Hepatic haemangioma

Hepatic haemangiomas, also known as hepatic venous malformations, are benign non-neoplastic hypervascular liver lesions. They are frequently diagnosed as an incidental finding on imaging, and most patients are asymptomatic. From a radiologic perspective, it is important to differentiate haemangiomas from hepatic neoplasms.

Terminology

It is important to note that according to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are merely known as slow flow venous malformations. Having said that, it is probably helpful in reports to retain the word haemangioma, as this term is ubiquitous in the literature and familiar to most clinicians. The remainder of this article uses the term 'hepatic haemangioma' for consistency with the majority of the existing literature.

Cavernous venous malformations are found throughout the body. This article focuses on hepatic cavernous haemangiomas. For a general discussion, please refer to the general article on cavernous venous malformation.  

Epidemiology

Hepatic haemangiomas are much more common in females, with a F:M of up to 5:1 17.

Pathology

Hepatic haemangiomas are thought to be congenital in origin, non-neoplastic, and are almost always of the cavernous subtype. Blood supply is predominantly hepatic arterial, similar to other liver tumours. A peripheral location within the liver is most common 3.

Sub types

The presence of a few hepatic haemangiomas in the liver is not uncommon, but rarely a large number hepatic haemangiomas may occur (see hepatic haemangiomatosis).

Associations

Radiographic features

Ultrasound
  • typically well-defined hyperechoic lesions
  • a small proportion (10%) are hypoechoic, which may be due to a background of hepatic steatosis, where liver parenchyma itself is of increased echogenicity
  • colour Doppler: may show peripheral feeding vessels 
  • contrast-enhanced ultrasound
    • arterial phase: peripheral nodular discontinuous enhancement
    • portal venous and delayed phases: continued "filling in" of the lesion, until the entire hemangioma is hyperechoic relative to background liver

See hyperechoic liver lesions for a further differential.

CT

Most haemangiomas are relatively well defined. The dynamic enhancement pattern is related to the size of its vascular space 1. Features of typical lesions include:

  • noncontrast: often hypoattenuating relative to liver parenchyma
  • arterial phase: typically show discontinuous, nodular, peripheral enhancement (small lesions may show uniform enhancement)
  • portal venous phase: progressive peripheral enhancement with more centripetal fill-in
  • delayed phase: further irregular fill-in and therefore iso- or hyper-attenuating to liver parenchyma

Other described features include:

MRI

Typical features include:

  • T1: hypointense relative to liver parenchyma
  • T2: hyperintense relative to liver parenchyma, but less than the intensity of CSF or of a hepatic cyst
  • T1 C + (Gd): often shows peripheral nodular discontinuous enhancement which progresses centripetally (inward) on delayed images
    • haemangiomas tend to retain contrast on delayed (>5 minutes) contrast-enhanced images
    • atypical haemangiomas may demonstrate slightly altered enhancement patterns
  • T1 C + (hepatobiliary contrast, Eovist)
    • in general, delayed imaging with Eovist/Gd- BOPTA may not be helpful since haemangiomas can have a variable appearance that ranges from hypointensity to diffuse and central enhancement
  • DWI: hyperintense on diffusion-weighted imaging (DWI) even with high b-values due to slow blood flow and are hypointense on ADC map indicating restricted diffusion 16
Nuclear medicine
SPECT

99Tc RBC labelled SPECT can be sensitive for larger lesions and typically demonstrate decreased activity on initial dynamic images followed by increased activity on delayed, blood pool images.

Treatment and prognosis

They are benign lesions. Recommendations for patients with no known risk factors for hepatic malignancy can range from centre to centre from performing confirmatory examinations (MR imaging, triphasic CT or scintigraphy) to considering follow-up ultrasound in 6 months to confirm stability, to performing no further imaging evaluation 13. Some authors propose surgical resection for patients with progressive abdominal pain in combination with size greater than 5 cm 14.

Differential diagnosis

The diagnosis of haemangioma can usually be made with high specificity if the imaging characteristics are typical. General imaging differential considerations for a haemangioma depend on the imaging modality and the patient's history, but may include:


Vascular tumours and malformations
Ultrasound - general index
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Article Information

rID: 7565
System: Hepatobiliary
Section: Pathology
Synonyms or Alternate Spellings:
  • Liver haemangioma
  • Hepatic cavernous haemangioma
  • Liver hemangioma
  • Hemangioma of the liver
  • Hepatic hemangioma
  • Hepatic haemangiomas
  • Hepatic hemangiomas
  • Hepatic hemangiomata
  • Hepatic haemangiomata
  • Hepatic haemangioma
  • Hepatic cavernous venous malformation
  • Hepatic venous malformations
  • Hepatic cavernous venous malformations
  • Hepatic venous malformation
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    Case 1: arterial phase
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    Haemangioma
    Case 2
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    Haemangioma: T2
    Case 4: MRI T2
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    Hepatic Hemangiom...
    Case 5: venous phase
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    Haemangioma
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    Note, the number ...
    Case 7: with sonographic contrast
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    T2W TE = 172ms
    Case 8
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    Fig. 1

Large T2-...
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    Case 11
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    Hyper echogenic a...
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    1 - No contrast. ...
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    Case 14: multi-focal
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    Case 15
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    Case 16
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    Case 17
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    The hepatic lesio...
    Case 18: flash fill haemangioma
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    Case 19
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    Ultrasound images
    Case 22: on ultrasound
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    Case 23
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    Case 24: on a fatty liver
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