Chin J Radiol 2004; 29: 263-268 263

73-year-old male was a victim of sigmoid coloncancer. He received a sigmoid-colectomy 10 yearsago. He suffered from watery diarrhea about 3times per day for 2-3 months recently. Magneticresonance imaging (MRI) showed a heteroge-neously enhanced mass in the transverse colon anda 9x8.2 cm well-marginated mass in the left lobe ofthe liver. The hepatic tumor showed mixed signalintensity on T1-weighted imaging (T1WI ), lowsignal intensity with small spotted high signals onT2-weighted imaging (T2WI). Recurrent coloncancer with liver metastasis was impressed. Thepatient received transverse and descending-colec-tomy and left hepatectomy. Histopathologicalexamination showed solitary hepatic mass virtuallyfilled with yellowish white necrotic material. Adark-red, blood clot-like substance at the peripherywas noted in gross. In microscopic examination, theliver tumor was composed entirely of fibrin clotand blood clot at center with closely aggregated,ectactic and congested thin- walled vessels at smallfocal area at the periphery of the tumor. Hepatichemangioma coexisting with a transverse colonmucinous adenocarcinoma was diagnosed by thepathologist.

The MRI findings did not showed the character-istics of hepatic hemangioma. The atypical appear-ance was due to marked hemorrhagic necrosis ofthe tumor. We report this unusual case, and suggest

to consider the possibility of atypical hemangiomain liver masses with similar imaging patterns.

Key words: Atypical hepatic hemangioma, Coloncancer, Magnetic resonance (MR) imaging, Necrosis.

Cavernous hemangioma is the most commonbenign tumor of liver [1], and it is usually an incidentalfinding of imaging study in asymptomatic patients.Differentiating hemangioma from other hepaticneoplasms is important, and computed tomography(CT) and sonography usually permit a definitediagnosis without resorting to angiography. MRimaging is highly reliable for diagnosis of typicalhemangioma, which has a sensitivity and specificity ofmore than 90% [2]. Most cavernous hemangiomashowed characteristic findings in MR imaging: veryhigh-signal on T2WI (especially in heavily T2WI),low-signal on T1WI, and peripheral nodular enhance-ment with fill-in phenomenon, and delayed washout indynamic study [3]. The presence of typical imagingfeatures of hemangioma can lead to the correctdiagnosis and vice versa [4]. Here we presented onecase which was mis-diagnosed as solitary liver metas-tasis from colon cancer because of its atypical MRappearance and the underlying malignancy in the colon.

CASE REPORT

A 73-year-old male was a victim of sigmoid coloncancer and received a sigmoid colectomy 10 years ago.Recently, he suffered from watery diarrhea about 3times per day for 2-3 months. No obvious body weightloss or abdominal pain was noted. LGI series showed arecurrent transverse colon cancer. He was admitted forfurther evaluation. After admission, laboratory exami-nation showed normal liver function, normal AFP, highCEA of 27.1 ng/ml (CEA normal range: 0-4 ng/ml),

Reprint requests to: Dr. Ran- Chou ChenDepartment of Radiology, Taipei Municipal Jen-Ai Hospital.No. 10, Sec 4, Jen Ai Road, Taipei 106, Taiwan, R.O.C.

Necrotic Hepatic Hemangioma MimickingLiver Metastasis at the MR Imaging:a case report MENG-YU CHEN

1 RAN-CHOU CHEN1 JIUNN-MING LII

1 CHAO-SHIANG LI1 WEN-CHANG SHU

2 LI-SHUN SHIH3

HSING-YANG TU1

Department of Radiology1, Surgery2, Pathology3, Taipei Municipal Jen-Ai Hospital

and strong positivity of stool occult blood (3+).Abdominal sonography revealed an 8.5x7 cm, mixedechoic tumor in the left lateral segment of the liver.Colonscopy showed a polypoid colon cancer in thetransverse colon.

Hepatic MR imaging was arranged with a 1.5-TMR machine (Philips Gyroscan ACS-NT,Netherlands), and a phased-array body coil. Turbospin-echo (TSE) T2-weighted images (TR, 1800msec;TE, 100msec; TSE factor, 23) without and with fat sat-

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Figure 1. 73- year-old man with giant hemangioma of leftlateral segment of liver and adenocarcinoma in transversecolon who presented with strong positive for stool occultblood, watery diarrhea and high level of serum CEA .a.T1-weighted MR image (T1WI) showed iso to high signalin the center with irregular low signal at the periphery ofthe tumor in the left hepatic lobe.b. T2-weighted MRimage showed generalized low signal intensity with smallscattered spotted high signal foci of the tumor. c. earlyarterial phase contrast-enhanced T1WI showed negativeenhancement of the tumor. d. porto-venous phase contrast-enhanced T1WI showed two small foci of peripheralnodular enhancement of the tumor. e. Delayed (7-8 minsafter IV injection) fat saturated T1WI showed slightlyincreased prominence of the nodular enhancement of thetumor.

1a 1b

1c

1e

1d

uration under respiratory trigger, heavily T2-weightedimages (TR/TE, 3680/120; TSE factor, 23) and T1-weighted images (TR, 210 msec; TE, in phase 2.3msec and out phase 4.6 msec) were obtained duringone breath hold. Dynamic study was done using fastfield echo (FFE) images (218/1.5; flip angle, 80˚) pre-contrastly, 18-20 seconds (arterial-dominant phase),50-55 seconds (portal-phase), and 7-8 minutes(delayed phase) after a manual intravenous injectionof gadopentetate dimeglumine (Magnevists; Schering,Berlin, Germany; 0.1mmol per kilogram of bodyweight). Delayed axial and coronal imaging wereperformed about 7-8 minutes after IV injection. Thesepulse sequences were performed with a single acquisi-tion during one breath hold.

MRI revealed a well-marginated 9 × 8.2 cm massin the left lobe of the liver (Fig. 1a-1e) which showediso to high signal intensity in the center with irregu-larly low signal intensity in the periphery on T1 WI(Fig. 1a) and generalized low signal intensity withsmall scattered, spotted high signal foci on T2 WI(Fig. 1b). Contrast enhanced dynamic MR scanshowed negative enhancement of the lesion in theearly arterial phase (Fig. 1c), two small foci of periph-eral nodular enhancement in the porto-venous phase(Fig. 1d), and slightly increased prominence ofnodular enhancement in the delayed fat saturatedimages (Fig. 1e).

MRI also revealed a 5.4x5 cm mass in the trans-verse colon. Recurrent colon cancer with atypical livermetastasis was impressed by MRI study.

The patient received transverse and descending-colectomy and left hepatectomy. A transverse colonictumor and a 9.8 × 9.0 × 7.5 cm solitary mass in the leftlateral segment of the liver were found. The pathologyevaluation showed a hemorrhagic necrotic hepaticmass filled with yellowish white and necrotic tissue.Thin irregular shaped blood clot-like substance at theperiphery was also noted in gross specimen (Fig. 2a).In microscopic examination, the hepatic tumor wascomposed entirely of fibrin clot and blood clot atcenter with closely aggregated, ectactic and congestedthin- walled vessels at small focal area at periphery ofthe tumor (Fig. 2b). The colon specimen showed awhitish tumor with multicystic pooling of mucoidmaterial, which invaded through the muscle layer tothe pericolonic fat and retracted the serosal surface.Mucinous adenocarcinoma of the colon coexistingwith a necrotic hepatic hemangioma was diagnosed.

DISCUSSION

The previous literature reported 7 types ofatypical hemangioma on MR imagings, whichincluded [5]: 1). Large, heterogeneous hemangiomas:greater than 4cm [6], well circumscribed, heteroge-neous enhancement [7], markedly hypointense onT1WI and markedly hyperintense center on T2 WI [7,8]. 2). Rapidly filling hemangioma: mostly small (<1cm in diameter) [9, 10]. 3). Calcified hemangiomas:low signal intensity of calcification part on T2 WI [11,12]. 4). Hyalinized hemangiomas: only slightly high

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Figure 2. The histological appearance of the hepatic tumor: a. The gross specimen showed one 9.8x9.0x7.5 cm solitarynecrotic mass composed mainly of yellowish white and necrotic tissue, with an irregular rim of dark-red, blood clot-likesubstance at the periphery. b. Under microscopy, the tumor composed almost entirely of fibrin clot and blood clot,surrounded by thick fibrous capsule. Ectatic thin-walled vessels were noted at the periphery of this tumor.

2a 2b

signal intensity on T2WI [13], lack of early enhance-ment [8] and slight peripheral enhancement in the latephase [13]. 5). Cystic or multilocular hemangiomas:one or several fluid-filled cavities [14]. 6).Hemangiomas with fluid-fluid levels [15, 16], and 7).Pedunculated hemangiomas: The lesion can beattached to the liver by a thin pedicle [17, 18].

Our case is one of the large, heterogeneoushemangioma (greater than 4 cm) [6]. The typicalimaging features of large hepatic hemangiomas areheterogeneous signal intensity with markedlyhypointense center on T1WI, incomplete filling-in indelayed phase of dynamic study and markedly hyper-intense on T2 WI [4]. However our case showed iso tohigh signal intensity on T1 WI (Fig. 1a), predomi-nently low signal intensity with small scattered spottedhigh signal foci on T2 WI (Fig. 1b), negative enhance-ment in the early arterial phase (Fig. 1c) and periph-eral small spotted enhancement in the porto-venousphase (Fig. 1d). It is not concordant with any one ofthe atypical hemangiomas mentioned in the above byVilgrain V. et al [5].

The atypical imaging patterns of large heman-gioma are closely correlated with the macroscopicappearance such as hemorrhage, thrombosis, necrosis,extensive hyalinization, liquefaction and fibrosis [5].The reasons for central core nonenhancement of thehemangioma were given by Johnson et al. [19], whichIncluded: 1). slow flow in the central sinusoids. 2).central fibrosis. 3). central thrombosis. 4). hemor-rhage. 5). complete hyalinization.

Compared with the pathologic findings, the lackof central core enhancement in our case was due to itshemorrhagic necrotic nature (Fig 2a) which correlatedwell with the previous report [5]. The atypical presen-tation of iso to high signal intensity on T1 WI and lowsignal intensity with small scattered spotted highsignal foci on T2 WI was resulted from the blood clotand fibrin clot occupying the tumor (Fig 2b), whichwas concordant with the atypical hemangiomamentioned in the report by Coumbaras M. et al [4].

This case was mis-diagnosed as solitary livermetastasis from colon cancer due to the atypical MRpresentation resulted from the marked hemorrhagicnecrosis of the cavernous hemangioma and the under-lying malignancy in colon.

We suggest that the diagnosis of cavernoushemangioma with hemorrhagic necrosis should beconsidered when the hepatic mass had low signalintensity with small spotted high signal foci on T2 WI,peripheral enhanced foci in porto-venous phase andincreased nodular enhancement in the delayed fatsaturated images on contrast enhanced MR images.

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