Understanding Benign Hepatic Hemangioma: A Common Yet Overlooked Liver Lesion

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Understanding Benign Hepatic Hemangioma: A Common Yet Overlooked Liver Lesion

Author: Dr. SB Lee, MD, PhD (Medicine & Biomedical Engineering)
Estimated reading time: 6 minutes

Introduction

Benign hepatic hemangioma, the most common benign liver tumor, often appears incidentally during imaging studies performed for unrelated reasons. Despite its frequent occurrence—up to 20% in the general population—many clinicians and patients are unfamiliar with its typical imaging features and clinical implications. In this column, I present a real case of a 42-year-old woman diagnosed with hepatic hemangioma, discuss its epidemiology, imaging characteristics, and differential diagnosis, and clarify when treatment is necessary.

Case Overview: A 42-Year-Old Woman with Hyperlipidemia

A 42-year-old woman with a history of hyperlipidemia visited the clinic for routine evaluation. An abdominal CT was performed, revealing a 3.2 x 2.9 cm hemangioma in the right hepatic lobe. Further abdominal MRI and ultrasonography confirmed the lesion, which exhibited classical imaging features of a cavernous hepatic hemangioma—gradual centripetal enhancement with well-defined margins and high signal intensity on T2-weighted MRI.


No associated symptoms, complications, or risk factors for malignancy were noted. Therefore, a conservative management strategy was adopted.

Epidemiology and Pathophysiology

Hepatic hemangiomas are mesenchymal tumors consisting of blood-filled vascular channels lined by a single layer of endothelial cells. They are generally considered non-neoplastic, congenital malformations rather than true tumors.
These lesions are:

  • Most common in women, often in their 30s to 50s

  • Asymptomatic in the vast majority of cases

  • Incidentally found during imaging for other reasons

There is no established risk of malignant transformation.

Imaging Features: Identifying Hemangiomas

Ultrasound (US)


  • Typically appears as a well-defined, hyperechoic, homogeneous mass

  • May show posterior acoustic enhancement

  • Larger lesions (>5 cm) may demonstrate heterogeneous echotexture due to thrombosis or fibrosis

Computed Tomography (CT)

  • Non-contrast CT: Hypodense relative to the surrounding parenchyma

  • Arterial phase: Peripheral, nodular enhancement

  • Portal/delayed phases: Progressive centripetal filling (classic hallmark of cavernous hemangioma)

Magnetic Resonance Imaging (MRI)

  • T1-weighted images: Hypointense

  • T2-weighted images: Markedly hyperintense (lightbulb sign)

  • Gadolinium-enhanced images show the same gradual filling pattern as seen on CT

Differential Diagnosis: Important Mimickers

Hepatic hemangiomas must be distinguished from other hypervascular liver lesions, especially in patients with risk factors for malignancy.

ConditionKey Features
Hepatocellular carcinoma (HCC)Often occurs in cirrhotic liver, shows washout in portal/delayed phase
Focal nodular hyperplasia (FNH)Central scar on MRI, uptake in hepatobiliary phase
Hepatic adenomaAssociated with oral contraceptives, may experience hemorrhage or transformation
MetastasesVariable enhancement, often multiple lesions

Key Quiz
Which of the following should be considered in the differential diagnosis of a hypervascular liver lesion?

  • Hepatocellular carcinoma

  • Hepatic hemangioma

  • Focal nodular hyperplasia

  • Hepatic adenoma
    Answer: All of the above

Treatment: When Is It Necessary?

In most cases, no treatment is required for hepatic hemangiomas, especially if they are:

  • <5 cm

  • Asymptomatic

  • Not growing over time

Surgical resection may be considered when:

  • Lesions exceed 10 cm and are symptomatic ("giant hemangioma")

  • There is diagnostic uncertainty

  • Complications such as Kasabach-Merritt syndrome occur (very rare)

Myths and Clarifications

Does oral contraceptive use cause malignancy in liver lesions?

False. Women on OCs may develop hepatic adenomas, which are benign, not malignant.

Does Herpes Simplex Virus (HSV) increase the risk of hepatic malignancy?

Unlikely. Unlike HBV, HCV, and HIV, HSV is not associated with cirrhosis or malignant transformation in the liver.

Conclusion

Benign hepatic hemangioma is a common and typically harmless liver lesion. With characteristic imaging features, it can be accurately diagnosed non-invasively, avoiding unnecessary biopsies or surgeries. Proper recognition and differentiation from other hypervascular lesions are critical to prevent misdiagnosis and overtreatment.

References

  1. Karhunen, P. J. (1986). Benign hepatic tumours and tumour-like conditions in men. Journal of Clinical Pathology, 39(2), 183–188. https://doi.org/10.1136/jcp.39.2.183

  2. Klotz, T., & Heuck, A. (2004). Liver hemangioma: Diagnostic pitfalls and differential diagnosis. European Radiology, 14(11), 2172–2180. https://doi.org/10.1007/s00330-004-2402-5

  3. Ichikawa, T., et al. (2000). Cavernous hemangioma of the liver: Spectrum of diagnostic CT findings. AJR American Journal of Roentgenology, 175(3), 935–939. https://doi.org/10.2214/ajr.175.3.1750935

  4. Brancatelli, G., et al. (2001). Focal liver lesions: CT and MR imaging findings. Radiographics, 21(4), 895–920. https://doi.org/10.1148/radiographics.21.4.g01jl01901

  5. Vilgrain, V., et al. (2000). Hepatic hemangiomas: Diagnosis and management. Gastroenterology Clinics of North America, 29(4), 863–882. https://doi.org/10.1016/S0889-8553(05)70120-7

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