Hepatic hemangioma

Changed by Muhammad Qasim Khan, 30 May 2020
Back to revision history

Updates to Article Attributes

Body was changed:

Hepatic haemangiomas are most common benign vascular liver lesions.  Infantile hepatic hemangioma (IHH) is the most common, benign, hepatic vascular tumor in infants. 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 malignancy.

Epidemiology

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

Associations

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.

Subtypes

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

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 the 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 haemangioma is hyperechoic relative to background liver
    • central haemorrhagic portions of cavernous haemangiomas remain non-enhancing

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:

  • non-contrast: 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 even with high b-values due to slow blood flow and can be hyperintense or mixed (hyper and hypointense regions) on ADC map 16
Nuclear medicine
SPECT

Tc-99m RBC labelled SPECT can be sensitive for larger lesionsand 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 (MRI, 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 a 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:

  • -<p><strong>Hepatic haemangiomas </strong>are benign vascular <a href="/articles/hypervascular-liver-lesions">liver lesions</a>. 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 malignancy.</p><h4>Epidemiology</h4><p>Hepatic haemangiomas are much more common in females, with a F:M of up to 5:1 <sup>17</sup>.</p><h5>Associations</h5><ul>
  • +<p><strong>Hepatic haemangiomas </strong>are most common benign vascular <a href="/articles/hypervascular-liver-lesions">liver lesions</a>.  Infantile hepatic hemangioma (IHH) is the most common, benign, hepatic vascular tumor in infants. 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 malignancy.</p><h4>Epidemiology</h4><p>Hepatic haemangiomas are much more common in females, with a F:M of up to 5:1 <sup>17</sup>. They are rarely seen in young children</p><h5>Associations</h5><ul>

References changed:

  • 19. Gnarra M, Behr G, Kitajewski A et al. History of the Infantile Hepatic Hemangioma: From Imaging to Generating a Differential Diagnosis. World J Clin Pediatr. 2016;5(3):273-80. <a href="https://doi.org/10.5409/wjcp.v5.i3.273">doi:10.5409/wjcp.v5.i3.273</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27610342">Pubmed</a>

ADVERTISEMENT: Supporters see fewer/no ads