Hepatic epithelioid Hemangioendothelioma presenting synchronously with hepatocellular carcinoma-a case report

Primary hepatic epithelioid hemangioendothelioma (HEHE) is a rare neoplasm of vascular origin with varying biologic behavior, making it challenging to diagnose.

We present a case of synchronous hepatocellular carcinoma (HCC) and HEHE in a 43-year-old Chinese male patient. Multiple hypoechoic liver lesions were depicted, but no specific imaging findings were detected on enhanced computed tomography (CT) or contrast-enhanced magnetic resonance imaging (MRI). The patient then underwent [¹⁸F]-FDG PET/CT, [¹¹C]-acetate PET/CT, and [⁶⁸Ga]Ga-FAPI-04 PET/CT. The HEHE lesions demonstrated no uptake on both ¹⁸F-FDG and ¹¹C-acetate PET/CT imaging, but presented a clear visualization in [⁶⁸Ga]Ga-FAPI-04 PET/CT. The largest lesion located in segment VII was finally diagnosed as HCC, while the other smaller ones were diagnosed as HEHE, which was confirmed by immunohistochemical staining for CD31. To the best of our knowledge, only 2 cases have been reported in the worldwide literature, and the first case undertook both ¹¹C-acetate and [⁶⁸Ga]Ga-FAPI-04 PET/CT instead of ¹⁸F-FDG PET/CT.

In this report, we show that HCC and HEHE may occur synchronously, and HEHE should be considered when liver lesions are detected. [⁶⁸Ga]Ga-FAPI-04 PET/CT has great potential in the detection, staging and therapy selection of HEHE.