What is the management of cavernous hemangioma (a type of benign vascular liver tumor) of the liver?

From the Guidelines

Management of cavernous hemangiomas of the liver typically involves observation for most asymptomatic lesions, as these benign vascular tumors rarely require intervention, with surgical resection considered for symptomatic or large lesions, particularly those greater than 10 cm, where the risk of rupture increases to 5% 1.

Asymptomatic Lesions

For small (<5 cm) asymptomatic hemangiomas, no treatment is necessary, and routine follow-up imaging is generally not required once the diagnosis is confirmed, as the risk of complications is low 1.

Symptomatic or Large Lesions

For larger or symptomatic hemangiomas, management depends on symptom severity and lesion characteristics, with options including surgical resection, transarterial embolization, or radiofrequency ablation, and the decision to intervene should balance the risks of the procedure against the severity of symptoms 1.

• Surgical resection is the definitive treatment for symptomatic hemangiomas, with options including enucleation or formal hepatic resection.
• Minimally invasive approaches like laparoscopic surgery can be used for accessible lesions.
• Alternative treatments include transarterial embolization to reduce blood flow to the hemangioma, which can be used as a standalone treatment or before surgery to reduce bleeding risk.
• Radiofrequency ablation may be suitable for smaller, symptomatic lesions.

Special Considerations

Liver transplantation is rarely indicated but may be considered for diffuse hemangiomatosis causing liver failure, and close monitoring is recommended for pregnant women with haemangiomas, particularly those with large or symptomatic lesions, as the risk of rupture or worsening symptoms during pregnancy is increased 1.

• The risk of hepatic rupture in a giant (>4 cm) liver haemangioma was 3.2%, with increased risk in peripherally located and exophytic lesions 1.
• Discussion of the merits of treatment prior to conception should be considered for lesions >10 cm, where the risk increases to 5% 1.

From the Research

Management of Cavernous Hemangioma of the Liver

The management of cavernous hemangioma of the liver involves various approaches, including surgical and non-surgical methods. The following are some key points to consider:

• Diagnosis of liver hemangioma is typically made 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.
• The indications for surgery include rupture, intratumoral bleeding, Kasabach-Merritt syndrome, and organ or vessel compression, but the size of the tumor does not represent a valid indication for treatment 2.
• Surgical resection is considered the only curative treatment for symptomatic patients, and the choice of surgical procedure depends on the location and morphology of the lesion 3.
• Other treatment options include liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy, which have been applied in recent years 2.

Surgical Approaches

Surgical approaches for cavernous hemangioma of the liver include:

• Hepatic resection or enucleation, which can be performed using open, laparoscopic, or robotic techniques 2.
• Formal liver resection or enucleation, which are safe forms of treatment that can effectively control symptomatology 3.
• Anatomic and atypical resections or enucleations, which can be performed depending on the location and morphology of the lesion 4.

Non-Surgical Approaches

Non-surgical approaches for cavernous hemangioma of the liver include:

• Observation, as many hemangiomas are asymptomatic and do not require treatment 5, 4.
• Preoperative selective hepatic artery embolization, which can help decrease operative blood loss 6.
• Radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy, which can be used as alternative treatment options 2.

Complications and Outcomes

Complications and outcomes of surgical treatment for cavernous hemangioma of the liver include:

• Postoperative complications, such as bleeding, fever, and abdominal hematoma, which can occur in some cases 3, 6.
• Operative mortality, which is rare 3, 4, 6.
• Symptom control, which can be effectively achieved with surgical treatment 3.