From the Guidelines
Hepatic cavernous hemangioma is a benign liver tumor that typically requires no treatment, but may need surgical resection or other interventions in symptomatic cases or those with a high risk of rupture, as determined on a case-by-case basis, guided by symptoms and risk to maternal and fetal outcomes, particularly in pregnant women with large lesions 1.
Diagnosis
The diagnosis of hepatic cavernous hemangioma is typically made incidentally during imaging studies, and the lesions are usually asymptomatic. However, in some cases, symptoms such as right upper quadrant pain, early satiety, or nausea may be present. The lesions appear as well-defined hypodense lesions on CT scan with peripheral nodular enhancement and progressive centripetal filling on contrast studies 1.
Treatment
The treatment approach for hepatic cavernous hemangioma depends on the size, location, presence of hemorrhage, and other factors.
- For asymptomatic cases, observation with periodic imaging is the standard approach.
- For symptomatic cases, surgical resection or enucleation may be considered, though this is rare.
- Other treatment options for symptomatic cases include radiofrequency ablation, radiation therapy, or liver transplantation in extreme cases.
- In pregnant women with large lesions, the risk of rupture is increased, and discussion of the merits of treatment prior to conception should be considered 1.
Management in Pregnancy
Pregnant women with hepatic cavernous hemangioma should be closely monitored, as the risk of rupture is increased during pregnancy, particularly in those with large lesions 1.
- Resection can be performed during pregnancy in case of rapidly enlarging cases or in those complicated by rupture.
- The decision to intervene should be approached with caution and be determined on a case-by-case basis, guided by symptoms and risk to maternal and fetal outcomes.
Key Considerations
- Size, location, presence of hemorrhage, and other factors are relevant in deciding the best therapeutic approach.
- Consultation with a hepatobiliary surgeon and interventional radiology should be considered.
- Post-HCA surveillance with US during pregnancy is indicated and should be continued postpartum, as HCAs continue to pose a risk during this period of rapid normalization of sex hormone levels 1.
From the Research
Diagnosis of Hepatic Cavernous Hemangioma
- Hepatic cavernous hemangioma is typically diagnosed using imaging modalities such as ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positron emission tomography combined with CT (PET/CT) and angiography 2.
- Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases 2.
- A diagnosis of hepatic cavernous hemangioma can also be made using enhanced CT and magnetic resonance imaging (MRI) 3.
Treatment of Hepatic Cavernous Hemangioma
- The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome, and organ or vessels compression, which represents a valid indication for surgery and at the same time are all complications of the tumor itself 2.
- Liver hemangiomas, when indication exists, have to be treated firstly by surgery (hepatic resection or enucleation, open, laparoscopic or robotic) 2.
- Other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied in recent years 2.
- Surgical resection is considered in symptomatic cases with rapidly growing tumors and coagulopathy 3.
- Preoperative selective hepatic artery embolization can help decrease operative hemorrhage in liver resection for these vascular tumors 4.
Indications for Surgery
- Presence of symptoms is the most common indication for treatment, with abdominal pain being the most frequent symptom 5, 6.
- Indications for surgery should be assessed in units with experience in liver surgery, where low morbidity and mortality rates can justify the intervention 6.
- Size of the tumor does not represent a valid indication for treatment 2.
- Rapid growth of the tumor can be an indication for surgery 5.