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Pediatric vascular tumors of the liver: beware!

P ediatric vascular liver tumors are divided into infantile heman- gioendothelioma (HE), cavernous hemangioma, and arterio-venous malformations. HE and cavernous hemangioma are mostly benign, asymptomatic, and found incidentally, and treatment is not necessary (1). They can be solitary or multifocal, they can be present in early infancy or appear later in childhood, they can recur even after having disappeared, and they can be of different histological types. Nevertheless, there is more than just the harmless incidental pediatric vascular liver tumor. Before we start a clinical discussion, we need to recognize that there are 2 types of histological patterns of liver HE in infants and children: HE type 1 is an orderly tumor having a pattern identical to that of the cutaneous hemangiomas, is usually benign, and regresses spontaneously with time; type 2 HE has, histologically, a more aggressive, irregular appearance, also can be called angiosarcoma, and is clearly a malignant tumor that needs aggressive treatment (2). Unfortunately, imaging studies do not easily help to definitely differentiate between HE types 1 and 2. They show different contrast enhancements in computed tomography scans (centripetal vs irregular central) (3), but this may only raise suspi-cion and must lead to the decision to perform a biopsy. Because HE can present as multifocal disease, definite histological diagnosis is difficult to obtain in such cases because histology may be different from nodule to nodule. Serum parameters help neither; a -fetopro-tein has no diagnostic value, because most often it is normal. What can help us to distinguish between children with HE type 1 or type 2? There are different clinical pictures that must raise suspicion. First, HE of the neonate or infant may present with complications (eg, congestive heart failure) needing treatment (eg, steroids, chemotherapy, interferon, embolization), but it usually resolves with time and will not bother anymore. But beware! It seems that multifocal disease can show