From the Guidelines
Hepatic hemangiomas are generally benign and do not require treatment unless they are large or symptomatic, with a risk of rupture being extremely rare, and management strategies should prioritize a conservative approach with periodic imaging and consideration of size and symptoms. The main risks associated with hepatic hemangiomas include potential rupture, compression of surrounding structures when large, and rarely, consumption coagulopathy (Kasabach-Merritt syndrome) 1. Most hemangiomas are discovered incidentally and can be safely monitored with periodic imaging, such as ultrasound or CT scans.
Key Considerations
- The risk of hepatic rupture in giant liver hemangiomas is estimated to be around 3.2% for lesions greater than 4 cm, with increased risk in peripherally located and exophytic lesions 1.
- Women with haemangiomas, even giant ones, should be advised that they do not preclude pregnancy, but close monitoring is recommended, especially for those with large or exophytic lesions 1.
- Imaging during each trimester of pregnancy is recommended to monitor haemangioma size in those at higher risk of rupture 1.
Management Strategies
- For asymptomatic hemangiomas less than 5 cm, observation is usually sufficient with ultrasound or CT imaging every 6-12 months initially, then less frequently if stable.
- For symptomatic or large hemangiomas, surgical options include enucleation or liver resection, and minimally invasive approaches such as arterial embolization or radiofrequency ablation may be considered 1.
- Medications are generally not effective, though some physicians have tried propranolol or corticosteroids with limited success, and women should be aware that estrogen-containing medications may cause hemangioma growth, so alternative contraception might be considered 1.
Patient Advice
- Patients with large hemangiomas should avoid contact sports or activities with high risk of abdominal trauma.
- Women planning pregnancy with a hepatocellular adenoma that has a diameter >5 cm should, where possible, have treatment prior to pregnancy, but haemangiomas do not preclude pregnancy 1.
From the Research
Risks Associated with Hepatic Haemangiomas
- Spontaneous or traumatic rupture, which can be life-threatening 2, 3, 4
- Intratumoral bleeding, which can lead to consumption coagulopathy 2
- Rapid growth, which can cause abdominal pain and other symptoms 2, 5
- Disseminated intravascular coagulation (Kasabach-Merritt syndrome), a rare but serious complication 4
Management Strategies for Hepatic Haemangiomas
- Observation, which is justified in the absence of symptoms 5, 4
- Surgical resection, which is indicated in patients with abdominal complaints, complications, or inconclusive diagnosis 2, 5, 4
- Enucleation, which is the preferred surgical method 5, 4
- Transcatheter arterial embolization (TAE), which can be used to manage symptomatic hemangiomas and reduce the risk of bleeding 3, 6
- Transcatheter arterial embolization (TAE) followed by tumor resection, which can be an effective treatment strategy for giant hepatic hemangiomas 3