Hepatic Hemangiomas Workup
- Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD more...
Routine laboratory tests
Results of routine laboratory studies are usually normal, although 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 the clinical suspicion of a benign hepatic mass lesion.
The modalities used to aid in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic contrast-enhanced computed tomography (CT) scanning, nuclear medicine studies using technetium-99m (99m Tc)–labeled red blood cells (RBCs), magnetic resonance imaging (MRI), hepatic arteriography, and digital subtraction angiography (DSA).
Ultrasonography 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.
The addition of color Doppler to routine ultrasonography provides qualitative and quantitative data and increases the sensitivity and specificity of the test. Serial ultrasonographic 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 (progressing inward toward the center) during the portal venous phase of enhancement. With delayed imaging, the lesion may completely "fill in." 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 the sensitivity from 78% to 100% and specificity from 23% to 92%. 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 computed tomography (CT) scanning or magnetic resonance imaging (MRI) to ensure a correct diagnosis.
Computed tomography scanning
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 scanning with delayed imaging).
First, the liver is imaged by CT scanning 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 for the diagnosis of hepatic hemangioma.[27, 28] 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 scanning. Typically, hemangiomas follow the signal intensity of blood. However, hemangiomas smaller than 2 cm may exhibit homogeneous enhancement in late arterial-phase imaging and can be mistaken for hepatocellular carcinoma or a hypervascular metastasis. The sensitivity for detection of hepatic hemangioma is upwards of 90%.
Giant cavernous hemangiomas (ie, >5 cm in diameter) may exhibit internal fluid levels on MRI and CT scan images. This finding is attributed to the separation of blood cells and serous fluid because of extremely slow blood flow through the tumor.
In the setting of hepatic fibrosis and cirrhosis, MRI features of hepatic hemangioma appear similar to those of normal livers.
In the authors' opinions, MRI with arterial and delayed contrast is the test of choice for investigating a liver mass of unclear origin. This is particularly the case when hepatic hemangioma is suspected.
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 is reported to be as high as 82%, with a specificity of up to 100%.
Single-photon emission computerized tomography (SPECT) scanning using Tc-99m pertechnetate-labeled RBCs is more accurate than planar imaging in helping to diagnose hepatic hemangioma. 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.
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.
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 ultrasonography, dynamic CT scanning, and MRI were compared in a retrospective study of 27 patients with 35 hemangiomas.
Sensitivities reported in the study were as follows :
Ultrasonography – 46% sensitivity
Combined B-mode and color Doppler ultrasonography – 69% sensitivity
Contrast-enhanced CT scanning - 66% sensitivity
T2-weighted MRI - 96% sensitivity
Gadolinium-enhanced MRI combined with dynamic CT scanning - 100% sensitivity
Hepatic angiosarcoma is a rare tumor that tends to grow rapidly. Although hepatic angiosarcoma is classically associated with risk factors, including exposure to Thorotrast, vinyl chloride, or arsenic, many cases have occurred in which no discrete risk factor has been identified. Unfortunately, hepatic angiosarcoma may occasionally be mistaken for hepatic hemangioma on MRI, and vice versa. In the case of a suspected hemangioma with an atypical enhancement pattern, it is reasonable to perform a follow-up radiologic study in a few months to rule out rapid interval growth of the lesion.[37, 38]
Features of angiosarcoma on multiphasic CT scanning and MRI include the following :
Rapidly progressive multifocal tumors
Arterial-phase foci of hypervascular enhancement without washout
Hypervascular foci with progressive expansion followed by blood pooling on multiphasic imaging
Enhancement pattern resembling that of cavernous hemangiomas or showing a "reverse hemangioma" centrifugal pattern
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 scanning or MRI.
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 ultrasonographically guided 18-gauge core needle biopsy in 51 hemangiomas ranging in size from 7-114 mm. However, the authors do not recommend its performance.
Some authorities contend that either a 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 scanning and MRI. Liver biopsy is only used when radiologic study results and alpha fetoprotein testing are equivocal.
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.
Hemangiomas are usually solitary. Multiple and diffuse hepatic lesions are seen infrequently. Sizes range from 2 mm to more than 20 cm. On gross examination, 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.[42, 43]
Dickie B, Dasgupta R, Nair R, et al. Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg. 2009 Jan. 44(1):125-33. [Medline].
Moser C, Hany A, Spiegel R. [Familial giant hemangiomas of the liver. Study of a family and review of the literature]. Praxis (Bern 1994). 1998 Apr 1. 87(14):461-8. [Medline].
Takahashi T, Kuwao S, Katagiri H, et al. Multiple liver hemangiomas enlargement during long-term steroid therapy for myasthenia gravis. Dig Dis Sci. 1998 Jul. 43(7):1553-61. [Medline].
Giannitrapani L, Soresi M, La Spada E, et al. Sex hormones and risk of liver tumor. Ann N Y Acad Sci. 2006 Nov. 1089:228-36. [Medline].
Glinkova V, Shevah O, Boaz M, et al. Hepatic haemangiomas: possible association with female sex hormones. Gut. 2004 Sep. 53(9):1352-5. [Medline].
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. 1997 Dec. 42(12):809-12. [Medline].
Dreyfus M, Baldauf JJ, Dadoun K, et al. Prenatal diagnosis of hepatic hemangioma. Fetal Diagn Ther. 1996 Jan-Feb. 11(1):57-60. [Medline].
Dong KR, Zheng S, Xiao X. Conservative management of neonatal hepatic hemangioma: a report from one institute. Pediatr Surg Int. 2009 Jun. 25(6):493-8. [Medline].
Bajenaru N, Balaban V, Săvulescu F, Campeanu I, Patrascu T. Hepatic hemangioma -review-. J Med Life. 2015. 8 Spec Issue:4-11. [Medline].
Reischle S, Schuller-Petrovic S. Treatment of capillary hemangiomas of early childhood with a new method of cryosurgery. J Am Acad Dermatol. 2000 May. 42(5 Pt 1):809-13. [Medline].
Aslan A, Meyer Zu Vilsendorf A, Kleine M, Bredt M, Bektas H. Adult Kasabach-Merritt Syndrome due to Hepatic Giant Hemangioma. Case Rep Gastroenterol. 2009 Nov 20. 3(3):306-312. [Medline]. [Full Text].
Suzuki T, Tsuchiya N, Ito K. Multiple cavernous hemangiomas of the liver in patients with systemic lupus erythematosus. J Rheumatol. 1997 Apr. 24(4):810-1. [Medline].
Tan ST, Itinteang T, Leadbitter P. Low-dose propranolol for multiple hepatic and cutaneous hemangiomas with deranged liver function. Pediatrics. 2011 Mar. 127(3):e772-6. [Medline].
Starkey E, Shahidullah H. Propranolol for infantile haemangiomas: a review. Arch Dis Child. 2011 Sep. 96(9):890-3. [Medline].
Huang SA, Tu HM, Harney JW, et al. Severe hypothyroidism caused by type 3 iodothyronine deiodinase in infantile hemangiomas. N Engl J Med. 2000 Jul 20. 343(3):185-9. [Medline].
Goodman Z. Benign tumors of the liver. Okuda K, Ishak KG. Neoplasms of the liver. Tokyo: Springer-Verlag; 1987. 105-25.
Hasan HY, Hinshaw JL, Borman EJ, Gegios A, Leverson G, Winslow ER. Assessing normal growth of hepatic hemangiomas during long-term follow-up. JAMA Surg. 2014 Dec. 149(12):1266-71. [Medline].
Li J, Huang L, Liu C, et al. New recognization of the natural history and growth pattern of hepatic hemangioma in adults. Hepatol Res. 2015 Oct 22. [Medline].
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].
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. 1994 Apr. 9(2):200-4. [Medline].
Pol B, Disdier P, Le Treut YP, et al. Inflammatory process complicating giant hemangioma of the liver: report of three cases. Liver Transpl Surg. 1998 May. 4(3):204-7. [Medline].
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].
Brannigan M, Burns PN, Wilson SR. Blood flow patterns in focal liver lesions at microbubble-enhanced US. Radiographics. 2004 Jul-Aug. 24(4):921-35. [Medline].
Dietrich CF, Mertens JC, Braden B, et al. Contrast-enhanced ultrasound of histologically proven liver hemangiomas. Hepatology. 2007 May. 45(5):1139-45. [Medline].
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. 2004 Dec. 23(12):1557-68. [Medline].
Strobel D, Seitz K, Blank W, 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. 2009 Aug. 30(4):376-82. [Medline].
Higashihara H, Murakami T, Kim T, et al. Differential diagnosis between metastatic tumors and nonsolid benign lesions of the liver using ferucarbotran-enhanced MR imaging. Eur J Radiol. 2010 Jan. 73(1):125-30. [Medline].
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. 2008 Sep-Oct. 32(5):750-6. [Medline]. [Full Text].
Farges O, Daradkeh S, Bismuth H. Cavernous hemangiomas of the liver: are there any indications for resection?. World J Surg. 1995 Jan-Feb. 19(1):19-24. [Medline].
Obata S, Matsunaga N, Hayashi K, et al. Fluid-fluid levels in giant cavernous hemangioma of the liver: CT and MRI demonstration. Abdom Imaging. 1998 Nov-Dec. 23(6):600-2. [Medline].
Duran R, Ronot M, Di Renzo S, Gregoli B, Van Beers BE, Vilgrain V. Is magnetic resonance imaging of hepatic hemangioma any different in liver fibrosis and cirrhosis compared to normal liver?. Eur J Radiol. 2015 May. 84(5):816-22. [Medline].
Kinnard MF, Alavi A, Rubin RA, et al. Nuclear imaging of solid hepatic masses. Semin Roentgenol. 1995 Oct. 30(4):375-95. [Medline].
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. 1993 Mar. 34(3):375-80. [Medline].
Tsai CC, Yen TC, Tzen KY. Pedunculated giant liver hemangioma mimicking a hypervascular gastric tumor on Tc-99m RBC SPECT. Clin Nucl Med. 1999 Feb. 24(2):132-3. [Medline].
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. 1997 Jan-Feb. 93(1-2):87-94. [Medline].
Okano A, Sonoyama H, Masano Y, et al. The natural history of a hepatic angiosarcoma that was difficult to differentiate from cavernous hemangioma. Intern Med. 2012. 51(20):2899-904. [Medline].
Pickhardt PJ, Kitchin D, Lubner MG, Ganeshan DM, Bhalla S, Covey AM. Primary hepatic angiosarcoma: multi-institutional comprehensive cancer centre review of multiphasic CT and MR imaging in 35 patients. Eur Radiol. 2015 Feb. 25(2):315-22. [Medline].
Heilo A, Stenwig AE. Liver hemangioma: US-guided 18-gauge core-needle biopsy. Radiology. 1997 Sep. 204(3):719-22. [Medline].
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. 2001 Sep. 35(3):421-30. [Medline].
Craig JR, Peters RL, Edmondson HA. Tumors of the liver and intrahepatic bile ducts. Atlas of tumor pathology. Washington, D.C.: Armed Forces Institute of Pathology; 1989. Second series, fasc. 26: 56-62.
Ishak KG, Markin RS. Liver. Damjanov I, Linder J, eds. Anderson's Pathology. 10th ed. Mosby: St. Louis, Mo; 1996. 1834.
Gibney RG, Hendin AP, Cooperberg PL. Sonographically detected hepatic hemangiomas: absence of change over time. AJR Am J Roentgenol. 1987 Nov. 149(5):953-7. [Medline].
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. 2008 Nov. 49(5):867-70. [Medline].
Miura JT, Amini A, Schmocker R, et al. Surgical management of hepatic hemangiomas: a multi-institutional experience. HPB (Oxford). 2014 Oct. 16(10):924-8. [Medline].
Belli G, D'Agostino A, Fantini C, et al. Surgical treatment of giant liver hemangiomas by enucleation using an ultrasonically activated device (USAD). Hepatogastroenterology. 2009 Jan-Feb. 56(89):236-9. [Medline].
Mocchegiani F, Vincenzi P, Coletta M, et al. Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: A large retrospective cross-sectional study. Dig Liver Dis. 2016 Mar. 48(3):309-14. [Medline].
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. 2010 Apr-Jun. 16(2):116-9. [Medline]. [Full Text].
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].
Donati M, Stavrou GA, Donati A, Oldhafer KJ. The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature. J Hepatobiliary Pancreat Sci. 2011 Nov. 18(6):797-805. [Medline].
Plackett TP, Lin-Hurtubise KM. Hepatic hemangiomas and parachuting. Aviat Space Environ Med. 2008 Oct. 79(10):986-8. [Medline].
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. 2010 Dec. 211(6):724-30. [Medline].
Arnoletti JP, Brodsky J. Surgical treatment of benign hepatic mass lesions. Am Surg. 1999 May. 65(5):431-3. [Medline].
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. 2009 Aug. 198(2):184-7. [Medline].
Zhu H, Obeidat K, Ouyang J, Roayaie S, Schwartz ME, Thung SN. Recurrent giant hemangiomas of liver: Report of two rare cases with literature review. World J Gastrointest Surg. 2012 Nov 27. 4(11):262-6. [Medline]. [Full Text].
Deutsch GS, Yeh KA, Bates WB 3rd, Tannehill WB. Embolization for management of hepatic hemangiomas. Am Surg. 2001 Feb. 67(2):159-64. [Medline].
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. 2001 Sep-Oct. 26(5):510-4. [Medline].
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. 2004 Sep-Oct. 27(5):481-5. [Medline].
Bozkaya H, Cinar C, Besir FH, Parıldar M, Oran I. Minimally invasive treatment of giant haemangiomas of the liver: embolisation with bleomycin. Cardiovasc Intervent Radiol. 2014 Feb. 37(1):101-7. [Medline].
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. 1998 Nov. 14(1-2):119-21. [Medline].
Hinshaw JL, Laeseke PJ, Weber SM, Lee FT Jr. Multiple-electrode radiofrequency ablation of symptomatic hepatic cavernous hemangioma. AJR Am J Roentgenol. 2007 Sep. 189(3):W146-9. [Medline].
Park SY, Tak WY, Jung MK, et al. Symptomatic-enlarging hepatic hemangiomas are effectively treated by percutaneous ultrasonography-guided radiofrequency ablation. J Hepatol. 2011 Mar. 54(3):559-65. [Medline].
Fan RF, Chai FL, He GX, et al. Laparoscopic radiofrequency ablation of hepatic cavernous hemangioma. A preliminary experience with 27 patients. Surg Endosc. 2006 Feb. 20(2):281-5. [Medline].
van Tilborg AA, Nielsen K, Scheffer HJ, et al. Bipolar radiofrequency ablation for symptomatic giant (>10 cm) hepatic cavernous haemangiomas: initial clinical experience. Clin Radiol. 2013 Jan. 68(1):e9-e14. [Medline].
Sharpe EE 3rd, Dodd GD 3rd. Percutaneous radiofrequency ablation of symptomatic giant hepatic cavernous hemangiomas: report of two cases and review of literature. J Vasc Interv Radiol. 2012 Jul. 23(7):971-5. [Medline].
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. 1993 Oct. 29(1):45-50. [Medline].
Biswal BM, Sandhu M, Lal P, et al. Role of radiotherapy in cavernous hemangioma liver. Indian J Gastroenterol. 1995 Jul. 14(3):95-8. [Medline].
Tepetes K, Selby R, Webb M, et al. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg. 1995 Feb. 130(2):153-6. [Medline].
Vagefi PA, Klein I, Gelb B, et al. Emergent orthotopic liver transplantation for hemorrhage from a giant cavernous hepatic hemangioma: case report and review. J Gastrointest Surg. 2011 Jan. 15(1):209-14. [Medline]. [Full Text].
Okano A, Sonoyama H, Masano Y, et al. The natural history of a hepatic angiosarcoma that was difficult to differentiate from cavernous hemangioma. Intern Med. 2012. 51(20):2899-904. [Medline].
Ozmen E, Adaletli I, Kayadibi Y, et al. The impact of share wave elastography in differentiation of hepatic hemangioma from malignant liver tumors in pediatric population. Eur J Radiol. 2014 Sep. 83(9):1691-7. [Medline].
Hsi Dickie B, Fishman SJ, Azizkhan RG. Hepatic vascular tumors. Semin Pediatr Surg. 2014 Aug. 23(4):168-72. [Medline].
Hardie AD, Egbert RE, Rissing MS. Improved differentiation between hepatic hemangioma and metastases on diffusion-weighted MRI by measurement of standard deviation of apparent diffusion coefficient. Clin Imaging. 2015 Jul-Aug. 39(4):654-8. [Medline].
Kumar N, Adam SZ, Goodhartz LA, Hoff FL, Lo AA, Miller FH. Beyond hepatic hemangiomas: the diverse appearances of gastrointestinal and genitourinary hemangiomas. Abdom Imaging. 2015 Oct. 40 (8):3313-29. [Medline].
Bai DS, Chen P, Qian JJ, et al. Modified laparoscopic hepatectomy for hepatic hemangioma. Surg Endosc. 2015 Nov. 29(11):3414-21. [Medline].