Workup of Liver Hemangioma
For incidentally detected liver lesions suspected to be hemangiomas, ultrasound with Doppler is the initial imaging modality of choice, and typical imaging features on ultrasound alone are sufficient for diagnosis in most cases without need for further workup. 1, 2
Initial Diagnostic Approach
Ultrasound Characteristics
- Small hemangiomas (<2 cm) appear uniformly echogenic on ultrasound 1
- Medium hemangiomas (2-5 cm) are mainly echogenic 1
- Large hemangiomas (>5 cm) show mixed echogenicity 1
- Doppler ultrasound is particularly useful for evaluating hepatic hemangiomas and should be the preferred initial imaging study 3, 1
When Additional Imaging is Needed
If ultrasound findings are inconclusive, MRI with contrast is the preferred next imaging modality due to its high diagnostic accuracy of 95-99% for hemangiomas. 1, 4
Contrast-Enhanced Ultrasound (CEUS)
- CEUS is highly effective for confirming diagnosis when standard ultrasound is equivocal 1
- Typical CEUS findings include:
- CEUS has diagnostic accuracy of approximately 85% 4
CT Imaging
- CT with contrast can be used but is not the first-line modality 3
- Shows characteristic peripheral nodular enhancement in arterial phase with centripetal filling 2
- CT angiography is valuable preoperatively in patients with large tumors being considered for resection (93% diagnostic accuracy) 5
Important Diagnostic Pitfalls
When to Avoid Biopsy
Biopsy is generally not recommended for suspected hemangiomas due to bleeding risk and should only be performed when imaging is inconclusive and malignancy cannot be excluded. 1
Distinguishing from Malignancy
- Hemangiomas should not show marked T2 hyperintensity or targetoid appearances on diffusion-weighted or contrast-enhanced images, which would suggest intrahepatic cholangiocarcinoma 3
- In high-risk patients (cancer predisposition syndromes, Li-Fraumeni syndrome), atypical hemangiomas should be categorized as ONCO-RADS category 4, indicating high likelihood of cancer requiring further investigation 3, 4
Unnecessary Tests to Avoid
- Do not measure serum AFP for benign hemangiomas, as AFP is a tumor marker for hepatocellular carcinoma, not hemangiomas 1
- Routine surveillance imaging is not required for typical-appearing hemangiomas in low-risk patients 1
Management Based on Workup Results
Typical Hemangiomas
- No specific treatment is indicated for asymptomatic hemangiomas regardless of size 2
- Conservative management with observation is appropriate for typical hemangiomas 1, 5
Giant Hemangiomas (>5 cm)
- Giant hemangiomas have a 3.2% risk of hepatic rupture, increasing to 5% in lesions >10 cm 1, 2
- Peripherally located and exophytic lesions have higher rupture risk 1
- Close monitoring with ultrasound is recommended during pregnancy for women with giant hemangiomas 1, 2
Indications for Intervention
Intervention is indicated for: 1, 6
- Symptomatic lesions causing pain or compression of adjacent structures
- Rapidly enlarging lesions
- Complications such as rupture or intratumoral bleeding
- Kasabach-Merritt syndrome (consumptive coagulopathy)
- Organ or vessel compression (gastric outlet obstruction, Budd-Chiari syndrome)
Size alone does not represent a valid indication for treatment. 6