A 56-year-old man who had hematuria for 2 weeks underwent ultrasonography. This disclosed a well-circumscribed cyst in the lower pole of the left kidney and echogenic foci in the upper pole of the right kidney, without any evidence of posterior shadowing. A hyperechoic, well-circumscribed, circular focus was also seen in the right lobe of the liver. Abdominal CT confirmed the presence of a left renal cyst and revealed a 4.7-cm hypodense lesion in the right lobe of the liver, which suggested hemangioma.
Accordingly, a technetium Tc 99m sulfur colloid autologous-labeled red blood cell scan was carried out, and this revealed hypoperfusion to the lower anterior right lobe of the liver (A). Immediate blood-pool images showed faint filling of this area, and delayed images demonstrated increased activity in this area (B, right anterior oblique; C, right lateral). The increased activity was also observed in single-photon emission CT (SPECT) images.
Hemangiomas are the most common benign tumors of the liver. Although they are usually asymptomatic, extremely large lesions can produce compressive symptoms, and spontaneous thrombosis or hemorrhage may cause pain. Their characteristic pathologic feature is their large blood volume.
Because of their prevalence, hepatic hemangiomas are often detected (frequently incidentally, as in this case) during ultrasonographic or CT abdominal examination. The radionuclide study makes a virtually 100% accurate diagnosis—a necessity, since biopsy of a hemangioma can cause significant hemorrhage.
The characteristic features on a radionuclide scan are little or no blood flow to the lesion on the early images and a typical appearance of increased activity on the delayed blood-pool images. On the delayed planar or SPECT images, accretion of the tagged red blood cells in the lesion is equal to or greater than in the surrounding liver parenchyma. Other types of lesions (eg, hepatic carcinoma and metastatic disease) can exhibit increased blood flow and early accretion of the radiolabeled cells, but they do not retain the cells as long as do hemangiomas. This case and the accompanying image studies were sent by Drs Navin Verma, Terence M. Brady, and Sonia Arunabh of Flushing, NY.