Arterial Embolization of Giant Hepatic Hemangiomas Constantinos Giavroglou, Hippolete Economou, Ioannis Ioannidis Department of Radiology, AHEPA Hospital, Aristotle University of Thessaloniki, Greece Abstract Hepatic cavernous hemangiomas are usually small and asymptom- atic. They are usually discovered incidentally and only a few require treatment. However, giant hemangiomas may cause symp- toms, which are indications for treatment. We describe four cases of symptomatic giant hepatic hemangiomas successfully treated with transcatheter arterial embolization, performed with polyvinyl alco- hol particles. There were no complications. Follow-up with clinical and imaging examinations showed disappearance of symptoms and decrease in size of lesions. Key words: Hemangioma, Therapeutic embolization—Giant cav- ernous hemangioma—Liver hemangioma—Embolization Cavernous hemangioma is the most common primary tumor of the liver. It is a benign tumor with an estimated prevalence of 5%–7% [1, 2]. Most of them are small and asymptomatic and usually discovered incidentally. However, giant hemangiomas are some- times symptomatic, requiring treatment. Corticosteroids, radiation therapy, cytotoxic agents, and surgical resection are the traditional methods used in the past [3– 8]. Recently, arterial embolization has been suggested as an alternative treatment. A few reports have suggested that palliation of symptoms can be accomplished less invasively with transcatheter arterial embolization, used either alone or as a preoperative procedure prior to surgical resection [8 –15]. We present four patients with symptomatic giant hepatic cav- ernous hemangioma successfully treated with transcatheter arterial embolization. Case Reports Case 1 A 28-year-old woman was admitted to our hospital complaining of inter- mittent mild pain in the right upper quadrant. Laboratory studies were normal. The abdominal ultrasound showed a large (8  6 cm) hepatic lesion that was identified as a probable hemangioma. The CT scan showed an enhancing mass within the right lobe and the technetium-labeled red blood cell study demonstrated a large solitary hypervascular mass. The diagnosis of hemangioma was confirmed angiographically. The patient was dis- charged with the suggestion to be followed up sonographically. For a 12-year period the lesion remained unchanged in appearance and size. After this, the pain became more intense and frequent. US study and MRI examination showed that the lesion had increased to 10  7 cm without any change in appearance. The portal vein was patent. Since no other diseases were found during her second hospitalization, hemangioma was presumed to be the cause of symptoms and it was decided, with consent, to perform embolotherapy. The right hepatic artery was superselectively catheterized and the feeding artery, distal to the cystic artery origin, was embolized with particles (150 –250 m) of polyvinyl alcohol (Ivalon). In the follow-up angiography there was absence of flow in the arterial supply of the hem- angioma. No complications were observed. Three years later, the patient is free of symptoms. The size of lesion, in the US study, decreased moderately (from 10  7 cm to 7  5.5 cm) with some changes in its internal echotexture (it became more inhomogeneous when compared with the pretreatment US studies). Case 2 A 58-year-old man was admitted to our hospital for severe pain in the right lower abdomen and a feeling of distention. On physical examination the abdomen was soft. Laboratory studies were normal. Ultrasonography, CT scan, and MRI of the abdomen showed three hepatic lesions, already known from previous examinations (3 years ago) as possible hemangiomas. These lesions remained unchanged in size and appearance compared to the pre- vious imaging procedures. The largest lesion (9  5.5 cm) was located in the left lobe. Portal vein was patent. Because the symptoms continued and the hepatic lesions were not thought to be the possible cause, an exploratory laparotomy was performed. The exploratory laparotomy findings were neg- ative for the abdomen and open biopsy confirmed the diagnosis of heman- giomas. After laparotomy, the symptoms were still present and an embolotherapy of the large hepatic lesion was suggested as the most appropriate treatment. Consent was obtained before embolization. The left hepatic artery was superselectively catheterized and subsequently emboli- zed with particles (150 –250 m) of Ivalon. Follow-up arteriography showed complete occlusion of the embolized vessel. There were no com- plications. Fifty-four months later the patient remains free of symptoms. In the US study, the internal echotexture of hemangioma was changed (became more inhomogeneous) and the size of the tumor decreased from 9  5.5 cm to 8  4.5 cm. Case 3 A 57-year-old woman was admitted to our hospital for mild abdominal pain in the hypogastrium. US study, CT scan, and MRI of the abdomen revealed three hepatic lesions: two measured less than 3 cm and the third was a large (10.5  8 cm) lesion located in the left lobe. The imaging characteristics of the lesions and the contrast enhancement pattern were typical for heman- giomas. The patient was discharged with the suggestion to be followed up sonographically. For a period of 2 years the lesion remained stable in size; the last 4 months the pain became more intense. Laboratory studies were normal. New CT scan and MRI examination showed no changes compared with the previous studies. The portal vein was patent. Since no other pathologic condition was present we determined that the hepatic lesions were the cause of the symptoms and we elected to perform embolization of Correspondence to: Constantinos Giavroglou, M.D., 8, Pavlou Mela Street, 54622 Thessaloniki, Greece; email: giacon@med.auth.gr Cardio V ascular and Interventional Radiology © Springer-Verlag New York, Inc. 2003 Cardiovasc Intervent Radiol (2003) 26:92–96 Published Online: 2 January 2003 DOI: 10.1007/s00270-002-2648-8