DOI: 10.1148/rg.236035024
(Radiographics. 2003;23:1649-1655.)
© RSNA, 2003
Infantile Hemangioendothelioma1
Justus E. Roos, MD,
Roger Pfiffner, MD,
Thomas Stallmach, MD,
Gerd Stuckmann, MD,
Borut Marincek, MD and
Ulrich Willi, MD
1 From the Institutes of Diagnostic Radiology (J.E.R., R.P., B.M.) and Pathology (T.S.), University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland; the Institute of Radiology, Cantonal Hospital Winterthur, Switzerland (G.S.); and the Institute of Radiology, Children’s Hospital Zurich, Switzerland (U.W.). Received January 30, 2003; revision requested March 10; revision received April 28; accepted April 28. Address correspondence to J.E.R. (e-mail: justus.roos@dmr.usz.ch).
Index Terms: Hemangioendothelioma, 761.3199 • Liver, CT, 761.1211 • Liver, MR, 761.1214 • Liver, US, 761.1298 • Liver neoplasms, diagnosis, 761.1211, 761.1214, 761.1298 • Liver neoplasms, in infants and children, 761.3199
 |
History
|
|---|
A 1-month-old baby girl presented with failure to thrive after an uneventful gestation and normal delivery. Physical examination showed a palpable mass in the left hemiabdomen but was otherwise unremarkable. Lactic dehydrogenase and ferritin levels were increased, whereas the 
-fetoprotein level was normal and testing for ß–human chorionic gonadotropin was negative. Various imaging procedures demonstrated a large, left upper abdominal tumor arising from the left hepatic lobe. The tumor was completely removed surgically. Histologic analysis demonstrated infantile hemangioendothelioma. Follow-up ultrasonography (US) showed no recurrence.
|
Imaging Findings
|
|---|
Thoracoabdominal radiography showed a homogeneous mass without calcification located in the left upper abdominal quadrant and displacing the transverse colon medially and caudally. The lungs, cardiomediastinal silhouette, and pulmonary vessels were normal. Abdominal US demonstrated a solid, well-defined heterogeneous left hepatic mass (8 x 6 x 6 cm) with a hypoechoic rim demarcating the mass from the normal liver parenchyma. Vascular structures in the adjacent part of the left hepatic lobe seemed compressed by the mass. Tiny intratumoral hyperechoic structures were interpreted as small calcifications (Fig 1). The spleen, kidneys, and adrenal glands were normal.
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Transverse US scan through the midabdomen shows a solid, heterogeneous but well-defined left hepatic mass. Arrows indicate demarcation between the mass and the normal liver parenchyma. The small hyperechoic structures (arrowheads) may represent tiny spots of calcification.
|
|
Magnetic resonance (MR) imaging with axial and coronal gradient-echo T1-weighted and fast spin-echo T2-weighted sequences was performed before and after intravenous administration of gadopentetate dimeglumine. MR imaging demonstrated a left-sided intraperitoneal tumor (8 x 5 cm) extending from the left hemidiaphragm to the pelvis in close relationship with the inferior surface of the spleen and the upper pole of the left kidney and displacing the stomach and adjacent intestine. Both adrenal glands were normal. On T2-weighted MR images, the tumor had high signal intensity centrally and intermediate signal intensity peripherally (Fig 2a, 2b). On unenhanced T1-weighted images, the tumor was hypointense relative to the normal liver and spleen; after contrast material injection, there was strong nodular enhancement peripherally and no contrast material uptake centrally (Fig 2c). No further involvement of the liver or other organ systems (including the adrenal glands, spinal canal, and bone marrow) was detected.
View larger version (166K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Axial (a) and coronal (b) fast spin-echo T2-weighted MR images demonstrate a large, mostly hyperintense mass with an isointense, somewhat irregular border in the left hemiabdomen. The axial image demonstrates the close relationship between the mass and the anteroinferior splenic surface (arrowhead) and the upper part of the left kidney (*). The coronal image shows that the mass displaces and compresses the stomach (arrows). (c) Axial contrast material-enhanced gradient-echo T1-weighted MR image demonstrates intense nodular enhancement at the tumor periphery and complete absence of contrast material in the bulk of the mass due to extensive tumor necrosis.
|
|
View larger version (147K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Axial (a) and coronal (b) fast spin-echo T2-weighted MR images demonstrate a large, mostly hyperintense mass with an isointense, somewhat irregular border in the left hemiabdomen. The axial image demonstrates the close relationship between the mass and the anteroinferior splenic surface (arrowhead) and the upper part of the left kidney (*). The coronal image shows that the mass displaces and compresses the stomach (arrows). (c) Axial contrast material-enhanced gradient-echo T1-weighted MR image demonstrates intense nodular enhancement at the tumor periphery and complete absence of contrast material in the bulk of the mass due to extensive tumor necrosis.
|
|
View larger version (144K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2c. Axial (a) and coronal (b) fast spin-echo T2-weighted MR images demonstrate a large, mostly hyperintense mass with an isointense, somewhat irregular border in the left hemiabdomen. The axial image demonstrates the close relationship between the mass and the anteroinferior splenic surface (arrowhead) and the upper part of the left kidney (*). The coronal image shows that the mass displaces and compresses the stomach (arrows). (c) Axial contrast material-enhanced gradient-echo T1-weighted MR image demonstrates intense nodular enhancement at the tumor periphery and complete absence of contrast material in the bulk of the mass due to extensive tumor necrosis.
|
|
Abdominal computed tomography (CT) showed an exophytic mass arising from the lateral aspect of hepatic segments II and III. At unenhanced CT, the tumor appeared mostly hypoattenuating (25 HU) relative to the normal liver parenchyma, with small areas of peripheral hyperattenuation representing calcifications (Fig 3a). Contrast-enhanced arterial phase CT showed intense contrast enhancement of the tumor periphery, mainly from arterial supply of hepatic segments II and III (Fig 3b). Early contrast material drainage by hepatic veins and persistent peripheral enhancement during the portal venous phase were present (Fig 3c). The central portion of the tumor demonstrated no enhancement during any imaging phase (Fig 3b–3d) due to central necrosis and fibrosis, which was confirmed histopathologically. The tumor was partially surrounded by a thin, hypoattenuating rim.
View larger version (86K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. (a) Axial unenhanced CT scan demonstrates faint hyperattenuating areas (arrowheads) surrounding the mass. (b, c) Contrast-enhanced arterial phase (b) and portal venous phase (c) CT scans show the mass with lower attenuation (25 HU) than that of the normal liver parenchyma. There is nodular enhancement of the tumor periphery (cf Fig 2c). Persistence of enhancement suggests the presence of peripheral venous lakes (arrows in c). Note also the change in aortic caliber above and below the celiac origin (double arrowheads) and the large size of the celiac artery (c). (d) Delayed CT scan obtained about 15 minutes after intravenous contrast material administration shows no enhancement in the tumor centrally due to extensive necrosis and fibrosis.
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. (a) Axial unenhanced CT scan demonstrates faint hyperattenuating areas (arrowheads) surrounding the mass. (b, c) Contrast-enhanced arterial phase (b) and portal venous phase (c) CT scans show the mass with lower attenuation (25 HU) than that of the normal liver parenchyma. There is nodular enhancement of the tumor periphery (cf Fig 2c). Persistence of enhancement suggests the presence of peripheral venous lakes (arrows in c). Note also the change in aortic caliber above and below the celiac origin (double arrowheads) and the large size of the celiac artery (c). (d) Delayed CT scan obtained about 15 minutes after intravenous contrast material administration shows no enhancement in the tumor centrally due to extensive necrosis and fibrosis.
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3c. (a) Axial unenhanced CT scan demonstrates faint hyperattenuating areas (arrowheads) surrounding the mass. (b, c) Contrast-enhanced arterial phase (b) and portal venous phase (c) CT scans show the mass with lower attenuation (25 HU) than that of the normal liver parenchyma. There is nodular enhancement of the tumor periphery (cf Fig 2c). Persistence of enhancement suggests the presence of peripheral venous lakes (arrows in c). Note also the change in aortic caliber above and below the celiac origin (double arrowheads) and the large size of the celiac artery (c). (d) Delayed CT scan obtained about 15 minutes after intravenous contrast material administration shows no enhancement in the tumor centrally due to extensive necrosis and fibrosis.
|
|
View larger version (111K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3d. (a) Axial unenhanced CT scan demonstrates faint hyperattenuating areas (arrowheads) surrounding the mass. (b, c) Contrast-enhanced arterial phase (b) and portal venous phase (c) CT scans show the mass with lower attenuation (25 HU) than that of the normal liver parenchyma. There is nodular enhancement of the tumor periphery (cf Fig 2c). Persistence of enhancement suggests the presence of peripheral venous lakes (arrows in c). Note also the change in aortic caliber above and below the celiac origin (double arrowheads) and the large size of the celiac artery (c). (d) Delayed CT scan obtained about 15 minutes after intravenous contrast material administration shows no enhancement in the tumor centrally due to extensive necrosis and fibrosis.
|
|
The abdominal aorta just proximal to the celiac origin was 3 mm wider in maximum diameter than the immediate infracelica aorta (Fig 3b, 3c). No other abnormalities were found at CT.
|
Pathologic Evaluation
|
|---|
Laparotomy showed a large, gray-red exophytic tumor arising from the lateral part of the left hepatic lobe. The transverse colon was displaced medially and caudally (Fig 4a). The gross surgical specimen manifested as a well-circumscribed oval mass with a smooth and glittery surface. The cut surface appeared white-red, somewhat solid, partially stranded, and centrally fibrotic with no evidence of hemorrhage. The tumor capsule contained abundant blood vessels (Fig 4b). Microscopic examination revealed extensive necrotic areas interspersed with moderately cellular, markedly myxoid connective tissue with variable vascular spaces as well as bile ducts (Fig 5a, 5b). The vascular spaces were lined by layers of endothelial cells without polymorphism. Some larger vessels showed signs of thrombosis of various duration. Several islands of extramedullary hematopoiesis and calcification were also present (Fig 5c, 5d).
View larger version (100K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4a. (a) Intraoperative photograph shows a large, well-circumscribed, gray-red exophytic tumor (arrows) with a smooth and glittery surface. The tumor arises from the lateral part of the left liver lobe and displaces the transverse colon (arrowheads). (b) Photograph of the sectioned surgical specimen shows a cross-section surface that is more or less homogeneous, partially stranded, and centrally fibrotic. No large areas of hemorrhage are evident. The periphery is characterized by abundant blood vessels of different sizes (arrowheads).
|
|
View larger version (110K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4b. (a) Intraoperative photograph shows a large, well-circumscribed, gray-red exophytic tumor (arrows) with a smooth and glittery surface. The tumor arises from the lateral part of the left liver lobe and displaces the transverse colon (arrowheads). (b) Photograph of the sectioned surgical specimen shows a cross-section surface that is more or less homogeneous, partially stranded, and centrally fibrotic. No large areas of hemorrhage are evident. The periphery is characterized by abundant blood vessels of different sizes (arrowheads).
|
|
View larger version (180K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5a. (a, b) Photomicrographs (original magnification, x40 [a] and x100 [b]; hematoxylin-eosin stain) (b is a magnified view of the area bounded by the rectangular box in a) reveal extensive areas of necrotic tumor (arrows) between moderately cellular connective tissue with vascular spaces of varying widths and some bile ducts (BD). (c, d) Photomicrographs (original magnification, x200 [c] and x400 [d]; hematoxylin-eosin stain) show vascular non-blood-filled spaces lined by endothelial cell layers without polymorphism. Nests of hematopoiesis (arrowheads) are also visible.
|
|
View larger version (169K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5b. (a, b) Photomicrographs (original magnification, x40 [a] and x100 [b]; hematoxylin-eosin stain) (b is a magnified view of the area bounded by the rectangular box in a) reveal extensive areas of necrotic tumor (arrows) between moderately cellular connective tissue with vascular spaces of varying widths and some bile ducts (BD). (c, d) Photomicrographs (original magnification, x200 [c] and x400 [d]; hematoxylin-eosin stain) show vascular non-blood-filled spaces lined by endothelial cell layers without polymorphism. Nests of hematopoiesis (arrowheads) are also visible.
|
|
View larger version (188K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5c. (a, b) Photomicrographs (original magnification, x40 [a] and x100 [b]; hematoxylin-eosin stain) (b is a magnified view of the area bounded by the rectangular box in a) reveal extensive areas of necrotic tumor (arrows) between moderately cellular connective tissue with vascular spaces of varying widths and some bile ducts (BD). (c, d) Photomicrographs (original magnification, x200 [c] and x400 [d]; hematoxylin-eosin stain) show vascular non-blood-filled spaces lined by endothelial cell layers without polymorphism. Nests of hematopoiesis (arrowheads) are also visible.
|
|
View larger version (166K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5d. (a, b) Photomicrographs (original magnification, x40 [a] and x100 [b]; hematoxylin-eosin stain) (b is a magnified view of the area bounded by the rectangular box in a) reveal extensive areas of necrotic tumor (arrows) between moderately cellular connective tissue with vascular spaces of varying widths and some bile ducts (BD). (c, d) Photomicrographs (original magnification, x200 [c] and x400 [d]; hematoxylin-eosin stain) show vascular non-blood-filled spaces lined by endothelial cell layers without polymorphism. Nests of hematopoiesis (arrowheads) are also visible.
|
|
|
Discussion
|
|---|
Hepatic tumors in children are relatively uncommon (about 2%–3% of all pediatric tumors) (1,2). However, infantile hemangioendothelioma is the third most common hepatic tumor in children (12% of all childhood hepatic tumors), the most common benign vascular tumor of the liver in infancy, and the most common symptomatic liver tumor during the first 6 months of life (3–5). Approximately 85% of affected patients present by 6 months of age (4–7), and in about 45%–50% of cases these patients also have cutaneous hemangiomas (3,5–7). The tumor has a 2:1 female predilection (3,6,7). The lesions may be single or multiple, and calcifications are seen at histopathologic analysis in 50% of cases (5). Infantile hemangioendotheliomas are usually benign, but malignant sarcomas have been reported to arise in existing hemangioendotheliomas (3,4,8). Most tumors continue to grow during the 1st year of life and then spontaneously regress, probably due to thrombosis and scar formation (3,5,7,8).
At histopathologic analysis, infantile hemangioendothelioma manifests as a mesenchymal tumor composed of a connecting network of predominantly small-diameter vascular channels lined by endothelial cells (8). Unlike cavernous hemangiomas, which contain larger blood-filled spaces with endothelial cell lining, infantile hemangioendotheliomas are not obviously vascular tumors at gross examination of the cut surface (7). Areas of varying degrees of hemorrhage, necrosis, calcification, thrombosis, or fibrosis are often present in large tumors (4,9). Two types of infantile hemangioendotheliomas have been identified on the basis of the tumor size and vascularity. Type I lesions are often calcified and consist of multiple small, vascular channels with an immature endothelial cell lining and a fibrous stromal separation containing bile ductules between the channels. Type II lesions have a more disorganized appearing endothelial cell lining and no stromal bile ductules (3).
The clinical manifestation of infantile hemangioendothelioma is variable. The tumor may be asymptomatic and discovered incidentally. More often, however, the tumor is large and manifests as hepatomegaly, abdominal distention, or a palpable upper abdominal mass. There may be extensive arteriovenous shunting within the lesion, resulting in decreased peripheral vascular resistance. Thus, increased blood volume and cardiac output are required to maintain vascular bed perfusion, which may lead to high cardiac output and congestive heart failure in up to 50%–60% of patients (3,5,10). Hematologic abnormalities may be seen, including anemia and especially thrombocytopenia caused by trapping of thrombocytes within the hemangioendothelioma with consumptive coagulopathy (Kasabach-Merritt syndrome) (3,5,6). Other symptoms such as jaundice, elevated transaminase levels, failure to thrive, respiratory difficulty, intestinal obstruction, or, rarely, hemoperitoneum and shock secondary to tumor rupture (3,4,7) may also be present. Serum -fetoprotein levels are usually normal or slightly elevated (3–5).
The imaging work-up of a child with hepatomegaly, an abdominal mass, or abdominal distention usually starts with abdominal radiography and US. Radiography may show hepatomegaly and a nonspecific mass effect in the upper abdomen with displacement of intestinal structures, as well as occasional calcifications within the projection of the liver or mass (6).
At US, infantile hemangioendothelioma appears as a complex, mostly solid hepatic lesion with variable hypo- and hyperechoic echotexture. In cases of significant arteriovenous shunting, dilated hepatic vasculature with prominent blood flow at Doppler US is typical. If large vascular spaces are present, anechoic regions with detectable flow may be seen (5,9,10). The lesions are often well demarcated from the surrounding liver parenchyma.
At unenhanced CT, infantile hemangioendothelioma usually manifests as a well-defined mass that is hypoattenuating relative to the normal liver parenchyma (8). In about 16%–40% of cases, the lesion is heterogeneous with central high-attenuation areas due to hemorrhage or calcifications (1,7,8). At contrast-enhanced CT, the enhancement pattern may resemble that of an adult giant hemangioma (4,8), with "nodular" peripheral puddling of contrast material in the early phase, subsequent peripheral pooling, and central enhancement with variable delay (1,6,8). In larger tumors, central enhancement is often lacking due to fibrosis, hemorrhage, or necrosis (4,9). Conversely, small lesions, which tend to be multifocal, frequently enhance completely and typically do not demonstrate hemorrhage or necrosis (8).
At unenhanced MR imaging, the lesions have low signal intensity on T1-weighted images and high signal intensity on T2-weighted images (4,6,9). In tumors with arteriovenous shunting and high blood flow, flow voids may be observed on T2-weighted images (6). Because of the simultaneous presence of hemorrhage, necrosis, and fibrosis, the mass often appears heterogeneous on both T1- and T2-weighted images (4). After intravenous administration of gadopentetate dimeglumine, the lesions usually show an enhancement pattern similar to that described at CT (4,8). In some cases, however, the lesions may show complete "rim enhancement" at dynamic gadolinium-enhanced MR imaging (as at CT), which might confuse the differential diagnosis of hepatic tumors in infants (4).
At angiography, a dilated and elongated hepatic artery and early filling of dilated draining hepatic veins may be seen in a hemangioendothelioma with significant arteriovenous shunting. Pooling of contrast material in large vascular spaces may be present (1,6,7). Because of the increased vascular supply to these tumors, a striking decrease in the aortic caliber is often seen distal to the celiac artery origin (1,5,7). This finding is also recognizable at US, CT, and MR imaging.
The most important alternative diagnosis to infantile hemangioendothelioma in this age group is hepatoblastoma (5). Hepatoblastoma is a malignant embryonic tumor, the most common primary hepatic neoplasm in infants and children under 5 years old (68% of tumors manifest in the first 2 years of life) (3,6). The tumor has a 3:2 male predilection and may be associated with Beckwith-Wiedemann syndrome, hemihypertrophy, fetal alcohol syndrome, and oral contraceptive use (1,5,6). It is more commonly located in the right hepatic lobe (>60% of cases). The serum -fetoprotein level is elevated in up to 90% of patients with hepatoblastoma (1–3,6). The lesions are usually large and solitary but may also be multifocal. At US, hepatoblastoma most often demonstrates heterogeneous echogenicity due to hemorrhage or necrosis (5,6). At unenhanced CT, the tumor shows irregular hypoattenuation and calcifications in up to 50% of cases (1), appearing less fine and granular than hemangioendothelioma (5). Contrast-enhanced CT typically demonstrates inhomogeneous intratumoral uptake that is generally less intense than in the normal liver parenchyma, and hemangioendothelioma remains relatively hypoattenuating compared with infantile hemangioendothelioma (1,5–7). However, hepatoblastoma may have similar imaging features and clinical findings (congestive heart failure, Kasabach-Merritt syndrome) as infantile hemangioendothelioma. The latter may often be diagnosed on the basis of clinical, imaging, and laboratory findings. Nevertheless, depending on the proclivities of the treating physicians, histopathologic confirmation of a radiologically suspected hemangioendothelioma is often obtained before medical treatment is initiated (5).
Mesenchymal hamartoma (3–5) is another important differential diagnosis. Mesenchymal hamartoma is a rare benign neoplasm that may occur within the liver and probably represents a congenital malformation. It usually occurs in children under 2 years old and seems to be somewhat more common in boys (3,6,8). Mesenchymal hamartomas characteristically have a cystic or multicystic appearance, which helps distinguish them from other hepatic masses (3,6,10). However, they may contain a variable amount of stromal elements with contrast material enhancement. If solid components predominate, differentiation between mesenchymal hamartoma, infantile hemangioendothelioma, and hepatoblastoma may be impossible (4,6,7).
Finally, metastatic neuroblastoma may contribute to the differential diagnostic spectrum. Lack of clinical evidence of further metastatic disease or elevated vanillylmandelic acid levels may argue against neuroblastoma, especially in children over 1 year old (1,4,5).
Other hepatic tumors that might be considered in the differential diagnosis of infantile hemangioendothelioma, such as hepatic focal nodular hyperplasia, adenoma, hepatocellular carcinoma, embryonal sarcoma, or rhabdomyosarcoma of the biliary tree, are quite rare in newborns but may occur in older children.
Patients with infantile hemangioendothelioma usually have an excellent prognosis, especially with spontaneous regression after the 1st year of life. Nevertheless, children may die of associated complications such as severe heart failure (6,8,9). Treatment is determined on the basis of the tumor size and the severity of symptoms (congestive heart failure, arteriovenous shunting, coagulopathy). Intervention is necessary only if the lesion is symptomatic and cannot be managed conservatively while the expected involution occurs. Surgical resection is indicated if life-threatening symptoms are present or if the mass cannot be distinguished from a malignant tumor radiologically (3). Medical therapy includes steroid and interferon therapy to accelerate the natural involution of the mass and radiation therapy or chemotherapy, as well as supportive care for congestive heart failure and coagulopathy (3,5,6,10). Hepatic artery embolization to reduce tumor vascularity and arteriovenous shunting may be performed prior to surgical intervention in patients who fail to respond to conventional medical treatment.
Finally, orthotopic liver transplantation has been performed as a last resort if all other therapies fail (3,5,6,10).
|
References
|
|---|
- Parker BR. The hepatobiliary system. In: Silverman FN, Kuhn JP, eds. Caffey’s pediatric x-ray diagnosis: an integrated imaging approach. Vol 1. 9th ed. St Louis, Mo: Mosby, 1993; 915-969.
- Pariente D. The liver, biliary tract and spleen. In: Carty H, Shaw D, Brunelle F, Kendall B, eds. Imaging children. Vol 1. New York, NY: Churchill Livingstone, 1994; 485-560.
- Zenge JP, Fenton L, Lovell MA, Grover TR. Case report: infantile hemangioendothelioma. Curr Opin Pediatr 2002; 14:99-102.[CrossRef][Medline]
- Mortelé KJ, Vanzieleghem B, Mortelé B, Benoit Y, Ros PR. Solitary hepatic infantile hemangioendothelioma: dynamic gadolinium-enhanced MR imaging findings. Eur Radiol 2002; 12:862-865.[CrossRef][Medline]
- Ingram JD, Yerushalmi B, Connell J, Karrer FM, Tyson RW, Sokol RJ. Hepatoblastoma in a neonate: a hypervascular presentation mimicking hemangioendothelioma. Pediatr Radiol 2000; 30:794-797.[CrossRef][Medline]
- Buonomo C, Taylor GA, Share JC, Kirks DR. Abnormalities of the hepatobiliary system. In: Kirks DR, Griscom NT, eds. Practical pediatric imaging: diagnostic radiology of infants and children. 3rd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 954-979.
- Sty JR, Wells RG, Starshak RJ, Gregg DC. The hepatobiliary system. In: Sty JR, Wells RG, Starshak RJ, Gregg DC, eds. Diagnostic imaging of infants and children. Vol 1. Gaithersburg, Md: Aspen, 1992; 247-293.
- Horton KM, Bluemke DA, Hruban RH, Soyer P, Fishman EK. CT and MR imaging of benign hepatic and biliary tumors. RadioGraphics 1999; 19:431-451.[Abstract/Free Full Text]
- Keslar PJ, Buck JL, Selby DM. From the archives of the AFIP. Infantile hemangioendothelioma of the liver revisited. RadioGraphics 1993; 13:657-670.
- Swischuk LE. Abnormalities of the liver. In: Swischuk LE, eds. Imaging of the newborn, infant and young child. 4th ed. Baltimore, Md: Williams & Wilkins, 1997; 501-521.
Top
History
Imaging Findings
