eMedicine Specialties > Gastroenterology > Liver

Hemangiomas, Hepatic: Differential Diagnoses & Workup

Author: David C Wolf, MD, FACP, FACG, AGAF, Medical Director of Liver Transplantation, Westchester Medical Center, Professor of Clinical Medicine, Division of Gastroenterology and Hepatobiliary Diseases, Department of Medicine, New York Medical College
Coauthor(s): Unnithan V Raghuraman, MD, FRCP, FACG, FACP, Consulting Staff, Department of Gastroenterology, St John Medical Center
Contributor Information and Disclosures

Updated: Dec 22, 2008

Differential Diagnoses

Other Problems to Be Considered

Hepatic hemangiomas should be differentiated from other benign and malignant space-occupying liver lesions. Benign liver tumors include cysts, adenomas, regenerating nodules, focal nodular hyperplasia, and abscesses. Malignant liver tumors include hepatocellular carcinoma and hepatic metastases.

Workup

Laboratory Studies

  • Routine laboratory tests
    • Results are usually normal.
    • Thrombocytopenia can result from sequestration and destruction of platelets in large lesions.
    • Hypofibrinogenemia has been attributed to intratumoral fibrinolysis.
    • Normal alpha-fetoprotein, CA 19-9, and carcinogenic embryonic antigen (CEA) levels bolster clinical suspicion of a benign hepatic mass lesion.

Imaging Studies

  • The modalities used to aid in the diagnosis of hepatic hemangiomas include ultrasonography (US), dynamic contrast-enhanced computed tomography (CT), nuclear medicine studies using technetium (Tc) 99m-labeled RBCs, magnetic resonance imaging (MRI), hepatic arteriography, and digital subtraction angiography (DSA).
  • Ultrasound
    • This is the most commonly used initial diagnostic tool. It is widely available and inexpensive. Hepatic hemangiomas usually are echogenic, but their sonographic appearance is variable and nonspecific.
    • Addition of color Doppler to routine ultrasound provides qualitative and quantitative data and increases the sensitivity and specificity of the test. Serial ultrasound examinations can be used to monitor any increase in size of the hemangioma over time.
    • The use of microbubble-enhanced ultrasonography has been studied. Lesions show peripheral puddles and pools of enhancement that expand in a centripetal pattern during the portal venous phase of enhancement.14 With delayed imaging, the lesion may completely "fill in."15 However, complete enhancement might not occur in large lesions where central thrombosis or scarring may be present.
    • In one study, the addition of a contrast agent to routine ultrasonography improved sensitivity from 78% to 100% and specificity from 23% to 92%.16 Unfortunately, contrast-enhanced ultrasonography is available at relatively few medical centers.
    • In general, the finding on ultrasonography of a suspected hemangioma should be diagnostically integrated with CT scan or MRI to ensure a correct diagnosis.
  • Computed tomography
    • Dynamic contrast-enhanced CT scanning is preferred to routine CT scanning. When requesting a CT scan to investigate a liver mass, the physician should inform the radiologist about the need for nonenhanced, arterial, portal venous, and delayed imaging (the so-called triple phase CT with delayed imaging).
    • First, the liver is imaged by CT before the administration of intravenous contrast. The next series of images is obtained about 30 seconds after the injection of contrast, at the time that contrast is entering the liver via the hepatic artery. Portal venous imaging occurs 60 seconds later, as contrast is returning to the liver from the mesenteric veins via the portal vein. Finally, delayed images are obtained several minutes later.
    • Hepatic hemangiomas are typically hypodense on precontrast imaging. In the arterial phase, there may be enhancement of the peripheral portions of the lesion. There may be ring enhancement or globular enhancement. The center of the lesion typically remains hypodense.
    • In the portal venous phase and in delayed images, contrast enhancement progresses centripetally. The center of the lesion may only become hyperdense in delayed images.
  • Magnetic resonance imaging
    • MRI is highly sensitive and specific in the diagnosis of hepatic hemangioma. Typically, hemangiomas have low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. When gadolinium is used as an intravenous contrast agent, hemangiomas enhance in a fashion similar to that seen on dynamic CT. The sensitivity for detection of hepatic hemangioma is upwards of 90%.17
    • Giant cavernous hemangiomas (ie, >5 cm in diameter) may exhibit internal fluid levels on MRI and CT scan images.18 This finding is attributed to the separation of blood cells and serous fluid because of extremely slow blood flow through the tumor.
  • Nuclear medicine studies
    • Planar scintigraphic studies using Tc-99m pertechnetate-labeled red blood cells have been used for many years to help in diagnosing hepatic hemangiomas. Sensitivity for hemangiomas greater than 2 cm in diameter was said to be as high as 82%, with a specificity of up to 100%.19
    • Single-photon emission computerized tomography (SPECT) using Tc-99m pertechnetate-labeled RBCs is more accurate than planar imaging in helping to diagnose hepatic hemangioma.20 However, it is not available at all medical centers.
    • SPECT is more specific than MRI, but it is less sensitive. This is particularly true for lesions near the heart or major blood vessels.20
    • Some investigators consider SPECT with 99mTc-labeled RBCs to be the criterion standard to establish a diagnosis of hepatic hemangiomas. However, the test may still miss some lesions. Also, pedunculated giant liver hemangiomas have been reported to mimic hypervascular gastric tumors on SPECT.21
  • Arteriography
    • The diagnostic accuracy of noninvasive tests has obviated the need for hepatic arteriography in most cases. However, this invasive modality still may be useful in helping to diagnose some hepatic hemangiomas.
    • Branches of the hepatic artery may be displaced and crowded together or stretched around the lesion, with normal vascular tapering.
    • Hemangiomas are characterized by the early opacification of irregular areas or lakes, with persistence of contrast in these areas long after arterial emptying. The hemangioma may appear as a ring or C-shaped lesion with an avascular center.
  • Accuracy of imaging studies
    • The diagnostic capabilities of ultrasonography, Doppler color ultrasound, dynamic CT scan, and MRI were compared in a retrospective study of 27 patients with 35 hemangiomas.22
    • Sensitivities reported in the study were as follows:
      • Ultrasonography – 46% sensitivity
      • Combined B-mode and color Doppler ultrasound – 69% sensitivity
      • Contrast-enhanced CT scan - 66% sensitivity
      • T2-weighted MRI - 96% sensitivity
      • Gadolinium-enhanced MRI combined with dynamic CT scan - 100% sensitivity
  • Imaging of hemangiomas less than 2 cm
    • Diagnostic accuracy diminishes for all imaging modalities when assessing a liver lesion that is less than 2 cm in diameter.
    • MRI and 99mTc-RBC SPECT are the most accurate radiologic studies to establish the diagnosis of a small hepatic hemangioma.
  • The authors continue to regard MRI as the diagnostic test of choice for hepatic hemangioma at most centers. Nuclear medicine studies may be used to confirm the diagnosis when a probable hemangioma is detected on ultrasonography. Nuclear medicine studies may also help to clarify the nature of a lesion when the diagnosis is equivocal on CT or MRI.

Procedures

  • Liver biopsy
    • Percutaneous biopsy of a hepatic hemangioma carries an increased risk of hemorrhage. Liver biopsy is contraindicated in most circumstances where a hemangioma is high in the differential diagnosis of a hepatic mass.
    • Liver biopsy can help provide an unequivocal histologic diagnosis and may shorten the diagnostic workup. One study reported the safe performance of ultrasound-guided 18-gauge core needle biopsy in 51 hemangiomas ranging in size from 7-114 mm.23 However, the authors do not recommend its performance.
    • Some authorities contend that either percutaneous liver biopsy or laparoscopic liver biopsy may be reasonable to perform in cases where a small liver lesion must be differentiated from hepatocellular carcinoma. However, since 2001, hepatologists and surgeons have been increasingly resistant to include liver biopsy in the diagnostic workup of suspected hepatocellular carcinoma. The diagnosis of most hepatocellular carcinomas can be made by using a combination of CT and MRI.24 Liver biopsy is only used when radiologic study results and alpha fetoprotein testing are equivocal.

Histologic Findings

Microscopically, hemangiomas are composed of cavernous vascular channels. The channels are lined by single layers of flattened endothelium and are separated by fibrous septa. These vascular spaces may contain thrombin, calcifications, or prominent scarring with hyalinization (sclerosed hemangioma). Phleboliths are rare. Malignant transformation has not been reported.

Pathology

Hemangiomas are usually solitary. Multiple and diffuse hepatic lesions are seen infrequently. Sizes range from 2 mm to more than 20 cm. Grossly, these lesions often appear as having a flat surface or as bulging subcapsular lesions.

Lesions are reddish-blue and well demarcated from surrounding tissue. Large tumors may become pedunculated.

Histologically, the tumor is thin walled. Its vascular spaces are lined by a single layer of endothelial cells that are separated by fibrous septa.25,26

More on Hemangiomas, Hepatic

Overview: Hemangiomas, Hepatic
Differential Diagnoses & Workup: Hemangiomas, Hepatic
Treatment & Medication: Hemangiomas, Hepatic
Follow-up: Hemangiomas, Hepatic
References
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References

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Further Reading

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Keywords

hepatic hemangiomas, hepatic hemangioma, hemangioma, cavernous hemangioma, liver tumor, liver lesions, liver hemangioma

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Contributor Information and Disclosures

Author

David C Wolf, MD, FACP, FACG, AGAF, Medical Director of Liver Transplantation, Westchester Medical Center, Professor of Clinical Medicine, Division of Gastroenterology and Hepatobiliary Diseases, Department of Medicine, New York Medical College
David C Wolf, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Unnithan V Raghuraman, MD, FRCP, FACG, FACP, Consulting Staff, Department of Gastroenterology, St John Medical Center
Unnithan V Raghuraman, MD, FRCP, FACG, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Vivek V Gumaste, MD, Associate Professor of Medicine, Mt Sinai School of Medicine, Adjunct Clinical Assistant, Mt Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center, Elmhurst, NY
Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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