What is cavernous hemangioma?

What is Cavernous Hemangioma?

Cavernous hemangiomas are benign vascular tumors of the liver, representing the most common benign hepatic lesion with a prevalence of 0.4% to 8%, typically asymptomatic and requiring no intervention unless they reach large size (>5-10 cm) or cause complications. 1

Definition and Pathology

• Cavernous hemangiomas are benign vascular malformations composed of blood-filled spaces lined by endothelium, creating a characteristic "cotton-wool" appearance on imaging 2
• These lesions are the most common benign tumor of the liver, occurring more frequently in women 1, 3
• The term "cavernous" refers to the large, dilated vascular channels that characterize these lesions 2

Clinical Characteristics

• Most lesions remain asymptomatic throughout life, with intervention needed in less than 1% of cases 1
• When symptomatic, patients may present with vague abdominal pain, though symptoms are often nonspecific 3
• Size classification matters clinically: cavernous hemangiomas are variably defined as lesions greater than 5 cm to greater than 10 cm in diameter 1
• Lesions can remain stable for years before unpredictably increasing in size, even without hormonal stimulation 3

Imaging Features

• CT scan before contrast shows well-demarcated, low-density spherical masses 2
• After contrast administration, characteristic peripheral enhancement with a corrugated inner margin appears, while the center remains low-density 2
• Angiography demonstrates normal hepatic arteries, absence of tumor vessels, and densely stained blood-filled spaces producing the classic "cotton-wool" appearance 2

Histologic Features Often Underrecognized

• Contrary to traditional teaching, 84% of large cavernous hemangiomas have irregular interfaces with liver parenchyma rather than well-defined fibrous capsules 4
• 79% of large lesions have hemangioma-like vessels extending 0.1-2.0 cm beyond the main lesion into adjacent liver parenchyma 4
• These features are important for surgeons to recognize during resection planning 4

Hormonal Considerations

• The association between estrogens and hepatic hemangiomas is not well established, unlike hepatic adenomas 1
• Pregnancy and combined hormonal contraception are considered safe with no monitoring required for typical hemangiomas 1
• Lesions can grow to massive proportions even without exogenous or endogenous estrogen supply 3

Special Considerations for Large Cavernous Hemangiomas

For cavernous hemangiomas >5-10 cm, particularly in pregnancy:

• Increased intra-abdominal pressure, blood volume expansion, and cytokine upregulation predispose to continued expansion and potential rupture, though rupture remains quite rare 1
• New onset of symptoms should prompt immediate investigation 1
• Consultation with hepatobiliary surgery and interventional radiology should be considered for symptomatic large lesions 1
• Size, location, presence of hemorrhage, and other factors guide therapeutic decisions on a case-by-case basis 1

Rare Complications

• Hemorrhage from giant cavernous hemangiomas can occur, potentially leading to Kasabach-Merritt syndrome (consumptive coagulopathy) and abdominal compartment syndrome 5
• In extreme cases with life-threatening hemorrhage and multiorgan involvement, emergent liver transplantation may be necessary 5
• Management at a center with liver transplantation expertise is warranted for patients with worsening disseminated intravascular coagulation or hemorrhage due to potential for rapid clinical decompensation 5

Management Approach

• For asymptomatic lesions of any size: observation with no routine monitoring required 1
• For large lesions (>5-10 cm) causing symptoms: surgical resection or enucleation may be considered 5
• Multiple cavernous hemangiomas in liver and other organs require pathologic confirmation but typically need only follow-up without intervention 6