MASSIVE HEMANGIOMAS OF THE LIVER*HARIWELL WILSON, M.D., AND WILLIAM T. TYSON, JR., M.D.

MEMPHIS, TENN.

LARGE HEMANGIOMAS of the liver are notfrequently encountered by surgeons. Smallones are occasionally seen during the courseof laparotomy or at autopsy, but such casesusually have little clinical significance.Shumacker27 in 1942, presented a carefulreview of the literature and was able tocollect only 66 cases of hemangiomas of theliver that had been operated upon. Resec-tion of the tumor was performed in 56 ofthese cases. Shumacker reported an addi-tional case of his own and mentioined thatno one surgeon had reported having oper-ated upon more than a single case. SinceShumacker's article there have been de-tailed reports of 17 other cases, bringing thetotal number of cases in which operationhas been performed to 84.2, 3, 5, 7, 9, 14,17-21,24-28 Resection of the tumor has been car-ried out in 71 of these cases. Preston andPriestley discussed seven patients operatedupon at the Mayo Clinic with symptomsand signs attributed to tumor of the liver.22Four of these seven cases were found to beinoperable. A detailed report of these caseswas not recorded. Shuller et al. report thesuccessful removal by Ochsner of a heman-gioma of the liver from an infant 22 daysold with recovery of the patient.26Because of the gravity of the problem

which may be presented by hemangiomasof the liver and because of the relativelylow incidence of occurrence, it seems worthwhile to briefly review the problem of diag-nosis and treatment and to present our ex-

perience with three large hemangiomas ofthe liver.Hemangiomas of the liver are practically

always of the cavernous type, and consid-erable caution is warranted in approachingthese tumors. D'Errico has emphasized theseriousness of spontaneous or accidentalrupture of these lesions. He found reportsof 14 cases in which rupture occurred, withdeath in all but two.8 Mantle reported adeath from hemorrhage resulting from as-piration of a hemangioma of the liver witha fine needle during the course of a laparot-omy.15 MacNaughton-Jones lost a patientas a result of a persistent ooze of bloodafter what appeared to be a successful re-section of such a tumor.13 Biopsy of ahemangioma may present a difficult prob-lem in controlling hemorrhage. In spite ofthe difficulties mentioned above, many largehemangiomas may be dealt with surgicallyin a relatively safe manner provided thatthe resection is done through normal livertissue. The importance of cutting throughnormal liver tissue rather than through vas-cular tumor was emphasized by Horslevin 1916.11

INCMIENCE

Liver hemangiomas of significant sizehave 'been found by surgeons in individualsof all ages, the extremes being 22 days and76 years. The majority of the patients op-erated upon have been in the third andfourth decades of life. These tumors havebeen found much more frequently inwomen than in men and the left lobe ofthe liver has been involved more frequently

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* Read before the Southern Surgical Associa-tion, Hot Springs, Virginia, December 5, 1951.

WILSON AND TYSON

than the right. In a few instances there hasbeen extensive involvement of both lobes.A correct diagnosis has seldom been madeprior to operation.

SIGNS AND SYMPTOMS

A patient with a large hemangioma ofthe liver usually presents himself to a phy-sician because of an abdominal mass or be-cause of pressure symptoms resulting from

A

FIG. 1.-Case 1 (A) This shows extent of the h(liver. (B) Gross appearance o:

such a mass. Patients occasionally state thatthe mass varies in size at different times.Chronic digestive symptoms such as nau-

sea, anorexia, and vomiting are not uncom-

mon and usually result from pressure ofthe tumor upon the stomach or some otherportion of the upper gastro-intestinal tract.Wakeley reported a case in which therewas marked dysphagia resulting from pres-

sure upon the cardia of the stomach by a

large hemangioma of the left lobe of theliver.29 Patients who at first notice only a

change in the size of the abdomen or- thepresence of a definite mass are apt later tocomplain of digestive symptoms. Chroniccholecystitis or peptic ulcer may be simu-lated. Rupture of the hemangioma may

occur and be the cause of unexplained

shock. The patient may present symptomssuggestive of acute appendicitis, perforatedpeptic ulcer or acute diverticulitis. Severaldeaths have been reported following rup-

ture of a hemangioma of the liver, and in a

few instances bleeding hemangiomas havebeen successfully resected after the abdo-men had been explored because of acuteabdominal symptoms produced by thehemorrhage.

B

emangioma, which appeared to involve the entiref the liver as seen at operation.

TREATMENT

In 1892, Hanks treated an angioma ofthe liver by galvanism, an electrode beingplaced beneath the rib margin.10 The tumoris said to have diminshed in size. In 1897,Keen brought such a tumor outside theabdominal cavity, placed an elastic tourni-quet about its base and excised the mass

six days later with subsequent recovery ofthe patient.12 In 1903, Cripps successfullyresected a cystic hemangioma of the liver,closing the abdomen without drainage.6As early as 1902, Carl Beck recognized thefact that intraperitoneal resection was pref-erable to exteriorization, although he re-

ported a case which he successfullv treatedby the latter method.4

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Excision of the tumor is the treatment ofchoice where this can be accomplished byperforming the resection through normalliver tissue. Overlapping through-and-through mattress sutures tied over Gelfoamwill usually permit a resection throughnormal hepatic tissue without difficulty.Hemangiomas of the liver which cannot be

through longitudinal incisions. We feel thatplacing a Penrose-type drain through a

stab wound is important because of the pos-

sibility of bile peritonitis which may oc-

casionally occur following hepatic surgery.

Resection of the left lobe may be greatlyfacilitated by division of the avascular liga-ment attaching it to the diaphragm.

A

FIG. 2.-Case 2. (A) Dotted line reveals extent of abdominal mass. Solid line shows bilateralsub-costal incision. (B) Appearance of tumor which involved almost entire left lobe of liver.

resected may be treated by roentgen ray

therapy. Several such cases have been re-

ported with favorable response in mostinstances.'6' 18, 23, 24 Bronson Ray placed sil-ver clips around the border of such a tu-mor and made roentgen films immediatelyafter operation and at intervals followingroentgen ray therapy.23 The tumor is saidto have decreased to about one-sixth itsoriginal size.The best exposure for resection of the

liver can be obtained through a generoustransverse inverted U-shaped incisionplaced subcostally. However, since the cor-

rect diagnosis is rarely made prior to op-eration, most resections have been done

CASE REPORTS

Case 1.-M. R., a white woman 53 years ofage, first consulted her physician in January,1950, because of jaundice, fever, pruritis, clay-colored stools, and vague upper abdominal dis-comfort. Cephalin flocculation and thymol tur-bidity tests were normal, although the BSP testshowed 100 per cent retention of the dye after 30minutes. Roentgen ray examination of the gall-bladder, upper gastro-intestinal tract and colonwas negative. The inferior border of the liver was

palpable 8 fingerbreadths below the right costalmargin and the left lobe was considerably en-

larged also. The diaphragm was elevated and thestomach depressed by the mass. The icterus indexvaried from 9 to 100 units. She had undergone a

hysterectomy 6 years previously and was told atthat time that her liver was enlarged.

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It was felt that she probably had infectioushepatitis and she was treated accordingly withoutmuch improvement, although her jaundice fluctu-ated clinically.

In November, 1950, 10 months after her initialclinical symptoms, exploratory laparotomy was per-formed under general anesthesia through a rightrectus incision. A massive, diffuse cavernous

hemangioma involving the entire liver was found(Fig. 1). A biopsy of the liver was obtained andbleeding was controlled with difficulty through theuse of Gelfoam and chromic catgut mattress sutureson an atraumatic needle.

She returned to us 5 years later in November,1950. Laparotomy had been performed 2 years

previously in another hospital. A large heman-gioma of the liver was found, biopsy performed,and the abdomen closed. The complaint at thetime of admission in 1950 was that of pain in thelower right chest and epigastrium. A firm, movable,irregular mass approximately 18 cm. in diameterwas easily palpable in the upper abdomen. Thismass at times was felt more to the right and on

other occasions seemed more to the left of themidline.

FIG. 3.-(Case 2) Appearance of liver after resection of tumor of left lobe. Note overlappingmattress sutures used to control hemorrhage from cut edge of liver.

Following surgery the jaundice, pruritis, andclay-colored stools continued with only slightperiods of remission. Six months after surgery,from May 4 to May 18, 1951, she was given roent-gen ray therapy consisting of a total of 700 r. tothe midline of the abdomen on the right over theliver through 2 anterior and posterior ports. Thehalf value layer consisted of 0.95 mm. of copper.

From August 27 to September 20, 1951, she re-

ceived 2700 r. to the midline of the right side ofthe abdomen through anterior and posterior portsover the liver with a half value layer of 2.25 mm.

of copper. Considerable nausea was experiencedduring the course of treatment. There has beensome decrease in the size of the liver and thejaundice has diminished slightly.

Case 2.-A. M. H., a colored female 34 years ofage, was first seen in the John Gaston Hospital inSeptember, 1945. Her chief complaint at that timewas a sense of fullness in the epigastrium follow-ing meals. A freely movable mass about 15 cm. indiameter was palpable in the epigastrium. Surgerywas refused by the patient and she left the hospital.

The abdomen was opened under general anes-

thesia through a transverse incision, which was

curved with the convexity in a cephalad direction.A large hemangioma of the left lobe was found(Fig. 2). The left lobe was mobilized by dividingits ligamentous attachment to the diaphragm.Practically the entire left lobe was resected, afterfirst placing overlapping mattress sutures of catgutthrough normal liver tissue well away from thetumor (Fig. 3). Very little loss of blood occurred.A Penrose drain was brought out through a stabwound before closure of the abdomen. The patientmade an uneventful recovery and was dischargedon the sixteenth day following operation.

Case 3.-L. A., a white female 44 years of age,was admitted to the Baptist Memorial HospitalApril 15, 1951, complaining of intermittent epi-gastric discomfort of several months' duration. Attimes the pain radiated around the right costal mar-

gin toward the back and a tentative diagnosis ofchronic cholecystitis was made. Peptic ulcer andhiatus hernia were also considered in the differ-ential diagnosis. Appendectomy and suspension of

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the uterus had been performed elsewhere 14 yearsbefore. Roentgen ray studies revealed a fillingdefect 5 cm. in diameter in the fundus of thestomach. The lesion preoperatively was thought tobe a benign gastric neoplasm.

The abdomen was opened through a high leftrectus incision. There was found a hemangioma of

the liver 4 cm. in diameter which was causing anindentation of the fundus of the stomach near thecardia. The triangular ligament was severed, per-mitting good mobilization of the left lobe. Over-lapping mattress sutures were placed through nor-mal liver tissue on either side of the tumor and awedge of hepatic tissue, including the hemangioma,was removed (Fig. 4). The raw edge of the liverwas covered with Gelfoam. Loss of blood was in-significant. A Penrose drain was brought outthrough a stab wound. Recovery was uneventfuland the patient was discharged ten days followingoperation.

A

of excision

'Deformityof stomach due

-wp-- ------ --to pressure of tumor

FIG. 4.-Case 3. (A) Incision through the left rectus muscle. (B) Hemangioma of leftlobe of liver producing filling defect in stomach. The line of excision is well beyond thetumor margin. (C) Left lobe after excision of tumor.

SUMMARY

A brief review of the incidence, clinicalmanifestations, and treatment of hemangi-oma of the liver is given. Three cases ofmassive hemangiomas of the liver are pre-

sented. All three occurred in women. Twoof these were in the left lobe and resectionDswere successfully performed.

In the other case the entire liver ap-peared to be involved by the hemangioma,making it unsuitable for excision. Some im-provement followed rotentgen ray therapy.

BIBLIOGRAPHYAlsen, P.: Two Operatively Treated Cases of

Hemangioma of the Liver. Acta chir. Scan-dinav., 96: 403, 1948.

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2 Altman, W. A.: Resection of Left Lobe of Liverfor Benign Hfemangioma, Report of a Case.J. A. M. A., 146: 254, 1951.

3 Ayres Netto, P., and J. Amorim: HemangiomaCavernoso do Lobo Esquerdo do Figado. Rev.de Cir. de Sao Paulo, 8: 257, 1942.

4 Beck, C.: Surgery of the Liver. J. A. M. A.,38: 1063, 1902.

* Caldwell, K. P. S.: Spontaneous intraperitonealHemorrhage due to Hemangioma of theLiver. Brit. M. J., 2: 1155, 1950.

6 Cripps, H.: Large Naevoid Tumor Removedfrom the Liver. Brit. M. J., 2: 18, 1903.

7 D'Errico, G.: I Cavernomi del Fegato: 2 CasiOperati di Resezione Epatica. Riforma Med.,60: 168, 1946.

8 -- : I Cavernomi del Fegato di InteresseChirurgico. Rivista Critica della Letteratura:71 Casi Operati. Gior. ital. chir., 2: 267,1946.

9 Hamilton, F. E., and R. H. Holmes: CavernousHemangioma of the Left Lobe of the Liver.Report of a Case. U. S. Armed Forces M. J.,1: 443, 1950.

10 Hanks, H. T.: Angioma of the Liver. Am. J.Obst., 25: 229, 1892.

Horsley, J. S.: Cavernous Angioma of the Liver.Interstate M. J., 23: 347, 1916.

12 Keen, W. W.: Removal of an Angioma of theLiver by Elastic Constriction External to theAbdominal Cavity, with a Table of 59 Casesof Operation for Hepatic Tumors. Pennsyl-vania M. J., 1: 193, 1897.

13 MacNaughton-Jones, H.: Large Angioma of theLiver Simulating Movable Kidney. Brit.Gynaec. J., 65: 40, 1901.

14 McKenzie, E. E.: Hemangioma of the Liver.Memphis M. J., 24: 20, 1949.

15 Mantle, A.: An Unusually Large Angioma ofthe Liver. Brit. M. J., 1: 365, 1903.

16 Morris, J. H.: Hemangioma of Liver, SuccessfulResection of Left Lobe. Ann. Surg., 111:147, 1940.

17 Morton, H. B.: Large Pendunculated CavernousHemangioma of the Liver, Case Report. Am.J. Surg., 56: 673, 1942.

18 O'Donaghue, J. B., and A. J. Nicosia: Caver-nous Hemangioma of the Liver. Illinois M.J., 98: 15, 1950.

19 Paulino, F., P. B. Pereira, and A. Pemintel: Ex-tirpaco Total do Lobo Esquerdo do Figadoem um Caso de Hemangioma Cavernosa,cura rev. brasil. de cir., 20: 839, 1950.

20 Peale, A. R., and J. N. Coombs: Large Heman-gioma Successfully Removed Surgically, Re-port of Case. Am. J. Clin. Path., 16: 792,1946.

21 Pickrell, K. L., and R. C. Clay: Lobectomy ofthe Liver, Report of 3 Cases. Arch. Surg.,48: 267, 1944.

22 Preston, F. W., and J. T. Priestley: Hemangiomaof the Liver. J. Iowa M. Soc., 40: 47, 1950.

23 Ray, B. S.: Large Cavernous Hemangiomata ofthe Liver, Report of an Inoperable CaseTreated with Roentgenotherapy. Ann. Surg.,109: 373, 1939.

24 Riddler, J. G., and S. F. Madding: Hemangiomaof the Liver, Report of a Case. Surgery, 25:744, 1949.

25 Seneque, J., and R. Aurousseau: Des possibilitesde l'hepatectomie dans le traitement destumeurs du foie. J. de chir., 66: 22, 1950.

26 Shuller, T., J. L. Rosenzweig and J. B. Arey:Successful Removal of Hemangioma of theLiver in an Infant. Pediatrics, 3: 328, 1949.

27 Shumacker, H. B.: Hemangioma of the Liver:Discussion of Symptomatology and Report ofPatient Treated by Operation. Surgery, 19:209, 1942.

28 Symmers, W. St. C., and J. N. Ward-McQuaid:Successful Resection of a Large CavernousLymphangiomatoid Tumor of the Liver of aChild Aged 19 Months. Brit. J. Surg., 38:12, 1950.

29 Wakeley, C. P. G.: A Large Cavernous Heman-gioma of the Left Lobe of the Liver CausingObstruction to the Cardiac Orifice of theStomach. Brit. J. Surg., 12: 590, 1925.

DIscusSION.-DR. WILLIAM F. RIENHOFF, JR.,Baltimore, Md.: I have enjoyed Doctor Cheno-weth's presentation of his two cases very muchindeed. I had the pleasure of reading his papersome time ago and I think his results are mostinteresting and gratifying.

I wonder if the second case he reported hasnot re-canalized the common hepatic arterythrough the single ligature which he applied. It is

my opinion that this patint should be re-operatedupon and perhaps the artery should be dividedinstead of being ligated in continuity.

I wish to emphasize one point particularly; thatis, one should be conservative and not too enthu-siastic about the effectiveness of this procedure atthe present time. This may prove to be just anotheroperation for the relief of intrahepatic portalhypertension, and fail as frequently as all those

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