A 57-year-old Taiwanese hepatitis B carrier female presented with a one-week history of epigastric pain, anorexia, malaise, intermittent nausea and vomiting in the preceding 6 months. Abdominal sonography revealed an ill-defined heterogeneous hyperechoic mass with internal calcification in the right lobe of the liver. Abdomen computed tomography and Magnetic Resonance Imaging showed a large lobulated mass and calcification in the right lobe liver. The image finding are compatible with a giant calcified hepatic hemangioma.
Hepatic, Calcification, Hemangioma, Necrosis, Heterogeneous
A 57-year-old Taiwanese hepatitis B carrier female with peptic ulcer disease presented with a one-week history of epigastric pain, anorexia, malaise, intermittent nausea and vomiting in the preceding 6 months. Her vital signs and physical examination were unremarkable, except for crackles and dullness to percussion over the right upper lobe. Laboratory investigation were unremarkable, except for a platelet count of 115 × 103/μL. Abdominal sonography revealed an ill-defined heterogeneous hyperechoic mass with internal calcification in the right lobe of the liver (Figure 1A). Abdomen computed tomography showed a large lobulated mass (15 × 12 cm2) with central cystic change, necrosis, peripheral nodular enhancement, and calcification in the right lobe liver (Figure 1B). Magnetic Resonance Imaging revealed high intensity signal on T2-weighted images, a globally heterogeneous lesion with zones of central calcification appear in hypointense (Figure 1C). The image finding are compatible with a giant calcified hepatic hemangioma. The patient declined further liver biopsy and was discharged after conservative treatment.
Hepatic hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases [1]. Hepatic hemangioma is female-predominant and seldom causes symptoms unless being of a giant size defined as larger than 10 cm in diameter, which may be complicated by hemorrhage, rupture, or intralesional hemolysis. It rarely requires surgical intervention except in the case of rupture, intratumoral bleeding, organ or vessel compression occurring. Calcification is a rare finding of hepatic hemangioma and seen in less than 10% of cases, usually in the central scar of the giant hemangioma. They attest to the presence of phleboliths [1]. The differential diagnosis of calcified hepatic tumor includes hepatocellular adenoma, hemangioma, hepatocellular carcinoma, fibrolamellar carcinoma, intrahepatic cholangiocarcinoma, epithelioid hemangioendothelioma and calcifying liver metastases from colon carcinoma [2].
Figure 1: A: Abdominal sonography revealed an ill-defined heterogeneous hyperechoic mass with internal calcification and obvious acoustic shadow in the right lobe of the liver.
B: Abdomen computed tomography showed a huge hepatic mass 15 × 12 cm2 with central cystic change, necrosis and calcification in the right lobe liver and early peripheral zones of enhancement compared with the central zone of progressive centripetal filling.
C: Magnetic Resonance Imaging revealed high intensity signal on T2-weighted images, a globally heterogeneous lesion with zones of central calcification appear in hypointense.