What is the recommended management approach for hepatic (liver) hemangioma?

From the Guidelines

The recommended management approach for hepatic hemangiomas is typically conservative observation for most patients, as these benign liver tumors rarely require intervention. Asymptomatic hemangiomas, especially those smaller than 5 cm, can be monitored with periodic imaging every 6-12 months initially, with less frequent follow-up if stability is demonstrated 1. No medications are specifically indicated for treatment of uncomplicated hemangiomas. Intervention becomes necessary only when hemangiomas cause significant symptoms (severe abdominal pain, early satiety), grow rapidly, or present complications like rupture or Kasabach-Merritt syndrome (thrombocytopenia). In these cases, surgical resection is the primary treatment option, with techniques ranging from enucleation to formal hepatic resection depending on size and location. Alternative interventions for poor surgical candidates include transarterial embolization, radiofrequency ablation, or radiation therapy. Some key considerations include:

• The risk of hepatic rupture in giant (>4 cm) liver haemangioma was 3.2%, with increased risk in peripherally located and exophytic lesions 1
• In lesions >10 cm, the risk increases to 5%; in these relatively higher risk cases, discussion of the merits of treatment prior to conception should be considered 1
• Haemangiomas can usually be managed conservatively, and resection is rarely required, but it can be performed during pregnancy in case of rapidly enlarging cases or in those complicated by rupture 1
• Women who are pregnant or taking estrogen-containing medications should be monitored more closely as hormonal influences may cause hemangioma growth 1. The conservative approach is justified because hepatic hemangiomas are benign vascular malformations with extremely low malignant potential and most remain stable or grow very slowly over time.

From the Research

Hepatic Hemangioma Management

The management of hepatic hemangiomas is a topic of interest due to their common occurrence as the most common primary tumor of the liver.

• Most hepatic hemangiomas are asymptomatic and can be managed conservatively, as seen in a study by 2 where 241 patients did not undergo surgery and did not present any complications related to the hemangioma during long-term follow-up.
• However, large hemangiomas can be symptomatic and may require surgical intervention or other treatment modalities, such as transcatheter arterial embolization (TAE) as reported in a case study by 3.

Treatment Options

The treatment options for hepatic hemangiomas include:

• Observation: for asymptomatic hemangiomas, as most are benign and do not require treatment 2.
• Surgical resection: for symptomatic hemangiomas, especially those that are large or causing significant symptoms, as seen in a study by 4 where 61 patients with giant hepatic hemangiomas were treated with surgical resection.
• Transcatheter arterial embolization (TAE): a minimally invasive procedure that can be used to treat symptomatic hemangiomas, as reported in a study by 5 where three patients underwent elective treatment of their hemangiomas with highly selective hepatic embolization.
• Enucleation: a surgical procedure that involves removing the hemangioma from the surrounding liver tissue, as mentioned in a study by 4.

Complications and Risks

The complications and risks associated with the treatment of hepatic hemangiomas include:

• Postoperative complications: such as bleeding, infection, and liver dysfunction, as seen in a study by 4 where 8 patients (13.1%) experienced complications after resection or enucleation.
• Tumor size and symptoms: large tumor size and symptomatic hemangiomas are associated with a higher risk of complications, as reported in a study by 4.
• Intraoperative blood loss and operative time: greater intraoperative blood loss and longer operative time are associated with a higher risk of complications, as seen in a study by 4.

Current State of Treatment

The current state of treatment for hepatic hemangiomas is evolving, with a focus on minimally invasive techniques and interventional treatments, as discussed in a review by 6.

• Interventional treatments, such as TAE and embolization, are becoming increasingly popular for the treatment of symptomatic hemangiomas.
• Surgical resection and enucleation are still considered safe and effective treatment options for symptomatic hemangiomas, especially those that are large or causing significant symptoms.