Percutaneous Sclerotherapy for Large Hepatic Hemangiomas

Percutaneous Sclerotherapy for Large Hepatic Hemangiomas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Percutaneous Sclerotherapy for Large Hepatic Hemangiomas Youssef Wahid Tantawy, Ahmed Mohamed Abouelhoda, Mohamed El-Gharib This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8871379/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Hepatic venous malformation (HVM), otherwise known as hepatic hemangioma, is considered the most common benign liver tumor. These liver tumors are common and are estimated to occur in up to 20% of the population. Although this tumor originates from a vascular malformation, its underlying pathophysiology remains poorly understood. Patients & Methods: This study is a prospective study – one arm clinical trial. In this study, 14 patients with large symptomatic or asymptomatic significantly growing hepatic hemangioma (more than 5 cm) will undergo percutaneous sclerotherapy by bleomycin with a follow up study by contrast enhanced cross-sectional imaging after 3 months. This study was conducted in an Interventional Radiology Unit in university hospital over the period from March 2024 to September 2024. The main source of data for this study will be patients with large symptomatic hepatic hemangiomas referred to IR unit. Results: Percutaneous transhepatic sclerotherapy with a bleomycin–lipiodol mixture is a minimally invasive, effective alternative to surgery for large symptomatic hepatic hemangiomas, achieving 45–80% size reduction and durable symptom relief with minimal complications. Compared to resection, it offers shorter procedures, faster recovery, fewer complications, and lower costs. Our study observed a statistically significant reduction in the lesion's largest dimension, Just three months after the injection procedure, with the mean decreasing to 7.99 ± 3.18 cm compared to 11.13 ± 3.2 cm in the pre-injected lesions, median to 7.75 cm (IQR: 6.5–10), and the range narrowing to 3.5–16 cm compared to 6-17 cm in the pre-injected lesions. With reduction in the lesion's largest dimension of 10% to 41% and reduction in volume (yet only obtained in 3 patients) of 45% to 68.8%, with follow-up only after 3 months. Conclusion: Percutaneous transhepatic sclerotherapy with bleomycin–lipiodol is a safe, effective, minimally invasive option for symptomatic giant hepatic hemangiomas, achieving significant lesion reduction and symptom relief with minimal complications. Despite promising outcomes, limitations include small sample sizes, short follow-up, and single-center data, highlighting the need for larger, multicenter prospective trials to validate long-term efficacy. Percutaneous Sclerotherapy Hepatic Hemangiomas Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Hepatic venous malformation (HVM), otherwise known as hepatic hemangioma, is considered the most common benign liver tumor. These liver tumors are common and are estimated to occur in up to 20% of the population. Although this tumor originates from a vascular malformation, its underlying pathophysiology remains poorly understood [ 1 ]. Clinical presentation typically depends on the tumor’s dimensions and anatomical site. The vast majority are asymptomatic, which make them belong to the class of hepatic “incidentalomas”, so-called because they are diagnosed incidentally, on imaging studies performed as routine examinations or for other reasons than the evaluation of a possible liver mass [ 2 ]. Based on the size of HVMs, they are categorized as small or giant (over 5 cm) and commonly vary in dimension from as little as 1 mm to as large as 50 cm. Hepatic hemangiomas (HH) are usually asymptomatic, but when they exceed 5 cm in size, symptoms may develop. These symptoms are often nonspecific, with patients commonly experiencing abdominal pain, discomfort, and a sense of fullness in the right upper quadrant due to stretching and inflammation of the Glisson’s capsule. Tumors larger than 10 cm can cause noticeable abdominal swelling. Depending on the location of the liver mass, it may press against nearby structures, leading to symptoms such as nausea, early satiety, and bloating after eating. Less commonly, patients may experience fever, jaundice, shortness of breath, high-output cardiac failure, or haemobilia. These symptomatic hemangiomas may require an intervention [ 3 ]. The most commonly used imaging methods to diagnose hepatic hemangiomas are ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). When lesions are atypical, more than one imaging test might be needed. US is generally the first imaging test performed due to its accessibility [ 3 ]. Many interventions could be done for the treatment of hepatic venous malformations (HVMs) include surgical resection, trans-catheter arterial embolization (TAE), radiofrequency or microwave ablation, and percutaneous sclerotherapy. The use of ethanol-based percutaneous sclerotherapy was first reported for HVM treatment in two patients, and subsequent studies further developed this technique, demonstrating positive outcomes, such as reduction in lesion size and symptom improvement without major complications [ 1 ]. Commonly used sclerosants in these interventions include lipiodol, ethanol, and bleomycin derivatives (such as Pingyangmycin). These agents have established roles in both TAE and percutaneous sclerotherapy protocols. Bleomycin, known as an mTOR inhibitor, has shown effectiveness in treating vascular malformations like HVMs. Lipiodol, while widely used in TAE due to its drug delivery and radio-opacity properties, has an unclear role in percutaneous sclerotherapy [ 1 ]. Percutaneous sclerotherapy for HH is usually done using a fine needle (angiocath or Chiba or spinal needle) to achieve percutaneous access guided by ultrasonography. Then about 5–10 ml of iodine-based contrast will be injected under fluoroscopy to secure the proper positioning of the needle to prevent delivery of sclerosant into unintended areas. Then for an adult patient dose: 45 to 60 IU of bleomycin (studies had shown that this concentration of bleomycin gives us the best results causing significant reduction of HH size and significant relief of symptoms in a 6 month follow up duration with almost no complications) is mixed with 10 ml of saline and 10 ml of lipiodol to obtain a total of 20ml. The 20 ml mixture syringe will be slowly injected under fluoroscopy. Then manual compression will be done after removal of our needle for about 5 mins [ 1 ]. To sum it up, bleomycin-based percutaneous sclerotherapy has shown substantial benefit in treating low-flow venous malformations. Consequently, this intervention is a viable and promising alternative for managing hepatic hemangiomas [ 4 ]. Aim of the Work To evaluate feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of large (> 5cm) hepatic hemangioma. Patients & Methods This study is a prospective study – one arm clinical trial. In this study, 14 patients with large symptomatic or asymptomatic significantly growing hepatic hemangioma (more than 5 cm) will undergo percutaneous sclerotherapy by bleomycin with a follow up study by contrast enhanced cross-sectional imaging after 3 months. This study was conducted in Ain Shams University Interventional Radiology Unit (El Demerdash Hospital) over the period from March 2024 to September 2024. The main source of data for this study will be patients with large symptomatic hepatic hemangiomas referred to IR unit. Inclusion Criteria: All patients with large (more than 5cm) hepatic hemangioma and met the eligibility criteria of our study. Patients unfit for surgery. Patients with multiple bilobar hepatic hemangiomas. Exclusion criteria: Presence of contraindications to an arterial procedure (coagulopathy). Patient with incomplete clinical data and labs. Other possible causes for abdominal pain like gallbladder stone. Patients older than 80 years. Small hepatic hemangiomas (less than 5 cm). Hepatic hemangiomas larger than 20 cm. Thrombosed hepatic hemangiomas. Study tools and procedures: Before procedure patients underwent: Full history taking, obtaining a written consent from the patient or his guardian, physical examination, echocardiography, laboratory tests: CBC, serum albumin, serum total bilirubin, AST, ALT, alpha-fetoprotein, bleeding profile and kidney function tests (creatinine level), abdominal tri-phasic CT or dynamic MRI for the assessment of hepatic hemangioma and confirming it. Procedure: This single-session procedure is conducted on an outpatient basis using conscious sedation and local anesthesia. To mitigate the risks of infection and delayed hypersensitivity to bleomycin, prophylactic antibiotics and a single dose of corticosteroids are administered 30 minutes pre-procedure. Intraprocedural monitoring includes continuous assessment of vital signs and cardiac rhythm. Following cutaneous sterilization, about 10 mL local anaesthetic (lidocaine hydrochloride 2%) is administrated around the capsule, intercostal muscles, and the overlying subcutaneous tissue. The first step involves ultrasound-guided puncture of the HH as shown in figure (1). To obtain percutaneous access to the HH, avoiding its central hypoechogenic or echo-free area, a fine Angiocath needle with a gauge of 22 is preferred. To minimize the risk of bleeding, the needle is passed through normal liver parenchyma before entering the HH. To evaluate the possible communication of the lesion with the portal or hepatic veins, hepatic artery, or biliary system, 10–20 mL of contrast agent is slowly injected under fluoroscopic guidance figure (2). If any abnormal communication is identified, the needle location was altered to avoid any of the aforementioned structures. To prepare the injection solution for an adult patient, 45 IU bleomycin was diluted in 10 mL of distilled water and then mixed with 10 mL ethiodized oil (Lipiodol) via a stopcock connecting two 20-mL syringes, for a total volume of 20 mL. The mixture was gradually injected within the lesion over 20–30 seconds and under fluoroscopic guidance figure (3). At the end of the procedure, manual compression was applied at the injection site for 5 minutes. A follow up study by contrast enhanced cross-sectional imaging (abdomen CECT or MR dynamic) after 3 months was done. Statistical Analysis The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 27). Data was presented and suitable analysis was done according to the type of data obtained for each parameter. P- value: level of significance: P > 0.05: Non-significant (NS), P < 0.05: Significant (S). Results This study was conducted on 14 patients with large mostly symptomatic hepatic hemangiomas to evaluate feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of large mostly symptomatic hepatic hemangioma. The mean age was 43.86 ± 8.42 years, ranging from 32 to 62 years. The average body weight was 81.21 ± 8.38 kg), with a range between 66 and 93 kg. Regarding sex distribution, female predominance was observed, with 10 females (71.43%) and 4 males (28.57%) (table 1). Regarding lobe involvement, the right lobe was the most frequently affected, with 8 cases (57.2%), followed by the left lobe in 5 cases (35.7%), and the caudate lobe in 1 case (7.1%). In terms of segmental involvement, the lesions were widely distributed. Single-segment involvement was noted in the caudate (segment I), segment III, and segment VIII, each accounting for 1 case (7.1%). Multisegmented involvement was more frequent, with segments VI & VII involved in 3 cases (21.3%), and segments V & VI in 2 cases (14.2%). Other multisegmented combinations included segments V & VIII, segments II & III, segments III & IVb, segments II, III & IVa, segment IV alone, and segment VII & VIII, each appearing in 1 case (7.1%) (table 2). The mean largest dimension of hemangioma size was 11.13 ± 3.2 cm, with a median of 10.9 cm (IQR: 9.5–12), and ranged from 6 to 17 cm. After the procedure, there was a notable reduction in lesion size, with the mean decreasing to 7.99 ± 3.18 cm, median to 7.75 cm (IQR: 6.5–10), and the range narrowing to 3.5–16 cm. There was a statistically significant decrease in the hemangioma size post injection (table 3). Note One patient was excluded due to lost follow-up. The majority of patients (78.57%) had only one single lesion. 3 patients (21.43%) had multiple hemangiomas scattered in right and left lobe of liver; yet only the largest lesion was injected (table 4). Incidentally, it was noted that the rest of the non-injected, non-targeted lesions in these patients significantly decreased in size as if they were injected; as detailed in the illustrative cases below. The majority of patients (78.57%) experienced symptoms such as right hypochondrial pain (being the most common presentation), early satiety and postprandial bloating. While 3 patients (21.43%) didn’t experience any symptoms; they needed an intervention only because their hepatic hemangioma got enlarged in a short period of time (table 5). The only post-procedural complication was right hypochondrial pain. The majority of patients (71.43%) experienced such pain after the injection which remained for less than 7 days that responded to analgesia, while 4 patients (28.57%) reported no such pain. Although pain was common, all cases responded to analgesics, so the intervention was well-tolerated and manageable from a symptom control perspective (table 6 Case 1 A 62-year-old female patient with a giant hepatic hemangioma at segment V & VIII, measuring 8.5x10.5 cm (APxTR), identified on a triphasic CT scan of abdomen and pelvis. The patient's primary complaint was right hypochondrial pain; therefore, an intervention was required. She underwent a single session of percutaneous transhepatic injection of a bleomycin and lipiodol mixture. A three-month follow-up triphasic CT scan of the abdomen and pelvis demonstrated a significant reduction in size to 5.5x8 cm (APxTR). Case 2 A 53-year-old female presented with symptomatic multiple hepatic hemangiomas scattered at right and left lobe of liver, including a dominant lesion in the left hepatic lobe measuring 10×17×12 cm (AP×TR×CC) with an estimated volume of 1,020 cm 3 , nearly occupying the entire left lobe sparing only segment IVb seen by triphasic CT scan of abdomen and pelvis. The patient's presenting symptoms included early satiety, postprandial bloating, and intermittent right hypochondrial pain, necessitating interventional management. A single session of sclerotherapy with bleomycin was performed for the dominant left lobe hemangioma. A three-month follow-up triphasic CT scan of abdomen and pelvis demonstrated a significant reduction in the size of the injected lesion to 7×16×10 (AP×TR×CC) cm, with an approximate 45% volume reduction to 560 cm 3 . Surprisingly, the follow-up imaging also revealed a concomitant reduction in the size of several non-injected hemangiomas located in the right hepatic lobe. Specifically, two lesions in segment VIII, previously measuring 8.5×7 cm and 3×2 cm, decreased to 6.7×6.5 cm and 2.5×1.7 cm, respectively. Additionally, a lesion in segment V, previously 2×2 cm, reduced to 1.7×1.8 cm. This observation suggests a systemic effect of bleomycin absorption contributing to the regression of non-targeted lesions. DISCUSSION Hepatic hemangiomas are the most frequently occurring benign tumors of the liver, estimated to be present in up to 20% of the population. This tumor arises from a vascular malformation; though the specific way they form isn't yet fully understood [ 1 ]. This study included 14 cases of giant hepatic hemangioma. Patients were mostly females, with 10 females (71.43%) and 4 males (28.57%). In Yazdi et al. [ 4 ] study it included 28 patients 25 (89.28%) of whom were females, only 3 (10.71%) were males. Other studies like Ayoobi Yazdi et al. [ 5 ] showed female predominance as well of 80%. Hepatic hemangiomas are significantly more common in females than in males. The female-to-male ratio is often cited in the range of 2:1 to 6:1, with some studies reporting it as high as 5:1. This sex dominance is believed to be linked to the influence of female sex hormones, particularly estrogen. Studies have suggested that conditions with high estrogen levels, such as pregnancy, or the use of oral contraceptives, may cause these benign tumors to grow [ 6 ]. The management of hepatic hemangiomas is based on the tumor's size, growth rate, and whether it causes symptoms. Most of these benign tumors are small, don't cause symptoms, and are discovered accidentally. These cases typically don't require any treatment. For the small number of patients who do experience symptoms or significant tumor growth, a variety of treatments are available, from surgery to less invasive procedures [ 3 ]. Percutaneous transhepatic sclerotherapy with bleomycin–lipiodol has emerged as an effective minimally invasive modality in managing large (≥ 5 cm), symptomatic hepatic hemangiomas. Initial pilot data in Ayoobi Yazdi et al. [ 5 ] study included a five patient series reported significant lesion volume reductions (45.6–71.1%) and complete symptom relief within months, with only a minor intraperitoneal hemorrhage in one case. Based on retrospective studies, percutaneous sclerotherapy is often the preferred treatment for large hemangiomas over surgical removal. Lin et al. [ 7 ] study of 89 patients found that it had several advantages, including shorter operative times, less blood loss, and reduced hospital stays and costs. Patients who underwent also experienced fewer minor complications, and the treatment was just as effective, reducing the tumor size by an average of 65% based on ultrasound follow-ups. More recently, a 2025 single arm series in Bangladesh Moben et al. [ 8 ] involving 20 patients showed lesion reduction in 70% at six months, minimal complications, and good tolerance of the procedure, further strengthening evidence from resource limited settings that percutaneous sclerotherapy is both safe and effective. In agreement to Ayoobi Yazdi et al. [ 5 ], Lin et al. [ 7 ] and Moben et al. [ 8 ]; Our study observed a statistically significant reduction in the lesion's largest dimension, Just three months after the injection procedure, with the mean decreasing to 7.99 ± 3.18 cm compared to 11.13 ± 3.2 cm in the pre-injected lesions, median to 7.75 cm (IQR: 6.5–10), and the range narrowing to 3.5–16 cm compared to 6–17 cm in the pre-injected lesions. In another words, our study involved 14 patients with reduction in the lesion's largest dimension of 10% to 41% and reduction in volume (yet only obtained in 3 patients) of 45% to 68.8%, with follow-up only after 3 months. Similarly, Ayoobi Yazdi et al. [ 5 ] study involved 5 patients with reduction in the lesion's largest dimension of 12.9% to 41% and reduction in volume of 45.6% to 71.1%, following up patients after 5 months. Also, our study showed similar results to Lin et al. [ 7 ] conducted on 89 patients with mean reduction in volume of 65%, with follow-up done after 9–24 months. Finally in agreement with Moben et al. [ 8 ] a Single-arm series from Bangladesh, involved 20 patients showing mean reduction in volume of 70%, with follow-up done after 9–24 months. Percutaneous transhepatic sclerotherapy shows very minimal intra-procedural and post-procedural complications. As seen in Ayoobi Yazdi et al. [ 5 ] study only one patient out of 5 (20%) experienced minor intraperitoneal hemorrhage in one case. In our study there were no any intraoperative complications. With minor postoperative complication seen in 4 patients (28.5%) experienced right hypochondrial pain responded to analgesics that lasted less than a week. Incidentally, our study showed 3 patients with multiple hemangiomas (more than 3 lesions), only the largest hemangioma was injected. It was noted, in all these patients, that the rest of the non-injected, non-targeted lesions in these patients significantly decreased in size as if they were injected; as detailed in the illustrative cases above. This was believed that this observation is due to the systemic absorption of bleomycin with no enough studies in literature to confirm, for further studies to be conducted. This effect is similar to the abscopal effect which is shrinkage or disappearance of tumors in areas of the body not directly treated by local cancer therapy. As a result we recommend that further studies should be done for patients with multiple HH. Like any study, our study had some limitations; one of them is the reduction in the lesion’s volume could only be obtained from 3 patients. Other limitations are that our study most available data derive from single center, non-randomized cohorts with small sample sizes and relatively short follow ups with 1 patient lost follow up. Further prospective, multicenter trials are needed to establish optimal sclerosant dosing, long term outcomes, and patient selection criteria journals. CONCLUSION Percutaneous transhepatic sclerotherapy with bleomycin–lipiodol is a safe, effective, minimally invasive option for symptomatic giant hepatic hemangiomas, achieving significant lesion reduction and symptom relief with minimal complications. Despite promising outcomes, limitations include small sample sizes, short follow-up, and single-center data, highlighting the need for larger, multicenter prospective trials to validate long-term efficacy. Abbreviations ALT Alanine Aminotransferase AP Anteroposterior AST Aspartate Aminotransferase CBC Complete Blood Count CC Craniocaudal CECT Contrast-Enhanced Computed Tomography CT Computed Tomography HH Hepatic Hemangiomas HVM Hepatic Venous Malformation IQR Interquartile Range IR Interventional Radiology IU International Units MRI Magnetic Resonance Imaging mTOR Mammalian Target of Rapamycin SD Standard Deviation SPSS Statistical Package for Social Science TAE Trans-catheter Arterial Embolization TR Transverse US Ultrasound Declarations Author Contribution Original research article Egyptian Journal of Radiology and Nuclear MedicinePercutaneous Sclerotherapy for Large Hepatic HemangiomasYoussef Wahid Tantawy1, Ahmed Mohamed Abouelhoda, MD1, Mohamed El-Gharib, MD1, 1 Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, EgyptCorresponding author:Youssef Wahid Tantawy, Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt Email: [email protected] No.: +201000379849Authors: Youssef Wahid Tantawy Radiology Resident Faculty of Medicine - Ain shams University - Egypt. [email protected] . Mohamed El-Gharib Professor of RadiologyFaculty of Medicine – Ain Shams University- Egypt. Dr. Ahmed Mohamed AbouelhodaLecturer of RadiologyFaculty of Medicine - Ain Shams University- Egypt. Correspondence to Youssef Wahid Tantawy, Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt Email: [email protected] No.: +201000379849Declarations:Ethics Approval and Consent to Participate: This study was approved by FMASU (Faculty Of Medicine Ain Shams University Research Ethics Committee) (approval no. MS 177/2025).Consent for publication: All patients included in this research gave written informed consent to publish the data contained within this study. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: No financial or non-financial competing interests.Competing interests: The authors declare that they have no competing interests. Funding: This study had no funding from any resource. Authors' contributions: RAE: collected and analyzed the data, wrote the main manuscript text, prepared the cases, performed the required measurements and statistical analysis, and prepared figures and tables. AFA: reviewed literature, shared in statistical analysis and manuscript editing. KSS: suggested the research, reviewed the manuscript and statistical analysis. All authors read and approved the final manuscript.Acknowledgments: The author thanks all the study participants for their patience and support References Ghaemi O, Nejad MM, Rouhezamin MR, Yazdi NA, Pourghorban R, Yazdi HR. A technical review of percutaneous sclerotherapy with bleomycin for giant hepatic venous malformation. CVIR Endovasc. 2023;6(1):47. Bajenaru N, Balaban V, Săvulescu F, Campeanu I, Patrascu T. Hepatic hemangioma -review-. J Med Life. 2015;8(5):4–11. Leon M, Chavez L, Surani S. Hepatic hemangioma: What internists need to know. World J Gastroenterol. 2020;26(1):11–20. Yazdi NA, Mehrabinejad M, Dashti H, Pourghorban R, Toosi MN, Yazdi HR. Percutaneous sclerotherapy with bleomycin and ethiodized oil: A promising treatment in symptomatic giant liver hemangioma. Radiology. 2021;301(2):464–71. Ayoobi Yazdi N, Dashti H, Batavani N, Borhani A, Shakiba M, Rokni Yazdi H. Percutaneous sclerotherapy for giant symptomatic liver hemangiomas: a pilot study. J Vasc Interv Radiol. 2018;29(2):233–6. Van Malenstein H, Maleux G, Monbaliu D, Verslype C, Komuta M, Roskams T, et al. Giant liver hemangioma: the role of female sex hormones and treatment. Eur J Gastroenterol Hepatol. 2011;23(5):438–43. Lin Z, Zhu X, Zhou J. Ultrasound-guided percutaneous sclerotherapy versus surgical resection in the treatment of large hepatic hemangiomas: a retrospective study. BMC Surg. 2022;22(1):130. Moben AL, Noor E Alam SM, Begum R, Rahim MA, Sadman OF, Abdur Rahman M, et al. Percutaneous sclerotherapy for management of large hepatic haemangioma: First series from Bangladesh. Br J Healthc Med Res. 2025;12(1):312–7. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8871379","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595675420,"identity":"7de908f6-865e-4a9c-ad79-4cd315bebcc9","order_by":0,"name":"Youssef Wahid Tantawy","email":"data:image/png;base64,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","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Youssef","middleName":"Wahid","lastName":"Tantawy","suffix":""},{"id":595675421,"identity":"f9753ecc-7774-46fd-82e2-ef6f78d8e2d0","order_by":1,"name":"Ahmed Mohamed Abouelhoda","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Mohamed","lastName":"Abouelhoda","suffix":""},{"id":595675422,"identity":"b73b9a90-6120-484a-b54e-f8cb6e695460","order_by":2,"name":"Mohamed El-Gharib","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"El-Gharib","suffix":""}],"badges":[],"createdAt":"2026-02-13 11:38:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8871379/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8871379/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104399022,"identity":"849757d9-8ab8-4afc-b56f-5a7c84971875","added_by":"auto","created_at":"2026-03-11 12:04:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":427606,"visible":true,"origin":"","legend":"\u003cp\u003eShows the first step of the procedure after local anaesthesia; Ultrasound-guided puncture of the hyperechoic hepatic hemangioma (arrow) by an angiocath with its tip seen at the center of the lesion (arrowhead).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/e56169dcb1cdf205db1c56cf.png"},{"id":103567372,"identity":"9bccb9b2-12be-4245-9033-b8798387745d","added_by":"auto","created_at":"2026-02-27 07:30:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":291119,"visible":true,"origin":"","legend":"\u003cp\u003eShows the second step of the procedure; 10–20 mL of contrast agent is slowly injected fluoroscopy guided.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/eea6409c19229e89910d1c8e.png"},{"id":103567368,"identity":"6f1cd190-86e4-4849-a87c-2fce14f7171c","added_by":"auto","created_at":"2026-02-27 07:30:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":210552,"visible":true,"origin":"","legend":"\u003cp\u003eShows the third step of the procedure; slowly inject 20-mL bleomycin \u0026amp; lipiodol mixture shown as radiopaque well-defined irregular cystic area (arrowhead) through the angiocath (arrow) fluoroscopy guided. Residual of previously injected contrast (star).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/668f2d1e87dafdfeb06076f7.png"},{"id":103567369,"identity":"2482bab9-d29f-47fd-b856-da19600e46a5","added_by":"auto","created_at":"2026-02-27 07:30:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":345945,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-procedural fluoroscopy image; shows post injection with bleomycin and lipiodol mixture with tip of needle (arrowhead) in the center of a radiopaque irregular well defined cystic area.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/5cfd4dc7e7f584b5c61ccb33.png"},{"id":104398555,"identity":"4e23c9a0-4209-4622-b417-ce67f4b7df82","added_by":"auto","created_at":"2026-03-11 12:02:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":461311,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eThis is a pre-procedural CT scan shows a hypodense giant hemangioma with its typical peripheral, nodular enhancement during the porto-venous phase (arrow) located at segment V \u0026amp; VIII.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003eThis is a post-procedural three months follow up CT scan showing regressive course of the same hypodense lesion (arrow) with hyperdense material seen at the center of the lesion denoting the previously injected lipiodol (arrowhead).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/154f7a6af1e29fabbc4b77d8.png"},{"id":103567373,"identity":"3d9a9042-fdbf-4609-a39f-560f0ccc5758","added_by":"auto","created_at":"2026-02-27 07:30:05","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":227359,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-procedural fluoroscopy image; shows post injection with bleomycin and lipiodol mixture shown as a radiopaque irregular well defined cystic area (arrowhead).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/b532d34d9e67a614252a1414.png"},{"id":104398392,"identity":"9f4ce44b-ceea-4dd9-ae3e-8f0216d1fd4f","added_by":"auto","created_at":"2026-03-11 12:02:09","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":465628,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eThis is a pre-procedural CT scan showing two giant hypodense hemangiomas with their typical peripheral, nodular enhancement during the porto-venous phase. Sclerotherapy was done to the larger lesion located at the left lobe (arrow); the other lesion is seen located at segment VIII (star).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003eThis is a post-procedural three months follow up CT scan showing regressive course of the same hypodense targeted lesion (arrow) with hyperdense material seen at the center and peripheral of the lesion denoting the previously injected lipiodol. Along with regressive course of the non-targeted, non-injected lesion seen at segment VIII (star).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC: \u003c/strong\u003ePre-procedural CT scan showing another small non-targeted, non-injected hemangioma located at segment VIII (arrowhead).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD: \u003c/strong\u003eWith post-procedural three months follow up CT scan showing regressive course of the same hypodense lesion (arrowhead).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/37e7eedf27f7b4d5220d0506.png"},{"id":104407451,"identity":"c312fd25-a6fa-4255-b274-7f9483668f15","added_by":"auto","created_at":"2026-03-11 12:38:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4248658,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/ffaa8c0a-a8bc-41b9-a93c-651d477a0895.pdf"},{"id":103567366,"identity":"c1aff286-6f03-4844-9d1e-99de59138419","added_by":"auto","created_at":"2026-02-27 07:30:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17499,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8871379/v1/910211d35d4d0a3dbdec6cfe.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Percutaneous Sclerotherapy for Large Hepatic Hemangiomas","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatic venous malformation (HVM), otherwise known as hepatic hemangioma, is considered the most common benign liver tumor. These liver tumors are common and are estimated to occur in up to 20% of the population. Although this tumor originates from a vascular malformation, its underlying pathophysiology remains poorly understood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical presentation typically depends on the tumor\u0026rsquo;s dimensions and anatomical site. The vast majority are asymptomatic, which make them belong to the class of hepatic \u0026ldquo;incidentalomas\u0026rdquo;, so-called because they are diagnosed incidentally, on imaging studies performed as routine examinations or for other reasons than the evaluation of a possible liver mass [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the size of HVMs, they are categorized as small or giant (over 5 cm) and commonly vary in dimension from as little as 1 mm to as large as 50 cm. Hepatic hemangiomas (HH) are usually asymptomatic, but when they exceed 5 cm in size, symptoms may develop. These symptoms are often nonspecific, with patients commonly experiencing abdominal pain, discomfort, and a sense of fullness in the right upper quadrant due to stretching and inflammation of the Glisson\u0026rsquo;s capsule. Tumors larger than 10 cm can cause noticeable abdominal swelling. Depending on the location of the liver mass, it may press against nearby structures, leading to symptoms such as nausea, early satiety, and bloating after eating. Less commonly, patients may experience fever, jaundice, shortness of breath, high-output cardiac failure, or haemobilia. These symptomatic hemangiomas may require an intervention [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most commonly used imaging methods to diagnose hepatic hemangiomas are ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). When lesions are atypical, more than one imaging test might be needed. US is generally the first imaging test performed due to its accessibility [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany interventions could be done for the treatment of hepatic venous malformations (HVMs) include surgical resection, trans-catheter arterial embolization (TAE), radiofrequency or microwave ablation, and percutaneous sclerotherapy. The use of ethanol-based percutaneous sclerotherapy was first reported for HVM treatment in two patients, and subsequent studies further developed this technique, demonstrating positive outcomes, such as reduction in lesion size and symptom improvement without major complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommonly used sclerosants in these interventions include lipiodol, ethanol, and bleomycin derivatives (such as Pingyangmycin). These agents have established roles in both TAE and percutaneous sclerotherapy protocols. Bleomycin, known as an mTOR inhibitor, has shown effectiveness in treating vascular malformations like HVMs. Lipiodol, while widely used in TAE due to its drug delivery and radio-opacity properties, has an unclear role in percutaneous sclerotherapy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePercutaneous sclerotherapy for HH is usually done using a fine needle (angiocath or Chiba or spinal needle) to achieve percutaneous access guided by ultrasonography. Then about 5\u0026ndash;10 ml of iodine-based contrast will be injected under fluoroscopy to secure the proper positioning of the needle to prevent delivery of sclerosant into unintended areas. Then for an adult patient dose: 45 to 60 IU of bleomycin (studies had shown that this concentration of bleomycin gives us the best results causing significant reduction of HH size and significant relief of symptoms in a 6 month follow up duration with almost no complications) is mixed with 10 ml of saline and 10 ml of lipiodol to obtain a total of 20ml. The 20 ml mixture syringe will be slowly injected under fluoroscopy. Then manual compression will be done after removal of our needle for about 5 mins [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo sum it up, bleomycin-based percutaneous sclerotherapy has shown substantial benefit in treating low-flow venous malformations. Consequently, this intervention is a viable and promising alternative for managing hepatic hemangiomas [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eAim of the Work\u003c/h3\u003e\n\u003cp\u003eTo evaluate feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of large (\u0026gt; 5cm) hepatic hemangioma.\u003c/p\u003e "},{"header":"Patients \u0026 Methods","content":"\u003cp\u003eThis study is a prospective study – one arm clinical trial. In this study, 14 patients with large symptomatic or asymptomatic significantly growing hepatic hemangioma (more than 5 cm) will undergo percutaneous sclerotherapy by bleomycin with a follow up study by contrast enhanced cross-sectional imaging after 3 months. This study was conducted in Ain Shams University Interventional Radiology Unit (El Demerdash Hospital) over the period from March 2024 to September 2024. The main source of data for this study will be patients with large symptomatic hepatic hemangiomas referred to IR unit.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAll patients with large (more than 5cm) hepatic hemangioma and met the eligibility criteria of our study.\u003c/li\u003e\n \u003cli\u003ePatients unfit for surgery.\u003c/li\u003e\n \u003cli\u003ePatients with multiple bilobar hepatic hemangiomas.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePresence of contraindications to an arterial procedure (coagulopathy).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatient with incomplete clinical data and labs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOther possible causes for abdominal pain like gallbladder stone.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients older than 80 years.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSmall hepatic hemangiomas (less than 5 cm).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHepatic hemangiomas larger than 20 cm.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThrombosed hepatic hemangiomas.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eStudy tools and procedures:\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBefore procedure patients underwent:\u003c/h2\u003e \u003cp\u003eFull history taking, obtaining a written consent from the patient or his guardian, physical examination, echocardiography, laboratory tests: CBC, serum albumin, serum total bilirubin, AST, ALT, alpha-fetoprotein, bleeding profile and kidney function tests (creatinine level), abdominal tri-phasic CT or dynamic MRI for the assessment of hepatic hemangioma and confirming it.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProcedure:\u003c/h2\u003e \u003cp\u003eThis single-session procedure is conducted on an outpatient basis using conscious sedation and local anesthesia. To mitigate the risks of infection and delayed hypersensitivity to bleomycin, prophylactic antibiotics and a single dose of corticosteroids are administered 30 minutes pre-procedure. Intraprocedural monitoring includes continuous assessment of vital signs and cardiac rhythm. Following cutaneous sterilization, about 10 mL local anaesthetic (lidocaine hydrochloride 2%) is administrated around the capsule, intercostal muscles, and the overlying subcutaneous tissue.\u003c/p\u003e \u003cp\u003eThe first step involves ultrasound-guided puncture of the HH as shown in \u003cb\u003efigure (1).\u003c/b\u003e To obtain percutaneous access to the HH, avoiding its central hypoechogenic or echo-free area, a fine Angiocath needle with a gauge of 22 is preferred. To minimize the risk of bleeding, the needle is passed through normal liver parenchyma before entering the HH.\u003c/p\u003e \u003cp\u003eTo evaluate the possible communication of the lesion with the portal or hepatic veins, hepatic artery, or biliary system, 10\u0026ndash;20 mL of contrast agent is slowly injected under fluoroscopic guidance \u003cb\u003efigure (2).\u003c/b\u003e If any abnormal communication is identified, the needle location was altered to avoid any of the aforementioned structures.\u003c/p\u003e \u003cp\u003eTo prepare the injection solution for an adult patient, 45 IU bleomycin was diluted in 10 mL of distilled water and then mixed with 10 mL ethiodized oil (Lipiodol) via a stopcock connecting two 20-mL syringes, for a total volume of 20 mL. The mixture was gradually injected within the lesion over 20\u0026ndash;30 seconds and under fluoroscopic guidance \u003cb\u003efigure (3).\u003c/b\u003e At the end of the procedure, manual compression was applied at the injection site for 5 minutes. A follow up study by contrast enhanced cross-sectional imaging (abdomen CECT or MR dynamic) after 3 months was done.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 27). Data was presented and suitable analysis was done according to the type of data obtained for each parameter. P- value: level of significance: P\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant (NS), P\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant (S).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study was conducted on 14 patients with large mostly symptomatic hepatic hemangiomas to evaluate feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of large mostly symptomatic hepatic hemangioma.\u003c/p\u003e \u003cp\u003eThe mean age was 43.86\u0026thinsp;\u0026plusmn;\u0026thinsp;8.42 years, ranging from 32 to 62 years. The average body weight was 81.21\u0026thinsp;\u0026plusmn;\u0026thinsp;8.38 kg), with a range between 66 and 93 kg. Regarding sex distribution, female predominance was observed, with 10 females (71.43%) and 4 males (28.57%) \u003cb\u003e(table 1).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRegarding lobe involvement, the right lobe was the most frequently affected, with 8 cases (57.2%), followed by the left lobe in 5 cases (35.7%), and the caudate lobe in 1 case (7.1%). In terms of segmental involvement, the lesions were widely distributed. Single-segment involvement was noted in the caudate (segment I), segment III, and segment VIII, each accounting for 1 case (7.1%). Multisegmented involvement was more frequent, with segments VI \u0026amp; VII involved in 3 cases (21.3%), and segments V \u0026amp; VI in 2 cases (14.2%). Other multisegmented combinations included segments V \u0026amp; VIII, segments II \u0026amp; III, segments III \u0026amp; IVb, segments II, III \u0026amp; IVa, segment IV alone, and segment VII \u0026amp; VIII, each appearing in 1 case (7.1%) \u003cb\u003e(table 2).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe mean largest dimension of hemangioma size was 11.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 cm, with a median of 10.9 cm (IQR: 9.5\u0026ndash;12), and ranged from 6 to 17 cm. After the procedure, there was a notable reduction in lesion size, with the mean decreasing to 7.99\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18 cm, median to 7.75 cm (IQR: 6.5\u0026ndash;10), and the range narrowing to 3.5\u0026ndash;16 cm. There was a statistically significant decrease in the hemangioma size post injection \u003cb\u003e(table 3).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003eOne patient was excluded due to lost follow-up.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe majority of patients (78.57%) had only one single lesion. 3 patients (21.43%) had multiple hemangiomas scattered in right and left lobe of liver; yet only the largest lesion was injected \u003cb\u003e(table 4).\u003c/b\u003e Incidentally, it was noted that the rest of the non-injected, non-targeted lesions in these patients significantly decreased in size as if they were injected; as detailed in the illustrative cases below.\u003c/p\u003e \u003cp\u003eThe majority of patients (78.57%) experienced symptoms such as right hypochondrial pain (being the most common presentation), early satiety and postprandial bloating. While 3 patients (21.43%) didn\u0026rsquo;t experience any symptoms; they needed an intervention only because their hepatic hemangioma got enlarged in a short period of time \u003cb\u003e(table 5).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe only post-procedural complication was right hypochondrial pain. The majority of patients (71.43%) experienced such pain after the injection which remained for less than 7 days that responded to analgesia, while 4 patients (28.57%) reported no such pain. Although pain was common, all cases responded to analgesics, so the intervention was well-tolerated and manageable from a symptom control perspective \u003cb\u003e(table 6\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCase 1\u003c/h2\u003e \u003cp\u003eA 62-year-old female patient with a giant hepatic hemangioma at segment V \u0026amp; VIII, measuring 8.5x10.5 cm (APxTR), identified on a triphasic CT scan of abdomen and pelvis. The patient's primary complaint was right hypochondrial pain; therefore, an intervention was required. She underwent a single session of percutaneous transhepatic injection of a bleomycin and lipiodol mixture. A three-month follow-up triphasic CT scan of the abdomen and pelvis demonstrated a significant reduction in size to 5.5x8 cm (APxTR).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCase 2\u003c/h2\u003e \u003cp\u003eA 53-year-old female presented with symptomatic multiple hepatic hemangiomas scattered at right and left lobe of liver, including a dominant lesion in the left hepatic lobe measuring 10\u0026times;17\u0026times;12 cm (AP\u0026times;TR\u0026times;CC) with an estimated volume of 1,020 cm\u003csup\u003e3\u003c/sup\u003e, nearly occupying the entire left lobe sparing only segment IVb seen by triphasic CT scan of abdomen and pelvis. The patient's presenting symptoms included early satiety, postprandial bloating, and intermittent right hypochondrial pain, necessitating interventional management. A single session of sclerotherapy with bleomycin was performed for the dominant left lobe hemangioma. A three-month follow-up triphasic CT scan of abdomen and pelvis demonstrated a significant reduction in the size of the injected lesion to 7\u0026times;16\u0026times;10 (AP\u0026times;TR\u0026times;CC) cm, with an approximate 45% volume reduction to 560 cm\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSurprisingly, the follow-up imaging also revealed a concomitant reduction in the size of several non-injected hemangiomas located in the right hepatic lobe. Specifically, two lesions in segment VIII, previously measuring 8.5\u0026times;7 cm and 3\u0026times;2 cm, decreased to 6.7\u0026times;6.5 cm and 2.5\u0026times;1.7 cm, respectively. Additionally, a lesion in segment V, previously 2\u0026times;2 cm, reduced to 1.7\u0026times;1.8 cm. This observation suggests a systemic effect of bleomycin absorption contributing to the regression of non-targeted lesions.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eHepatic hemangiomas are the most frequently occurring benign tumors of the liver, estimated to be present in up to 20% of the population. This tumor arises from a vascular malformation; though the specific way they form isn't yet fully understood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study included 14 cases of giant hepatic hemangioma. Patients were mostly females, with 10 females (71.43%) and 4 males (28.57%). In \u003cb\u003eYazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] study it included 28 patients 25 (89.28%) of whom were females, only 3 (10.71%) were males. Other studies like \u003cb\u003eAyoobi Yazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] showed female predominance as well of 80%.\u003c/p\u003e \u003cp\u003eHepatic hemangiomas are significantly more common in females than in males. The female-to-male ratio is often cited in the range of 2:1 to 6:1, with some studies reporting it as high as 5:1. This sex dominance is believed to be linked to the influence of female sex hormones, particularly estrogen. Studies have suggested that conditions with high estrogen levels, such as pregnancy, or the use of oral contraceptives, may cause these benign tumors to grow [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe management of hepatic hemangiomas is based on the tumor's size, growth rate, and whether it causes symptoms. Most of these benign tumors are small, don't cause symptoms, and are discovered accidentally. These cases typically don't require any treatment. For the small number of patients who do experience symptoms or significant tumor growth, a variety of treatments are available, from surgery to less invasive procedures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePercutaneous transhepatic sclerotherapy with bleomycin\u0026ndash;lipiodol has emerged as an effective minimally invasive modality in managing large (\u0026ge;\u0026thinsp;5 cm), symptomatic hepatic hemangiomas. Initial pilot data in \u003cb\u003eAyoobi Yazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] study included a five patient series reported significant lesion volume reductions (45.6\u0026ndash;71.1%) and complete symptom relief within months, with only a minor intraperitoneal hemorrhage in one case.\u003c/p\u003e \u003cp\u003eBased on retrospective studies, \u003cb\u003epercutaneous sclerotherapy\u003c/b\u003e is often the preferred treatment for large hemangiomas over surgical removal. \u003cb\u003eLin et al.\u003c/b\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] study of 89 patients found that it had several advantages, including shorter operative times, less blood loss, and reduced hospital stays and costs. Patients who underwent also experienced fewer minor complications, and the treatment was just as effective, reducing the tumor size by an average of 65% based on ultrasound follow-ups.\u003c/p\u003e \u003cp\u003eMore recently, a 2025 single arm series in Bangladesh \u003cb\u003eMoben et al.\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] involving 20 patients showed lesion reduction in 70% at six months, minimal complications, and good tolerance of the procedure, further strengthening evidence from resource limited settings that percutaneous sclerotherapy is both safe and effective.\u003c/p\u003e \u003cp\u003eIn agreement to \u003cb\u003eAyoobi Yazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], \u003cb\u003eLin et al.\u003c/b\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and \u003cb\u003eMoben et al.\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; Our study observed a statistically significant reduction in the lesion's largest dimension, Just three months after the injection procedure, with the mean decreasing to 7.99\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18 cm compared to 11.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 cm in the pre-injected lesions, median to 7.75 cm (IQR: 6.5\u0026ndash;10), and the range narrowing to 3.5\u0026ndash;16 cm compared to 6\u0026ndash;17 cm in the pre-injected lesions.\u003c/p\u003e \u003cp\u003eIn another words, our study involved 14 patients with reduction in the lesion's largest dimension of 10% to 41% and reduction in volume (yet only obtained in 3 patients) of 45% to 68.8%, with follow-up only after 3 months. Similarly, \u003cb\u003eAyoobi Yazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] study involved 5 patients with reduction in the lesion's largest dimension of 12.9% to 41% and reduction in volume of 45.6% to 71.1%, following up patients after 5 months. Also, our study showed similar results to \u003cb\u003eLin et al.\u003c/b\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] conducted on 89 patients with mean reduction in volume of 65%, with follow-up done after 9\u0026ndash;24 months. Finally in agreement with \u003cb\u003eMoben et al.\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] a Single-arm series from Bangladesh, involved 20 patients showing mean reduction in volume of 70%, with follow-up done after 9\u0026ndash;24 months.\u003c/p\u003e \u003cp\u003ePercutaneous transhepatic sclerotherapy shows very minimal intra-procedural and post-procedural complications. As seen in \u003cb\u003eAyoobi Yazdi et al.\u003c/b\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] study only one patient out of 5 (20%) experienced minor intraperitoneal hemorrhage in one case. In our study there were no any intraoperative complications. With minor postoperative complication seen in 4 patients (28.5%) experienced right hypochondrial pain responded to analgesics that lasted less than a week.\u003c/p\u003e \u003cp\u003eIncidentally, our study showed 3 patients with multiple hemangiomas (more than 3 lesions), only the largest hemangioma was injected. It was noted, in all these patients, that the rest of the non-injected, non-targeted lesions in these patients significantly decreased in size as if they were injected; as detailed in the illustrative cases above. This was believed that this observation is due to the systemic absorption of bleomycin with no enough studies in literature to confirm, for further studies to be conducted. This effect is similar to the abscopal effect which is shrinkage or disappearance of tumors in areas of the body not directly treated by local cancer therapy. As a result we recommend that further studies should be done for patients with multiple HH.\u003c/p\u003e \u003cp\u003eLike any study, our study had some limitations; one of them is the reduction in the lesion\u0026rsquo;s volume could only be obtained from 3 patients. Other limitations are that our study most available data derive from single center, non-randomized cohorts with small sample sizes and relatively short follow ups with 1 patient lost follow up. Further prospective, multicenter trials are needed to establish optimal sclerosant dosing, long term outcomes, and patient selection criteria journals.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePercutaneous transhepatic sclerotherapy with bleomycin\u0026ndash;lipiodol is a safe, effective, minimally invasive option for symptomatic giant hepatic hemangiomas, achieving significant lesion reduction and symptom relief with minimal complications. Despite promising outcomes, limitations include small sample sizes, short follow-up, and single-center data, highlighting the need for larger, multicenter prospective trials to validate long-term efficacy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAlanine Aminotransferase\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAnteroposterior\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAspartate Aminotransferase\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComplete Blood Count\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCraniocaudal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCECT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eContrast-Enhanced Computed Tomography\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComputed Tomography\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHepatic Hemangiomas\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHepatic Venous Malformation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInterquartile Range\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInterventional Radiology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInternational Units\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMagnetic Resonance Imaging\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003emTOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMammalian Target of Rapamycin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStandard Deviation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStatistical Package for Social Science\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTrans-catheter Arterial Embolization\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTransverse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUltrasound\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eOriginal research article Egyptian Journal of Radiology and Nuclear MedicinePercutaneous Sclerotherapy for Large Hepatic HemangiomasYoussef Wahid Tantawy1, Ahmed Mohamed Abouelhoda, MD1, Mohamed El-Gharib, MD1, 1 Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, EgyptCorresponding author:Youssef Wahid Tantawy, Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt Email: [email protected] No.: +201000379849Authors: Youssef Wahid Tantawy Radiology Resident Faculty of Medicine - Ain shams University - Egypt. [email protected]. Mohamed El-Gharib Professor of RadiologyFaculty of Medicine \u0026ndash; Ain Shams University- Egypt. Dr. Ahmed Mohamed AbouelhodaLecturer of RadiologyFaculty of Medicine - Ain Shams University- Egypt. Correspondence to Youssef Wahid Tantawy, Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt Email: [email protected] No.: +201000379849Declarations:Ethics Approval and Consent to Participate: This study was approved by FMASU (Faculty Of Medicine Ain Shams University Research Ethics Committee) (approval no. MS 177/2025).Consent for publication: All patients included in this research gave written informed consent to publish the data contained within this study. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: No financial or non-financial competing interests.Competing interests: The authors declare that they have no competing interests. Funding: This study had no funding from any resource. Authors' contributions: RAE: collected and analyzed the data, wrote the main manuscript text, prepared the cases, performed the required measurements and statistical analysis, and prepared figures and tables. AFA: reviewed literature, shared in statistical analysis and manuscript editing. KSS: suggested the research, reviewed the manuscript and statistical analysis. All authors read and approved the final manuscript.Acknowledgments: The author thanks all the study participants for their patience and support\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGhaemi O, Nejad MM, Rouhezamin MR, Yazdi NA, Pourghorban R, Yazdi HR. A technical review of percutaneous sclerotherapy with bleomycin for giant hepatic venous malformation. CVIR Endovasc. 2023;6(1):47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBajenaru N, Balaban V, Săvulescu F, Campeanu I, Patrascu T. Hepatic hemangioma -review-. J Med Life. 2015;8(5):4\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeon M, Chavez L, Surani S. Hepatic hemangioma: What internists need to know. World J Gastroenterol. 2020;26(1):11\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYazdi NA, Mehrabinejad M, Dashti H, Pourghorban R, Toosi MN, Yazdi HR. Percutaneous sclerotherapy with bleomycin and ethiodized oil: A promising treatment in symptomatic giant liver hemangioma. Radiology. 2021;301(2):464\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyoobi Yazdi N, Dashti H, Batavani N, Borhani A, Shakiba M, Rokni Yazdi H. Percutaneous sclerotherapy for giant symptomatic liver hemangiomas: a pilot study. J Vasc Interv Radiol. 2018;29(2):233\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Malenstein H, Maleux G, Monbaliu D, Verslype C, Komuta M, Roskams T, et al. Giant liver hemangioma: the role of female sex hormones and treatment. Eur J Gastroenterol Hepatol. 2011;23(5):438\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Z, Zhu X, Zhou J. Ultrasound-guided percutaneous sclerotherapy versus surgical resection in the treatment of large hepatic hemangiomas: a retrospective study. BMC Surg. 2022;22(1):130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoben AL, Noor E Alam SM, Begum R, Rahim MA, Sadman OF, Abdur Rahman M, et al. Percutaneous sclerotherapy for management of large hepatic haemangioma: First series from Bangladesh. Br J Healthc Med Res. 2025;12(1):312\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Percutaneous Sclerotherapy, Hepatic Hemangiomas","lastPublishedDoi":"10.21203/rs.3.rs-8871379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8871379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHepatic venous malformation (HVM), otherwise known as hepatic hemangioma, is considered the most common benign liver tumor. These liver tumors are common and are estimated to occur in up to 20% of the population. Although this tumor originates from a vascular malformation, its underlying pathophysiology remains poorly understood.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients \u0026amp; Methods: \u003c/strong\u003eThis study is a prospective study – one arm clinical trial. In this study, 14 patients with large symptomatic or asymptomatic significantly growing hepatic hemangioma (more than 5 cm) will undergo percutaneous sclerotherapy by bleomycin with a follow up study by contrast enhanced cross-sectional imaging after 3 months. This study was conducted in an Interventional Radiology Unit in university hospital over the period from March 2024 to September 2024. The main source of data for this study will be patients with large symptomatic hepatic hemangiomas referred to IR unit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u0026nbsp;\u003c/strong\u003ePercutaneous transhepatic sclerotherapy with a bleomycin–lipiodol mixture is a minimally invasive, effective alternative to surgery for large symptomatic hepatic hemangiomas, achieving 45–80% size reduction and durable symptom relief with minimal complications. Compared to resection, it offers shorter procedures, faster recovery, fewer complications, and lower costs.\u003c/p\u003e\n\u003cp\u003eOur study observed a statistically significant reduction in the lesion's largest dimension, Just three months after the injection procedure, with the mean decreasing to 7.99 ± 3.18 cm compared to 11.13 ± 3.2 cm in the pre-injected lesions, median to 7.75 cm (IQR: 6.5–10), and the range narrowing to 3.5–16 cm compared to 6-17 cm in the pre-injected lesions. With reduction in the lesion's largest dimension of 10% to 41% and reduction in volume (yet only obtained in 3 patients) of 45% to 68.8%, with follow-up only after 3 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePercutaneous transhepatic sclerotherapy with bleomycin–lipiodol is a safe, effective, minimally invasive option for symptomatic giant hepatic hemangiomas, achieving significant lesion reduction and symptom relief with minimal complications. Despite promising outcomes, limitations include small sample sizes, short follow-up, and single-center data, highlighting the need for larger, multicenter prospective trials to validate long-term efficacy.\u003c/p\u003e","manuscriptTitle":"Percutaneous Sclerotherapy for Large Hepatic Hemangiomas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 07:30:00","doi":"10.21203/rs.3.rs-8871379/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"29a4eb96-a51b-409e-8a14-b4f980683fbe","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T10:38:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 07:30:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8871379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8871379","identity":"rs-8871379","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}