Hepatic Hemangiomas Treatment & Management

  • Author: David C Wolf, MD, FACP, FACG, AGAF; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 8, 2011
 

Medical Care

Most hepatic hemangiomas are small and asymptomatic at the time of diagnosis, and they are likely to remain that way. In one prospective study, an increase in hemangioma size was noted in only one of 47 patients who were rescanned 1-6 years after the initial diagnosis.[32] In addition, malignant transformation has not been reported in hepatic hemangiomas. For these reasons, most hepatic hemangiomas may be left safely alone.

Radiologic study follow-up

Once the diagnosis of hepatic hemangioma is confirmed by radiologic studies, it remains uncertain whether follow-up radiologic studies are warranted to reassess the size of the tumor. In the authors' practices, patients typically undergo ultrasonography at 6 months and at 12 months after the initial diagnosis. Providing that no change in hemangioma size has occurred, long-term follow-up radiologic studies are probably not necessary.

However, there are a number of important exceptions to this practice. Certainly, patients with a new onset of abdominal pain deserve a follow-up imaging study. The same is true for patients who are undergoing treatment with estrogens or have become pregnant. Finally, patients with large hemangiomas (ie, >10 cm) may deserve long-term follow-up radiologic studies, perhaps annually, because of their probable increased risk of complications.

Until recently, no medical therapy capable of reducing the size of hepatic hemangiomas had been described. A case report in 2008 demonstrated reduction in the size of hepatic hemangiomas in a patient treated for colon cancer. The patient had received bevacizumab, a monoclonal antibody capable of inhibiting the activity of vascular endothelial growth factor (VEGF).[33]

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Surgical Care

Hepatic hemangiomas warrant therapy if they are causing significant symptoms. Unfortunately, in some individuals, determining if the symptoms are caused by a hemangioma or by another process (eg, irritable bowel syndrome) is difficult. One article described how 14 patients underwent surgical or angiographic therapy for "incapacitating symptoms" that were related to a hepatic hemangioma. One half of these patients remained symptomatic after therapy, implying that the hemangioma was not responsible for their complaints.[22]

Surgical treatment may be appropriate in cases of rapidly growing tumors. Surgery may also be warranted in cases where a hepatic hemangioma cannot be differentiated from hepatic malignancy on imaging studies.

Management of large hemangiomas

Hepatic hemangiomas have been treated with a wide array of therapies. Traditionally, surgical resection and surgical enucleation are the treatments of choice.[34] Minimally invasive therapies for hepatic hemangioma include arterial embolization, radiofrequency ablation, and hepatic irradiation. Orthotopic liver transplantation has been performed as treatment in rare circumstances.

The classical indications for either surgery or minimally invasive therapy are the relief of symptoms due to the hemangioma or the treatment of the spontaneously ruptured hemangioma. The latter event is potentially life-threatening. However, emergent surgical resection of the ruptured hemangioma is associated with a high morality rate.

Top priority in the patient with a ruptured hepatic hemangioma is hemodynamic stabilization. Some authors have recommended surgical ligation of the hepatic artery as a next step. Others have recommended arterial embolization instead. Once the patient is stabilized, formal surgical resection of the hepatic hemangioma can be performed.[35]

The management of a large (ie, >10 cm) hepatic hemangioma is controversial. Certainly, large symptomatic hemangiomas should undergo treatment. However, the management of the large asymptomatic lesion is not clear-cut. Some surgeons have advocated resection for such lesions because of the potential risk of spontaneous rupture, intratumoral hemorrhage, or high-output congestive heart failure. However, literature searches identified only 33 published cases of spontaneous rupture in adults without a history of trauma.[36, 37] Congestive heart failure is even less frequently identified as a complication.

A retrospective cohort study used a patient survey to assess the outcomes of 289 patients with hemangiomas greater than 4 cm in size. Twenty percent of the 233 patients in the nonoperative group reported hemangioma-related symptoms, including life-threatening complications in 2%. Fourteen percent of the 56 patients undergoing surgery for hepatic hemangioma experienced perioperative complications, including life-threatening complications in 7%. The authors concluded that operative treatment should be reserved for patients with severe symptoms or complications of their disease.[38]

Surgical resection

The size and location of a lesion will influence the surgeon's decision to perform either a formal segmental resection of the hemangioma or an enucleation of the hemangioma. Typically, these procedures are performed using an open approach, but laparoscopic surgery can be performed in some cases. Hepatic lobectomy may be necessary in the case of large lesions.

In general, both surgical resection and enucleation are safe and are well tolerated by patients. Mortality rates of 0% have been reported in large series. Typically, postoperative morbidity is minimal, and the average length of hospital stay is 6 days.[39]

In a study of 172 patients with hepatic hemangiomas, Fu et al examined the safety of enucleation surgery for centrally located lesions versus that for peripheral lesions (76 and 96 patients, respectively).[40] In both groups, the frequency of major complications was low, although vascular inflow occlusion time, operating time, and hospital stay were longer in the central lesion group, and the volume of blood loss was greater. No hospital mortality occurred in either group. The authors concluded that enucleation is safe for either centrally or peripherally located hemangiomas, but that the surgery is technically more demanding for the former.

In the absence of tumor-promoting factors, such as estrogen therapy, hemangiomas rarely recur after successful resection.

Arterial embolization

Surgical resection may not be possible in certain cases because of the massive or diffuse nature of the lesion, its proximity to vascular structures, or the patient's comorbidities. Arterial embolization is an option in such circumstances. Branches of the hepatic artery can be embolized with polyvinyl alcohol and other substances.[41, 42, 43]

Embolization results in shrinking of the tumor, thereby minimizing the risk of complications. Pain, fever, and nongranulomatous arteritis with eosinophilic infiltration are recognized complications of this procedure.

The long-term success rate of embolization (without subsequent surgical resection) is not well studied.

Surgical ligation of feeding vessels

Transhepatic compression sutures using polytetrafluoroethylene (PTFE) pledgets and selective ligation of large feeding vessels have been described. In one case, this technique successfully reduced intratumoral shunting that otherwise would have led to intractable cardiac failure.[44]

Radiofrequency ablation

Both percutaneous and laparoscopic radiofrequency ablation have been used successfully to improve abdominal pain in small numbers of patients with symptomatic hepatic hemangiomas.[45, 46, 47]

Hepatic irradiation

Hepatic irradiation with a dose of 15-30 Gy in 15-22 fractions over several weeks has been used to treat symptomatic hemangiomas. Tumor regression and symptom relief were noted in most patients, with minimal morbidity.[48, 49]

Orthotopic liver transplantation

This option is occasionally offered to symptomatic patients with large or diffuse lesions. Several cases have now been reported in the medical literature.[50]

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Consultations

  • Consultation with a surgeon is warranted if resection is the choice of therapy.
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Diet

  • No special dietary management is required.
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Activity

  • No restriction of physical activity is indicated for most patients with hepatic hemangiomas.
  • Patients with large hemangiomas may need to be instructed to avoid trauma to the right upper abdominal quadrant.
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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.

Specialty Editor Board

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

Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior 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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

  1. Dickie B, Dasgupta R, Nair R, Alonso MH, Ryckman FC, Tiao GM, et al. Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg. Jan 2009;44(1):125-33. [Medline].

  2. Moser C, Hany A, Spiegel R. [Familial giant hemangiomas of the liver. Study of a family and review of the literature]. Praxis (Bern 1994). Apr 1 1998;87(14):461-8. [Medline].

  3. Takahashi T, Kuwao S, Katagiri H, et al. Multiple liver hemangiomas enlargement during long-term steroid therapy for myasthenia gravis. Dig Dis Sci. Jul 1998;43(7):1553-61. [Medline].

  4. Giannitrapani L, Soresi M, La Spada E, et al. Sex hormones and risk of liver tumor. Ann N Y Acad Sci. Nov 2006;1089:228-36. [Medline].

  5. Glinkova V, Shevah O, Boaz M, et al. Hepatic haemangiomas: possible association with female sex hormones. Gut. Sep 2004;53(9):1352-5. [Medline].

  6. Spitzer D, Krainz R, Graf AH, et al. Pregnancy after ovarian stimulation and intrauterine insemination in a woman with cavernous macrohemangioma of the liver. A case report. J Reprod Med. Dec 1997;42(12):809-12. [Medline].

  7. Dreyfus M, Baldauf JJ, Dadoun K, et al. Prenatal diagnosis of hepatic hemangioma. Fetal Diagn Ther. Jan-Feb 1996;11(1):57-60. [Medline].

  8. Dong KR, Zheng S, Xiao X. Conservative management of neonatal hepatic hemangioma: a report from one institute. Pediatr Surg Int. Jun 2009;25(6):493-8. [Medline].

  9. Suzuki T, Tsuchiya N, Ito K. Multiple cavernous hemangiomas of the liver in patients with systemic lupus erythematosus. J Rheumatol. Apr 1997;24(4):810-1. [Medline].

  10. Goodman Z. Benign tumors of the liver. In: Okuda K, Ishak KG. Neoplasms of the liver. Tokyo: Springer-Verlag; 1987:105-125.

  11. Mikami T, Hirata K, Oikawa I, et al. Hemobilia caused by a giant benign hemangioma of the liver: report of a case. Surg Today. 1998;28(9):948-52. [Medline].

  12. Lee CW, Chung YH, Lee GC, et al. A case of giant hemangioma of the liver presenting with fever of unknown origin. J Korean Med Sci. Apr 1994;9(2):200-4. [Medline].

  13. Pol B, Disdier P, Le Treut YP, et al. Inflammatory process complicating giant hemangioma of the liver: report of three cases. Liver Transpl Surg. May 1998;4(3):204-7. [Medline].

  14. Huang SA, Tu HM, Harney JW, et al. Severe hypothyroidism caused by type 3 iodothyronine deiodinase in infantile hemangiomas. N Engl J Med. Jul 20 2000;343(3):185-9. [Medline].

  15. Lorette G, Georgesco G, Sirinelli D, et al. [Cutaneous immature hemangioma and hepatic angioma: there is no frequent association]. Ann Dermatol Venereol. 1996;123(12):789-90. [Medline].

  16. Brannigan M, Burns PN, Wilson SR. Blood flow patterns in focal liver lesions at microbubble-enhanced US. Radiographics. Jul-Aug 2004;24(4):921-35. [Medline].

  17. Dietrich CF, Mertens JC, Braden B, et al. Contrast-enhanced ultrasound of histologically proven liver hemangiomas. Hepatology. May 2007;45(5):1139-45. [Medline].

  18. von Herbay A, Vogt C, Willers R, et al. Real-time imaging with the sonographic contrast agent SonoVue: differentiation between benign and malignant hepatic lesions. J Ultrasound Med. Dec 2004;23(12):1557-68. [Medline].

  19. Strobel D, Seitz K, Blank W, Schuler A, Dietrich CF, von Herbay A, et al. Tumor-specific vascularization pattern of liver metastasis, hepatocellular carcinoma, hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound (CEUS). Ultraschall Med. Aug 2009;30(4):376-82. [Medline].

  20. Higashihara H, Murakami T, Kim T, Hori M, Onishi H, Nakata S, et al. Differential diagnosis between metastatic tumors and nonsolid benign lesions of the liver using ferucarbotran-enhanced MR imaging. Eur J Radiol. Nov 17 2008;[Medline].

  21. Vossen JA, Buijs M, Liapi E, Eng J, Bluemke DA, Kamel IR. Receiver operating characteristic analysis of diffusion-weighted magnetic resonance imaging in differentiating hepatic hemangioma from other hypervascular liver lesions. J Comput Assist Tomogr. Sep-Oct 2008;32(5):750-6. [Medline].

  22. Farges O, Daradkeh S, Bismuth H. Cavernous hemangiomas of the liver: are there any indications for resection?. World J Surg. Jan-Feb 1995;19(1):19-24. [Medline].

  23. Obata S, Matsunaga N, Hayashi K, et al. Fluid-fluid levels in giant cavernous hemangioma of the liver: CT and MRI demonstration. Abdom Imaging. Nov-Dec 1998;23(6):600-2. [Medline].

  24. Kinnard MF, Alavi A, Rubin RA, et al. Nuclear imaging of solid hepatic masses. Semin Roentgenol. Oct 1995;30(4):375-95. [Medline].

  25. Krause T, Hauenstein K, Studier-Fischer B, et al. Improved evaluation of technetium-99m-red blood cell SPECT in hemangioma of the liver. J Nucl Med. Mar 1993;34(3):375-80. [Medline].

  26. Tsai CC, Yen TC, Tzen KY. Pedunculated giant liver hemangioma mimicking a hypervascular gastric tumor on Tc-99m RBC SPECT. Clin Nucl Med. Feb 1999;24(2):132-3. [Medline].

  27. De Franco A, Monteforte MG, Maresca G, et al. [Integrated diagnosis of liver angioma: comparison of Doppler color ultrasonography, computerized tomography, and magnetic resonance]. Radiol Med. Jan-Feb 1997;93(1-2):87-94. [Medline].

  28. Heilo A, Stenwig AE. Liver hemangioma: US-guided 18-gauge core-needle biopsy. Radiology. Sep 1997;204(3):719-22. [Medline].

  29. Bruix J, Sherman M, Llovet JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. Sep 2001;35(3):421-30. [Medline].

  30. Craig JR, Peters RL, Edmondson HA. Tumors of the Liver and Intrahepatic Bile Ducts, 2nd series, fascicle 26. Washington, DC. Armed Forces Institute of Pathology. 1989;191.

  31. Ishak KG, Markin RS. Liver. In: Damjanov I, Linder J, eds. Anderson's Pathology. 10th ed. Mosby: St. Louis, Mo; 1996:1834.

  32. Gibney RG, Hendin AP, Cooperberg PL. Sonographically detected hepatic hemangiomas: absence of change over time. AJR Am J Roentgenol. Nov 1987;149(5):953-7. [Medline].

  33. Mahajan D, Miller C, Hirose K, McCullough A, Yerian L. Incidental reduction in the size of liver hemangioma following use of VEGF inhibitor bevacizumab. J Hepatol. Nov 2008;49(5):867-70. [Medline].

  34. Belli G, D'Agostino A, Fantini C, Cioffi L, Belli A, Limongelli P, et al. Surgical treatment of giant liver hemangiomas by enucleation using an ultrasonically activated device (USAD). Hepatogastroenterology. Jan-Feb 2009;56(89):236-9. [Medline].

  35. Jain V, Ramachandran V, Garg R, Pal S, Gamanagatti SR, Srivastava DN. Spontaneous rupture of a giant hepatic hemangioma - sequential management with transcatheter arterial embolization and resection. Saudi J Gastroenterol. Apr-Jun 2010;16(2):116-9. [Medline]. [Full Text].

  36. Corigliano N, Mercantini P, Amodio PM, et al. Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case. Surg Today. 2003;33(6):459-63. [Medline].

  37. Ribeiro MAF, Papaiordanou F, Gonçalves JM, Chaib E. Spontaneous rupture of hepatic hemangiomas: A review of the literature. World J Hepatol. Dec 27 2010;2(12):428-33. [Medline]. [Full Text].

  38. Schnelldorfer T, Ware AL, Smoot R, Schleck CD, Harmsen WS, Nagorney DM. Management of giant hemangioma of the liver: resection versus observation. J Am Coll Surg. Dec 2010;211(6):724-30. [Medline].

  39. Arnoletti JP, Brodsky J. Surgical treatment of benign hepatic mass lesions. Am Surg. May 1999;65(5):431-3. [Medline].

  40. Fu XH, Lai EC, Yao XP, et al. Enucleation of liver hemangiomas: is there a difference in surgical outcomes for centrally or peripherally located lesions?. Am J Surg. Aug 2009;198(2):184-7. [Medline].

  41. Deutsch GS, Yeh KA, Bates WB 3rd, Tannehill WB. Embolization for management of hepatic hemangiomas. Am Surg. Feb 2001;67(2):159-64. [Medline].

  42. Srivastava DN, Gandhi D, Seith A, et al. Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study. Abdom Imaging. Sep-Oct 2001;26(5):510-4. [Medline].

  43. Zeng Q, Li Y, Chen Y, et al. Gigantic cavernous hemangioma of the liver treated by intra-arterial embolization with pingyangmycin-lipiodol emulsion: a multi-center study. Cardiovasc Intervent Radiol. Sep-Oct 2004;27(5):481-5. [Medline].

  44. Rokitansky AM, Jakl RJ, Gopfrich H, et al. Special compression sutures: a new surgical technique to achieve a quick decrease in shunt volume caused by diffuse hemangiomatosis of the liver. Pediatr Surg Int. Nov 1998;14(1-2):119-21. [Medline].

  45. Hinshaw JL, Laeseke PJ, Weber SM, Lee FT Jr. Multiple-electrode radiofrequency ablation of symptomatic hepatic cavernous hemangioma. AJR Am J Roentgenol. Sep 2007;189(3):W146-9. [Medline].

  46. Park SY, Tak WY, Jung MK, et al. Symptomatic-enlarging hepatic hemangiomas are effectively treated by percutaneous ultrasonography-guided radiofrequency ablation. J Hepatol. Sep 29 2010;[Medline].

  47. Fan RF, Chai FL, He GX, et al. Laparoscopic radiofrequency ablation of hepatic cavernous hemangioma. A preliminary experience with 27 patients. Surg Endosc. Feb 2006;20(2):281-5. [Medline].

  48. Gaspar L, Mascarenhas F, da Costa MS, Dias JS, Afonso JG, Silvestre ME. Radiation therapy in the unresectable cavernous hemangioma of the liver. Radiother Oncol. Oct 1993;29(1):45-50. [Medline].

  49. Biswal BM, Sandhu M, Lal P, et al. Role of radiotherapy in cavernous hemangioma liver. Indian J Gastroenterol. Jul 1995;14(3):95-8. [Medline].

  50. Tepetes K, Selby R, Webb M, et al. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg. Feb 1995;130(2):153-6. [Medline].

 
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