title: Multifocal epitheloid hemangioendothelioma of liver after long-term oral contraceptive use--a case report and discussion of management difficulties encountered.
abstract: METHODS
  A 43-year-old woman presented with right upper abdominal pain, on and off for 3-4 years. One year prior to her presentation, a space-occupying lesion was found in the right lobe of the liver, which was suspected to be hemangioma, as the patient had history of combined oral contraceptive pill use for the last 15 years. On examination, she was thinly built and had pallor; abdominal examination revealed tender hepatomegaly 3 cm below the costal margin, smooth surface, sharp regular edge with left lobe enlargement, and no bruit.
  
  
  RESULTS
  All routine biochemical and hematologic investigations were normal, except hemoglobin of 7.6 gm/dl. On triple-phase CT scan, there were hypodense ill-defined lobulated area in right lobe of liver; similar lesions were also seen in segments V and VII of liver along with a few sub-diaphragmatic and para-aortic nodes. Liver biopsy showed features suggestive of hemangioendothelioma, and immunohistochemistry showed CD 31 and CD 34 positivity but negative for estrogen receptors. Laparoscopy revealed presence of multiple deposits on left lobe of liver and ascites.
  
  
  CONCLUSIONS
  Tumor was unresectable, and the patient was found to be a candidate for liver transplant. Chemoembolization was tried as a palliation awaiting transplant, but the procedure was unsuccessful due to the hypovascular nature of the tumor. The patient died within 4 months of diagnosis due to liver failure, awaiting liver transplant, as a suitable donor was not available.
  
  
  CONCLUSIONS
  A clinical suspicion based on demographics, risk factors and imaging, familiarity with the pathologic findings, and utilization of advanced imaging techniques may allow early diagnosis of these tumors and hence their appropriate management.
authors.affiliation: Division of Gastroenterology, Medicine, Maulana Azad Medical College and Lok Nayak Hospital, University of Delhi, New Delhi, India. sdsinghal@gmail.com
authors.forename: Shashideep
authors.initials: S
authors.lastname: Singhal
authors.forename: Shilpa
authors.initials: S
authors.lastname: Jain
authors.forename: Montish
authors.initials: M
authors.lastname: Singla
authors.forename: Ram Babu
authors.initials: RB
authors.lastname: Pippal
authors.forename: Ranjana
authors.initials: R
authors.lastname: Gondal
authors.forename: Anil
authors.initials: A
authors.lastname: Agarwal
authors.forename: Premashis
authors.initials: P
authors.lastname: Kar
mesh_terms: D000328:Adult; D003278:Contraceptives, Oral, Hormonal / Q000009:adverse effects*; D005260:Female; D018323:Hemangioendothelioma, Epithelioid / Q000139:chemically induced* / Q000473:pathology*; D006801:Humans; D007150:Immunohistochemistry; D008113:Liver Neoplasms / Q000139:chemically induced* / Q000473:pathology*
chemical_list: D003278:Contraceptives, Oral, Hormonal