Cavernous malformation or cavernous hemangioma: an appropriate term to define liver hemangioma.

Sir, We read with interest the article by Caseiro-Alves and colleagues in the June 2007 issue of European Radiology [1]. We appreciated the authors’ work to provide an overview of the range of appearances of hemangiomas, explored with ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Caseiro-Alves and colleagues [1] classified liver hemangioma (LH) as small (capillary) or large,with cavernous vascular spaces that may show thrombosis, calcifications, and hyalinization. We disagree with this classification since the capillary LH was not reported in the recentWorld Health Organization (WHO) classification [2]. LHs are exclusively malformative cavernous lesions. The presence of capillary vascular channels in LHs is secondary to degenerative changes such as fibrosis and thrombosis [3]. The LHs are congenital lesions although the diagnosis is frequently performed in young adulthood. In the clinical practice and in scientific papers the appropriated term for LHs is “cavernous malformations or cavernous hemangiomas” [3]. Thank you for the interest in our review article on liver hemangiomas [1]. We agree with Dr. Scialpi since in the vast majority of cases liver hemangiomas are seen in pathology with large, cavernous blood-filled spaces as described in the WHO classification. For didactic purposes we thought that it would be advantageous to subdivide hemangiomas according to the size of blood-filled spaces into small (“capillary-type”) and large (cavernous). The rationale is that smaller hemangiomas more often tend to show a flash-filling pattern on contrastenhanced studies, presumably due to smaller vascular spaces, unlike larger tumors, where peripheral puddling and heterogeneity are to be more expected [2]. We must however stress that capillary liver hemangioma in the adult has already been reported and a “flash-filling” contrast-enhancement pattern was recognized. The most striking pathological difference from regular LH was the size range of the vascular spaces, around 20 μm [3].