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IMAGES IN RADIOLOGY
Year : 2009  |  Volume : 55  |  Issue : 4  |  Page : 290-291

Giant hemangioma of liver presenting as deep vein thrombosis of the lower limbs


Department of Radiodiagnosis,All India Institute of Medical Sciences,New Delhi - 110 029, India

Date of Submission12-Jul-2008
Date of Decision03-Sep-2009
Date of Acceptance05-Sep-2009
Date of Web Publication14-Jan-2010

Correspondence Address:
D N Srivastava
Department of Radiodiagnosis,All India Institute of Medical Sciences,New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.58939

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How to cite this article:
Madhusudhan K S, Srivastava D N, Gamanagatti S. Giant hemangioma of liver presenting as deep vein thrombosis of the lower limbs. J Postgrad Med 2009;55:290-1

How to cite this URL:
Madhusudhan K S, Srivastava D N, Gamanagatti S. Giant hemangioma of liver presenting as deep vein thrombosis of the lower limbs. J Postgrad Med [serial online] 2009 [cited 2020 Feb 26];55:290-1. Available from: http://www.jpgmonline.com/text.asp?2009/55/4/290/58939


Hemangiomas are the most common benign tumors of the liver occurring in 0.4-20%. [1] These tumors are soft and seldom cause compression of bile ducts, portal vein or inferior vena cava (IVC). Rarely, hemangioma of the caudate lobe compresses the IVC, especially when it is large in size (giant hemangiomas) or when it becomes hard by internal hemorrhage or thrombosis. [1] We present a case of thrombosis of bilateral iliac and femoral veins (DVT) and IVC caused by giant hemangioma in the caudate lobe of the liver.

A 58-year-old male presented with short history of painful swelling of both the lower limbs. A similar episode that had occurred six months back had resolved spontaneously. Examination revealed pitting edema and normal arterial pulses in the lower limbs. Abdominal examination was unremarkable. Color Doppler ultrasonography of the lower limbs showed thickened irregular wall and luminal narrowing of the femoral veins. Intraluminal echogenic thrombus was seen extending from the superficial femoral veins to lower IVC [Figure 1]a. Abdominal scan showed a well-defined hyperechoic mass in the caudate lobe of the liver, compressing the IVC [Figure 1]b. Multiphase computed tomography (CT) scan showed central patchy enhancement of the lesion in arterial phase with complete filling in delayed phase. The mass completely obstructed the IVC. A diagnosis of atypical hepatic hemangioma occluding the IVC with DVT of the lower limbs was made. The coagulation profile was normal and functional assay of Protein-C showed normal activity (89%). The patient was treated with heparin (IV bolus of 6000 U followed by infusion of 1000 U per hour for six days), which resulted in reduction of the limb edema and he was discharged a week later. Oral anticoagulant (Warfarin 2 mg, once a day) was advised for two months. Magnetic resonance imaging (MRI) of the abdomen done two months later showed the lesion to be hypointense on T1-weighted and hyperintense on the T2W images [Figure 2]a. Multi-phasic contrast MRI showed central patchy enhancement in arterial phase, which progressively increased in size in portal venous and equilibrium phases with complete opacification of the lesion at delayed images taken at one hour [Figure 2]b and c. These features were suggestive of hemangioma with atypical enhancement. The patient had no limb edema and oral anticoagulation was discontinued. As the patient was asymptomatic, and the liver lesion was benign, surgery was deferred. He is on regular clinical and sonographic follow-up.

Compression of IVC is commonly caused by malignant tumors; few cases of benign lesions causing IVC compression are found in the literature. [2] In a study of 24 patients with giant hemangiomas, only three had IVC compression; but none of them had symptoms related to it, indicating partial obstruction.[3] Cases of IVC thrombus due to liver hemangioma, that have resulted in pulmonary thromboembolism without DVT have been reported. [4]

Sonography plays a vital role in evaluation of patients with DVT. Usually only the pelvis is scanned for any tumors responsible for thrombosis. Our case underlines the importance of screening the entire abdomen to search for a cause. Hemangioma on multiphase contrast-enhanced CT or MRI shows peripheral nodular enhancement in the early phase and gradual centripetal filling in the delayed phase. Giant hemangiomas usually show incomplete central filling-in due to central fibrosis or thrombosis. [1],[3] In our case, the hemangioma showed central patchy enhancement in early phase and complete filling in delayed phase; such a pattern is unusual in giant hemangiomas. [3] Hemangiomas are usually 'no-touch' lesions. Most are managed conservatively; symptomatic lesions may require surgical excision or angioembolization.[5] However, in some situations, surgery may not be beneficial and a conservative approach is appropriate, as was decided in our case.

 
 :: References Top

1.Coumbaras M, Wendum D, Monnier-Cholley L, Dahan H, Tubiana JM, Arrive L. CT and MR imaging features of pathologically proven atypical giant hemangiomas of the liver. AJR Am J Roentgenol 2002;179:1457-63.  Back to cited text no. 1      
2.England RA, Wells IP, Gutteridge CM. Benign external compression of the inferior vena cava associated with thrombus formation. Br J Radiol 2005;78:553-7.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Danet IM, Semelka RC, Braga L, Armao D, Woosley JT. Giant hemangioma of the liver: MR imaging characteristics in 24 patients. Magn Reson Imaging 2003;21:95-101.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Paolillo V, Sicuro M, Nejrotti A, Rizzetto M, Casaccia M. Pulmonary embolism due to compression of the inferior vena cava by a hepatic hemangioma. Tex Heart Inst J 1993;20:66-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Srivastava DN, Gandhi D, Seith A, Pande GK, Sahni P. Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: A prospective study. Abdom Imaging 2001;26:510-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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