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 the hemangioma size was noted in only 1 of 47 patients who were rescanned 1-6 years after the initial diagnosis. [48] In addition, malignant transformation has not been reported in hepatic hemangiomas. For these reasons, most hepatic hemangiomas may be left safely alone.
Consultation with a surgeon is warranted if resection is the choice of therapy.
No inpatient care is required for routine follow-up. Hospitalization is limited to the time when surgery is planned as a treatment option.
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.
Possible utility of growth factor and kinase inhibitors
Until relatively 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). [49]
Sorafenib, a multikinase inhibitor, was used in the management of a 76-year-old man with a giant cavernous hemangioma measuring more than 20 cm in diameter. Tumor volume decreased from 1492 mL at baseline to 665 mL after 78 days of treatment with sorafenib 600 mg/day. [50]
Surgical Care
Hepatic hemangiomas warrant therapy if they are causing significant symptoms. [51] 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 believed to be related to a hepatic hemangioma. One half of these patients remained symptomatic after therapy, implying that the hemangioma was not responsible for their complaints. [34]
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. [52] Minimally invasive therapies for hepatic hemangioma include arterial embolization, radiofrequency ablation, and hepatic irradiation. Orthotopic liver transplantation has been performed in rare circumstances.
The classic indications for either surgery or minimally invasive therapy are the relief of symptoms due to the hemangioma or the treatment of a spontaneously ruptured hemangioma. The latter event is potentially life-threatening. However, emergent surgical resection of the ruptured hemangioma is associated with a high mortality rate. In one study, the risk of rupture was 3.2% for giant hemangiomas, particularly with exophytic lesions and those located peripherally. [53]
The top priority in a 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. [54]
The management of a large (ie, >10 cm) hepatic hemangioma is controversial. Certainly, large symptomatic hemangiomas should undergo treatment. However, the management of a large asymptomatic lesion is not clear-cut. Some surgeons have advocated resection of such lesions because of the potential risk of spontaneous rupture, intratumoral hemorrhage, or high-output congestive heart failure. However, more recent literature searches identified only 33 published cases of spontaneous rupture in adults without a history of trauma. [55, 56] A 2011 review described only 46 published cases of spontaneous rupture over the last century. [57] The risk for traumatic rupture is also low, [58] with only 51 cases described over the last century. [57] 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. [59] 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. [59]
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. [11] 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. [60]
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). [61] 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 both centrally and 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. [62]
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. [63, 64, 65] One report described 26 patients with symptomatic giant hemangiomas who underwent successful embolization with bleomycin mixed with lipiodol. [66]
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 the intratumoral shunting that otherwise would have led to intractable cardiac failure. [67]
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. [68, 69, 70, 71, 72]
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. [73, 74]
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. [75, 76]
Diet and Activity
No special dietary management is required, and 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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Hemangioma of the liver as seen on ultrasound. Courtesy of Wikimedia Commons/James Heilman, MD (https://commons.wikimedia.org/wiki/File:Hemangiomaliver.PNG).
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Hepatic hemangioma. (a): Transverse sonogram of left lobe of liver presenting a typical hyperechogenic hemangioma. (b) and (c): Two different hypoechogenic liver lesions suspected to be atypical hemangioma, subsequently confirmed by computed tomography scanning. Courtesy of BMC Gastroenterology (https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).
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Hepatic hemangioma. Moderately (a) and heavily (b) T2-weighted magnetic resonance images show typical bright lesions. Courtesy of BMC Gastroenterology https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).
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Hepatic hemangioma. (A) On plain computed tomography (CT) scan, an oval, low-density lesion with clear boundaries and central liquefactive necrosis is seen). (B) and (C): CT-enhanced scans show nodular enhancement at the edges of the lesion during the early arterial phase, and a higher density than the normal liver, appearing as the “fast out, slow in” sign. Courtesy of PLoS One (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135158).
