Three cases of histologically proven hepatic epithelioid hemangioendothelioma evaluated using a second-generation microbubble contrast medium in ultrasonography: case reports

Abstract

BackgroundHepatic epithelioid hemangioendothelioma (HEH) is rare; it is reported in < 1 person in 1,000,000 individuals. For accurate diagnosis, information regarding multiple graphic modalities in HEH is required. However, there is very little information concerning Sonazoid® contrast enhanced ultrasonography (CEUS) in HEH.Case presentationThe present report describes the histologically proven three HEH cases evaluated using Sonazoid® CEUS. Case 1 was a 33-year-old female patient with no relevant past medical history, who experienced right upper quadrant pain. Conventional abdominal US revealed multiple low echoic liver nodules with vague borderlines. In CEUS, the vascularity of the nodules was similar to that seen in the neighboring normal liver. Later in the portal venous and late phases (PVLP) and post vascular phase, washout of Sonazoid® was detected in the nodules. Case 2 was a 93-year-old female patient with a previous medical history including operations for breast cancer and ovary cancer in her 50’s. Conventional abdominal US revealed multiple low echoic nodules, some of which contained cystic lesions. In the early vascular phase of CEUS, nodules excluding the central anechoic regions were enhanced from peripheral sites. Although the enhancement inside the nodules persisted in both the PVLP and post vascular phase, anechoic areas in the center of some nodules were not enhanced at all. Case 3 was a 39-year-old male patient presented with right upper-quadrant pain, without any relevant past medical history. Conventional abdominal US revealed multiple low echoic liver nodules. In the early vascular phase of CEUS, nodules were gradually enhanced from the peripheral sites as ringed enhancement. Sonazoid®was washed out from the nodules in the PVLP and post vascular phase.ConclusionsThe most important feature was peripheral enhancement in the early vascular phase. In case 2, the enhancement of the parenchyma of liver nodules persisted even in the PVLP; indicating the lower degree of malignant potential than others. Actually, the tumors did not extend without any treatment in case 2. Since case 2 is the first case report of HEH with cystic lesions, in patients with liver nodules including cystic lesions, HEH is a potential diagnosis.

Laparoscopic resection of hepatic epithelioid hemangioendothelioma: report of eleven rare cases and literature review

“…HEHE is an extremely rare borderline tumor of mesenchymal tissue-vascular endothelium origin and affects less than one in a million individuals [ 7 ]. The degree of malignancy of epithelioid hemangioendothelioma varies greatly between benign disease and aggressive cancer with widespread metastases.…”

Contrast-Enhanced Ultrasound as a Main Radiological Diagnostic Method for Primary Liver Neoplasms and Hemangiomas

“…CEUS can be used as a reliable method for differentiation between focal liver lesions and malignant neoplasms [12]. Hepatic epithelioid hemangioendothelioma (HEHE) are rare, low-grade sarcomas and the diagnosis is quite tricky for radiologists [20], as well as for pathologists [21]. The study by Klinger et al shows three main types of enhancements for HEHE: centripetal enhancement with washout, rim-like hyperenhancement with washout, and inversed target sign with washout [22].…”

Muscular Metastasis of Hepatocellular Carcinoma: Case Report and Literature Review

“…Sonazoid is a second-generation microbubble contrast medium used in CEUS to visualize the vascular pattern inside liver nodules (20)(21)(22). A bolus of Sonazoid suspension was intravenously injected, and the vascular phase was defined as previously reported (23). In brief, the phases from 15 to 30 seconds and from 30 seconds to 2 minutes after injection were defined as the early vascular phase and the portal venous and late phases (PVLP), respectively (24).…”