Fact-sheet: Hepatic hemangioma
Updated on 09/17/2021 at 12:16 PM
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Definition
Benign liver tumor measuring 2 to 20 cm, composed of multiple vascular channels lined by a single layer of endothelial cells resting on a thin fibrous stroma.
Multiple in 10-50% of cases.
Accounts for 5-10% of liver tumors.
Sex ratio: M/F=1/5, increased by multiparity
Clinical features
Asymptomatic except when the tumor is large, occasionally painful or tender hepatomegaly.
Exceptional complications:
- spontaneous hemorrhagic rupture
- infection with abscess formation
- Hemangioma with inflammatory syndrome:
Fever, chills, right upper quadrant pain, inflammatory syndrome,
normal liver function tests and WBC count -
Acute complete or partial thrombosis of the hemangioma, CT: Spontaneous hyperdensity
- Kasabach-Merritt syndrome:
Exceptional, more common in children.
Coagulopathy within the hemangioma: intravascular coagulation + fibrinolysis.
Risk of progression to DIC
Laboratory findings
Normal except for thrombocytopenia in Kasabach-Merritt syndrome
Radiography
Hepatomegaly if the hemangioma is large, with possible calcification projecting over the liver.
Ultrasound
Well-defined homogeneous hyperechoic nodule with posterior acoustic enhancement, located near the hepatic veins.
Sometimes atypical appearance: iso-echoic or hypoechoic mass with a peripheral hypoechoic rim in cases of fatty liver, or large heterogeneous mass with echogenic margins in giant hemangiomas.
The enhancement kinetics after IV microbubble injection are identical to those seen on MRI, and allow confirmation of the diagnosis.
CT
Without contrast: heterogeneous hypodense or isodense mass relative to the liver.
After IV contrast: peripheral nodular enhancement, followed by progressive centripetal enhancement and homogenization on delayed studies.
Enhancement may be more variable: intense arterial enhancement of small hemangiomas and variable venous enhancement over time, particularly for giant hemangiomas
MRI
Classically: - T1: Well-defined iso- to hypointense nodule. - T2: Hyperintense nodule or mass, similar to CSF, with increased signal intensity on delayed echoes - T1 after gadolinium administration: peripheral nodular enhancement with centripetal filling and homogenization over time. For small hemangiomas, enhancement may be homogeneous during the arterial or portal phase. Giant hemangiomas may show hypointense septa.
Vascular intervention
On hepatic X-Ray Angiography: opacification of dilated, irregular, well-defined vascular lakes during the late arterial or capillary phase, with a peripheral halo
Nuclear medicine
Tc-99m-labeled red blood cell scintigraphy: hypoactivity on early studies with increasing activity over time
Management
No treatment is required in the majority of cases, as hemangiomas smaller than 4 cm in diameter do not enlarge.
Segmental liver resection is exceptionally performed for large, symptomatic tumors. These large hemangiomas may increase in size
Classification
Imaging classification:
-Giant hemangiomas: > 5 cm
-Fast-flow hemangiomas < 2 cm
-Slow-flow hemangiomas
-Hemangiomas with arteriovenous shunting.
Pathologic classification:
- Cavernous hemangioma, mainly in adults
- Capillary hemangioma, mainly in children
- Sclerosing hemangioma (partial fibrous component)
- Sclerotic hemangioma (extensive fibrosis)
Differential diagnosis
All liver tumors, particularly hypervascular ones:
- hepatocellular carcinoma,
- metastases,
- adenoma,
- FNH.