). Page 59 of 62

60 Fig. 54: Selective angiogram showed a hypervascularized mass in the left liver lobe corresponding to liver adenoma Page 60 of 62

61 Fig. 55: CT 1 month after embolization showed significant decrease in size and absence of gastric compression, but persistent of arterial enhancement in the medial and posterior aspects. Page 61 of 62

62 References Birn J, Williams TR, Croteau D et al. Transarterial embolization of symptomatic focal nodular hyperplasia. J Vasc Interv Radiol 2013;24: Vassiou K, Rountas H, Liakou P, etal. Embolization of a giant hepatic hemangioma prior to urgent liver resection. Case report and review of a literature. Cardiovasc Intervent Radiol 2007;30: Anderson SW, Kruskal JB, Kane RA. Benign hepatic tumors and itrogenic pseudotumors. RadioGraphics 2009; 2: Barthelmes L, Tait IS. Liver cell adenoma and liver cell adenomatosis. HPB (Oxford) 2005;7: Curry MP, Afdhal NH. Hepatic Adenoma. UpToDate 2014 Zhou JX, Huang JW, Wu H at al. Successful liver resection in a giant hemangioma with intestinal obstruction after embolization. World J Gastroenterol 2013;19: Erdogan D, van Delden OM, Busch OR et al. Selective transcatheter arterial embolization for treatment of bleeding complications or reduction of tumor mass of hepatocellular adenomas. Cardiovasc Intervent Radiol 2007; 30: Page 62 of 62