Hepatic Hemangioma

Hepatic cavernous hemangioma is the most common benign hepatic tumour, a vascular malformation of blood filled spaces lined by endothelium.

• Prevalence 5 to 20% on imaging; female to male 3:1 to 5:1; peaks at age 30 to 50.
• Usually solitary, under 5 cm; giant when over 10 cm.
• Growth may be driven by oestrogen and pregnancy.
• Complications are rare: spontaneous rupture (under 1%), consumptive coagulopathy (Kasabach Merritt syndrome in infants or giant lesions), heart failure in infantile hepatic haemangioma with shunting, thrombosis.
• Infantile hepatic hemangioma (GLUT1 positive) differs from adult cavernous lesions.

• Asymptomatic and found incidentally in over 90%.
• Giant lesions: abdominal pain, early satiety, nausea, palpable mass, fever.
• Acute pain from thrombosis or haemorrhage.
• Infants: hepatomegaly, high output cardiac failure, hypothyroidism (type 3 deiodinase).

• Ultrasound: well defined hyperechoic lesion with posterior enhancement.
• Dynamic contrast CT or MRI: peripheral nodular discontinuous enhancement with progressive centripetal fill in, and persistent enhancement in delayed phase; T2 bright (light bulb sign) on MRI.
• Technetium labelled red cell scintigraphy (SPECT) for confirmation in difficult cases.
• Avoid biopsy (risk of bleeding) unless diagnostic doubt exists.
• Normal liver tests. Check platelets, fibrinogen, D dimer for giant lesions.
• Infantile haemangioma: Doppler, thyroid function, echocardiography.

• Observation for asymptomatic lesions of any size; no follow up imaging is needed for typical small lesions, and surveillance at 6 to 12 months for large ones.
• Oestrogen therapy and pregnancy are not contraindicated.
• Intervention for severe symptoms, rapid growth, complications, or diagnostic uncertainty:
  • Surgical enucleation (preferred over resection, low morbidity) or resection.
  • Transarterial embolisation for inoperable or preoperative devascularisation.
  • Radiofrequency or microwave ablation for small symptomatic lesions.
  • Radiotherapy (20 to 30 Gy) rarely.
  • Liver transplantation for unresectable giant lesions with refractory symptoms (rare).
• Kasabach Merritt phenomenon: sirolimus 0.8 mg/m2 twice daily (trough 5 to 15 ng/mL), prednisolone 2 mg/kg, vincristine, propranolol 2 mg/kg/day.
• Infantile hepatic haemangioma: propranolol 2 to 3 mg/kg/day in divided doses; levothyroxine for consumptive hypothyroidism; treat heart failure; embolisation or transplant for refractory disease.
• No malignant potential.