From the Guidelines
Hepatic haemangiomas are typically characterized by peripheral nodular enhancement in the arterial phase with progressive centripetal fill-in during the portal venous and delayed phases on contrast-enhanced imaging, as seen in the most recent study from 2020 1.
Key Imaging Findings
- On ultrasound, hepatic haemangiomas appear as well-defined, homogeneous hyperechoic lesions, with their appearance varying based on size: lesions smaller than 2 cm tend to be universally echogenic, those sized 2-5 cm are mainly echogenic, while those larger than 5 cm exhibit a pattern of mixed echogenicity 1.
- On contrast-enhanced CT, they demonstrate peripheral nodular enhancement in the arterial phase with progressive centripetal fill-in during the portal venous and delayed phases, eventually becoming isodense or hyperdense compared to normal liver parenchyma 1.
- MRI shows low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, often described as "light bulb" brightness, with gadolinium contrast demonstrating the same enhancement pattern as CT but with better sensitivity 1.
Diagnostic Approach
- Contrast-enhanced ultrasound (CEUS) is very useful in the diagnosis of hepatic hemangioma, with typical findings including peripheral nodular enhancement in the arterial phase and complete or incomplete centripetal filling in the portal venous and late phases 1.
- The combination of an enhancement pattern comprising “peripheral nodular arterial enhancement” and “complete PV fill-in” yielded a sensitivity of 98% for histologically proven hemangiomas 1.
- For indeterminate liver lesions greater than 1 cm on initial imaging with US, multiphase contrast-enhanced CT has high accuracy for diagnosis of hemangioma, FNH, and HCC, making it a recommended next step in characterization 1.
From the Research
Hepatic Haemangioma Image Findings
- Hepatic haemangiomas are benign tumors of the liver consisting of clusters of blood-filled cavities, lined by endothelial cells, fed by the hepatic artery 2
- Typical hemangiomas, the so-called capillary hemangiomas, range from a few mm to 3 cm, do not increase in size over time and therefore are unlikely to generate future symptomatology 2
- Small (mm-3 cm) and medium (3 cm-10 cm) hemangiomas are well-defined lesions, requiring no active treatment beside regular follow-ups 2
- Giant liver hemangiomas, of up to 10 cm (most commonly) and even 20+ cm in size, can develop symptoms and complications that require prompt surgical intervention or other kind of therapy 2
Diagnosis and Imaging
- Hepatic hemangiomas require a careful diagnosis to differentiate from other focal hepatic lesions, co-occurring diagnoses are also possible 2
- Methods for diagnosis include ultrasonography, computed tomography scan, magnetic resonance imaging and selective hepatic arteriography or combinations of more than one technique 3
- On-table angiogram capabilities can be used to perform hemangioma inflow embolization and immediate hepatic resection under the same anesthesia in a single procedure 4
Treatment and Management
- Surgical resection is a treatment option for hepatic haemangiomas, with indications including spontaneous or traumatic rupture, consumption coagulopathy, rapid growth, abdominal pain and uncertain diagnosis 3
- Combining on-table embolization with immediate resection can enhance the safety of the resection by decreasing the size of the tumor, enabling compressibility, and facilitating exposure of the vascular inflow and outflow 4
- Treatment options for giant hemangiomas include observation, surgical resection, and transcatheter arterial embolization 5
- Expectant management of small asymptomatic haemangiomas appears appropriate, while embolization may reduce pain but the risk of abscess formation is high for large tumours 6