Transarterial embolization with bleomycin–lipiodol for symptomatic multifocal hepatic hemangiomas: Concurrent nontarget lesion devascularization via permitted reflux

Abstract

Hepatic hemangiomas are the most common benign liver tumors and are typically managed conservatively. Larger or symptomatic lesions may require intervention. Transarterial chemoembolization with bleomycin-lipiodol is a minimally invasive alternative to surgery, offering symptom relief and a favorable safety profile. The therapeutic reach of bleomycin-based transarterial chemoembolization in multifocal hepatic hemangioma—including its effects on nontarget lesions—remains under investigation. A 41-year-old female presented with 2 months of progressive right upper quadrant pain refractory to analgesics. Computed tomography demonstrated 2 right hepatic hemangiomas. The patient underwent transarterial chemoembolization with bleomycin–lipiodol targeting the dominant subdiaphragmatic lesion. During super-selective embolization of the dominant lesion, a limited degree of reflux into an adjacent arterial branch supplying the inferior lesion was permitted, resulting in angiographic devascularization of both lesions. After treatment, the patient experienced complete symptomatic resolution at 7 months. Serial computed tomography demonstrated sustained treatment response, with estimated lesion volume reductions of approximately 72% (dominant) and 58% (inferior) using the ellipsoid approximation. This case supports bleomycin–lipiodol transarterial chemoembolization for symptomatic hepatic hemangiomas and contributes to growing evidence that bleomycin-based transarterial chemoembolization may be associated with size reduction of nontargeted lesions. However, the mechanism underlying this finding cannot be established from a single case, and the relative contributions of permitted reflux, shared arterial supply, and the systemic effects of bleomycin-based TACE to the observed size reduction of the nontarget lesion remain undetermined. Transarterial chemoembolization represents a compelling option for symptomatic hepatic hemangiomas, particularly where surgical complications are high.