Management of Liver Hemangiomas in Adults
Asymptomatic liver hemangiomas, regardless of size, generally require no treatment and can be managed conservatively with observation, as they rarely cause complications. 1, 2
Diagnosis and Evaluation
Liver hemangiomas are the most common benign liver tumors with a prevalence of 0.4-7.3% and a female-to-male ratio of up to 5:1 2
Typical hemangiomas have characteristic imaging features that vary by size 1:
- Small hemangiomas (<2 cm): Usually appear uniformly echogenic on ultrasound
- Medium hemangiomas (2-5 cm): Mainly echogenic
- Large hemangiomas (>5 cm): Show mixed echogenicity
When ultrasound findings are inconclusive, MRI with contrast is the preferred next imaging modality due to its high accuracy (95-99%) for diagnosing hemangiomas 1
Biopsy is generally not recommended for suspected hemangiomas due to risk of bleeding and is only necessary when imaging is inconclusive and malignancy cannot be excluded 1
Management Algorithm
For Asymptomatic Hemangiomas
- No specific treatment is indicated for asymptomatic hemangiomas regardless of size 2
- Routine surveillance is not required for patients with typical-appearing hemangiomas on ultrasound, as they generally follow a benign course 1
For Giant Hemangiomas (>5 cm)
- Giant hemangiomas have an increased risk of complications, with hepatic rupture risk of approximately 3.2%, increasing to 5% in lesions >10 cm 1, 2
- Peripherally located and exophytic lesions have a higher rupture risk 1
- Close monitoring may be warranted, especially during pregnancy due to potential growth from hormonal changes 1, 2
Indications for Intervention
Intervention is indicated for 1, 3:
- Symptomatic lesions causing pain or compression of adjacent structures
- Rapidly enlarging lesions
- Complications such as rupture
- Kasabach-Merritt syndrome (consumptive coagulopathy)
- Uncertainty of diagnosis
Treatment Options When Intervention Is Indicated
Surgical Options
- Enucleation is the preferred surgical method for accessible hemangiomas, as it results in less blood loss, shorter operative time, and fewer transfusion requirements compared to resection 4, 5
- Hepatic resection may be necessary for very large or anatomically complex hemangiomas 4, 5
- For extremely large hemangiomas, pre-operative transcatheter arterial embolization (TAE) may be performed to reduce tumor volume and ensure safer subsequent surgical resection 6
Non-Surgical Options
- Transcatheter arterial embolization can be used as a standalone treatment or as a pre-operative measure to reduce tumor size 6
- Radiofrequency ablation may be considered for smaller symptomatic hemangiomas in patients who are poor surgical candidates 3
Special Considerations
- Pregnancy is not contraindicated in women with hepatic hemangiomas, even giant ones 2
- For women with giant hemangiomas (>10 cm) planning pregnancy, discussion about potential treatment prior to conception should be considered 1, 2
- Close monitoring with ultrasound is recommended during pregnancy for women with giant hemangiomas 1, 2
Complications and Risks
- Spontaneous or traumatic rupture is rare but has a high mortality rate (36-39%) 7
- Kasabach-Merritt syndrome (consumptive coagulopathy) is an uncommon but serious complication requiring intervention 7
- Surgical complications include bleeding, pleural effusion, liver abscess, and wound infection, but mortality is very low 4