Thrombosed Giant Multifocal Hepatic Cavernous Hemangioma Mimicking Lymphatic Malformation on Coaxial Biopsy in an Adult with Recurrent Fever: A Case Report and Focused Literature Review

Hepatic cavernous hemangioma is the most common benign liver tumor, but giant or extensively thrombosed variants may lose their characteristic imaging features and mimic other cystic or vascular lesions. A 32-year-old man presented with recurrent fever for more than two months, massive hepatomegaly, leukocytosis (white blood cell count 14.46 × 109/L), C-reactive protein 165.30 mg/L, and greatly elevated D-dimer (48.44 mg/L) and fibrin degradation products (323.52 mg/L), with normal platelet count, fibrinogen, prothrombin time, and activated partial thromboplastin time. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated multiple bilateral cystic or cystic-solid hepatic lesions with calcifications and no classic blood-pool enhancement pattern. 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (PET/CT) showed no significant uptake, and an extensive microbiological workup was negative. Ultrasound-guided percutaneous biopsy (coaxial technique, 15-gauge needle, five cores from the solid component of the largest right-lobe lesion) favored a benign vascular/lymphatic tumor most consistent with hepatic lymphatic malformation (LM). Subsequently, the patient underwent staged laparoscopic partial hepatectomy combined with microwave ablation at another hospital. The resection pathology demonstrated cystically dilated, blood-filled channels with organizing thrombi, infarction, cholesterol granulomas, and calcification, diagnostic of hepatic cavernous hemangioma with thrombus formation—discordant with the biopsy interpretation. The patient has remained afebrile since surgery, with normalization of inflammatory markers and a fall in D-dimer to 6.95 mg/L. Extensive thrombosis, fibrosis, and calcification can abolish the classic imaging and histopathological features of hepatic hemangioma and make it resemble a lymphatic malformation on coaxial biopsy.