What MRI is needed for diagnosis of hepatic hemangioma (liver hemangioma)?

From the Guidelines

For diagnosing a liver hemangioma, a contrast-enhanced MRI with specific sequences, including T1-weighted, T2-weighted, and dynamic contrast-enhanced sequences using gadolinium-based contrast agents, is the preferred imaging method. This approach is supported by the most recent and highest quality study 1, which demonstrates that MRI with extracellular gadolinium contrast has a sensitivity of 93%, specificity of 99%, accuracy of 98%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 99% for the diagnosis of hemangioma.

The key sequences in the MRI protocol include:

• T1-weighted images to assess the lesion's morphology and signal characteristics
• T2-weighted images, which are particularly valuable as hemangiomas typically appear as well-defined, homogeneous hyperintense (bright) lesions
• Dynamic contrast-enhanced sequences to show peripheral nodular enhancement in the arterial phase with progressive centripetal fill-in during the portal venous and delayed phases, a pattern considered diagnostic for hemangiomas
• Diffusion-weighted imaging (DWI) may also be included to help differentiate hemangiomas from malignant lesions, although its value is limited in patients without a history of malignancy due to the overlap of apparent diffusion coefficient (ADC) values between solid benign and malignant lesions 1.

While contrast-enhanced ultrasound (CEUS) can be useful in the diagnosis of hepatic hemangioma, especially in real-time observation of perfusion through the lesion 1, MRI offers superior soft tissue contrast and can characterize hemangiomas with high specificity, reducing the need for biopsy. The combination of MRI sequences, including DWI and hepatobiliary phase (HBP) imaging, allows for correct classification of lesions as benign or malignant in 91% of cases and exact characterization in 85% of cases 1.

Therefore, a contrast-enhanced MRI with the specified sequences is the recommended imaging method for diagnosing liver hemangioma, providing a definitive non-invasive diagnosis and guiding further management.

From the Research

MRI Protocols for Liver Hemangioma

To diagnose and characterize liver hemangiomas, various MRI protocols can be employed. The choice of protocol depends on the specific requirements of the diagnosis and the equipment available.

• T2-weighted imaging is commonly used for the detection and characterization of liver hemangiomas 2, 3, 4.
• Heavily T2-weighted conventional spin-echo sequences can help differentiate hemangiomas from malignant tumors 3.
• T2-weighted turbo spin-echo sequences and serial gadolinium-enhanced T1-weighted FLASH sequences can also be used for the evaluation of hepatic hemangiomas 2.
• Diffusion-weighted imaging (DWI) with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhancement can be effective in distinguishing liver hemangiomas from metastatic tumors 5.
• T2-enhanced spin-echo imaging using the time-reversed gradient echo sequence in the hepatobiliary phase of gadoxetic acid-enhanced MRI can also be useful for differentiating hemangiomas from metastatic tumors 6.

Key Imaging Features

The key imaging features for liver hemangiomas include:

• High signal intensity on T2-weighted images 2, 3, 4
• Immediate uniform enhancement on gadolinium-enhanced T1-weighted images for small hemangiomas 2
• Persistent central hypointensity on gadolinium-enhanced T1-weighted images for large hemangiomas 2
• High lesion-to-liver contrast-to-noise ratios on T2-weighted images 2, 3

Diagnostic Accuracy

The diagnostic accuracy of MRI protocols for liver hemangiomas can be evaluated using receiver operating characteristic (ROC) analysis.

• T2 relaxation times have been shown to perform better than subjective reader analysis for liver lesion characterization 4.
• The combination of T2-weighted imaging and diffusion-weighted imaging can achieve high diagnostic accuracy for differentiating hemangiomas from metastatic tumors 5, 6.