Staged radiotherapy for symptomatic unresectable giant hepatic hemangiomas with diffuse bilobar involvement

Although most hepatic hemangiomas require no treatment, giant lesions causing progressive symptoms, consumptive coagulopathy, or compression of adjacent organs may require intervention. Surgery remains the standard treatment but may not be feasible in patients with extensive bilobar disease or excessive operative risk. A 44-year-old woman presented with progressive abdominal fullness caused by multiple giant hepatic hemangiomas involving both hepatic lobes, the largest of which measured approximately 30 cm. Five years earlier, central bisectionectomy had been complicated by massive intraoperative bleeding, and the residual lesions subsequently enlarged. Because further surgery was considered high risk, staged three-dimensional conformal radiotherapy was performed to avoid simultaneous irradiation of the entire liver. The left-lobe lesion received 30 Gy in 15 fractions, followed approximately 2 years later by the same regimen for the enlarging right-lobe lesion. Both treatments resulted in marked tumor regression and symptomatic improvement. Fibrin degradation products and D-dimer levels decreased, fibrinogen levels normalized, and thrombocytopenia partially improved in association with the radiographic response. No grade 2 or higher treatment-related adverse events occurred. These findings suggest that staged bilateral radiotherapy may represent a feasible strategy for selected patients with symptomatic, unresectable giant hepatic hemangiomas and diffuse bilobar involvement for whom surgery is not feasible.