Hepatic Hemangiomas

Back

Background

Hemangiomas are the most common benign tumors affecting the liver[1] and usually discovered incidentally. They are mesenchymal in origin, usually solitary, and composed of masses of blood vessels that are atypical or irregular in arrangement and size. Typically, there are large vascular cavities surrounded by a simple layer of endothelial cells, supported by fibrous connective tissue.[2] The majority of these lesions are smaller than 5 cm in diameter.[2]

The etiology of these lesions remains unknown. Some authorities consider hemangiomas to be benign congenital hamartomas.

Given the frequency with which the diagnosis of hepatic hemangiomas is made, it is important that clinicians understand the natural history of these tumors, as well as their optimal monitoring and management.

Pathophysiology

Hepatic hemangiomas may result from abnormal angiogenesis.[3]

Some authors have reported that steroid therapy,[4] female sex hormones,[5] ;and pregnancy[6] could increase the size of an already existing hemangioma. A study that prospectively evaluated 94 women with hepatic hemangiomas (mean follow-up of 7.3 years; range, 1-17 years) demonstrated an increase in the size of the hemangiomas in 23% of the women who received hormonal therapy as opposed to 10% of control subjects (P = 0.05).[5] Hemangiomas have also been reported in pregnant women following ovarian stimulation therapy with clomiphene citrate and human chorionic gonadotropin.[7] That said, the focal liver lesion practice guideline of the American College of Gastroenterology (ACG) states: "There has been no clear causative link between hemangiomas and female sex hormones, and thus, it is not recommended to avoid OCP [oral contraceptive pills] or pregnancy in patients with hemangiomas."[8]

Three main histologic subtypes of hepatic hemagioma exist:

Each of these lesions has a somewhat different appearance radiologically.[9] Cavernous hemangiomas are characterized by large vascular spaces. During a contrast magnetic resonance image (MRI) study, there is slow flow of radiologic contrast medium into the tumor. The tumors exhibit nodular peripheral enhancement, as well as progressive centripetal filling (progressing inward toward the center). Capillary hemangiomas, however, are chacterized by smaller vascular spaces. During contrast MRI, there is rapid flow of contrast material, resulting in early enhancement.[9] Typically, capillary hemangiomas are smaller than 2 cm in diameter.[10]

Cavernous hemangiomas can grow to sizes much larger than 4 cm in diameter, the size that typically defines a "giant hemangioma." Giant hemangiomas can be complicated by the rather uncommon Kasabach-Merritt syndrome, in which it is postulated that platelets become entrapped in the vascular spaces of the tumor. This, in turn, leads to consumptive coagulopathy and fibrinolysis. Intratumoral bleeding can occur, resulting in enlargement of the tumor.[11]

Sclerosed hemangiomas are at the other end of the histologic sprecturm. It is postulated that some cavernous hemangiomas will degenerate and undergo fibrous replacement, leading to the development of the relatively uncommon sclerosed hemangioma.[11] Like cavernous hemangiomas, sclerosed hemangiomas exhibit slow contrast enhancement on MRI. These lesions also exhibit peripheral nodular enhancement but are marked by very late homogeneous filling with contrast medium.[9]

Epidemiology

Prevalence

Autopsy series have reported the prevalence of hepatic hemangioma to range from 0.4% to as high as 20%.[12] The widespread use of noninvasive abdominal imaging modalities has led to increased detection of asymptomatic lesions. Large reviews of radiology databases have estimated a 2.5-5.1% prevalence of hepatic hemangiomas.[13, 14]

Sex- and age-related demographics

Women, especially women with a history of multiparity, are affected more often than men. The female-to-male ratio is 4-6:1.

Hepatic hemangiomas can occur at all ages, but most are diagnosed in individuals aged 30-50 years. Female patients often present at a younger age and with larger tumors.

Hepatic hemangiomas may be seen in infancy. They have also been detected prenatally in a growing fetus.[15, 16]

Prognosis

The vast majority of hepatic hemagiomas are asymptomatic. Malignant transformation has not been described. Overall, a patient with an hepatic hemangioma has an excellent prognosis.

Complications

The most common reason for a patient with hepatic hemangioma to undergo surgery is abdominal pain. Increasing tumoral size and intratumoral bleeding can cause progressive abdominal pain. Less commonly, surgery is performed to addresse the rare complications noted below.

History and Physical Examination

History

Hemangiomas present a diagnostic challenge, not only because they can be mistaken for hypervascular malignancies of the liver, but they can also coexist with (and occasionally mimic) other benign and malignant hepatic lesions, such as:

Hepatic hemangiomas can occur as a part of well-defined clinical syndromes. In Klippel-Trenaunay-Weber syndrome (triad of capillary malformation, venous malformations, overgrowth of soft tissue and bone), hepatic hemangiomas occur in association with congenital hemiatrophy and nevus flammeus, with or without hemimegalencephaly.

In Kasabach-Merritt syndrome (giant hepatic hemangiomas, thrombocytopenia, intravascular coagulation),[21] patients are typically male and younger than 1 year.[22] The goal of treatment in Kasabach-Merritt syndrome is eradication of the hemangioma, with subsequent control over the patient's coagulopathy.[23]

Osler-Rendu-Weber disease is characterized by numerous small hemangiomas of the face, nares, lips, tongue, oral mucosa, gastrointestinal tract, and liver.

Von Hippel-Lindau disease is marked by cerebellar and retinal angiomas, with lesions also seen in the liver and pancreas.

Multiple hepatic hemangiomas have been reported in patients with systemic lupus erythematosus.[24]

Infantile hemangioma is a common tumor in infancy; it may be seen in 5-10% of children aged 1 year. The hemangiomas typically regress during childhood.[16] Typically, the tumors affect the skin and the subcutaneous tissue; occasionally, they can affect the liver. Case reports have described the regression of infantile hemangiomas after treatment with propranolol.[25, 26, 27, 28]

Reports have also described infants with massive hepatic hemangiomas and hypothyroidism. In these cases, the tumor was found to express type 3 iodothyronine deiodinase, which resulted in an increased rate of inactivation of the thyroid hormone.[29]

Physical examination

Patients with hepatic hemangiomas infrequently present with an enlarged liver, an abdominal mass, or an arterial bruit over the right upper quadrant.

Cutaneous hemangiomas are a common finding in adults. It is unclear whether or not these lesions are associated with hepatic hemangiomas.[30]

Clinical Features

Hepatic hemangiomas are more common in the right lobe of the liver than in the left lobe. These lesions are usually small and asymptomatic and are most often discovered when the liver is imaged for another reason or when the liver is examined at laparotomy or autopsy.[20] Larger and multiple lesions may produce symptoms that necessitate surgery. Up to 40% of patients with 4-cm hemangiomas and 90% of those with 10-cm hemangiomas may experience symptoms.[31]

Typical symptoms include right upper quadrant pain or fullness.[20] In some cases, pain is explained by thrombosis and infarction of the lesion, hemorrhage into the lesion, or compression of the adjacent tissues or organs. In other cases, pain is unexplained.

Up to 40% of hepatic hemangiomas grow over time, at a modest rate of about 2 mm per year in linear dimension and 17.4% per year in volume, based on data from a 10-year retrospective study.[32] In a another retrospective study, hemangiomas increased in size in 61.0% of patients, with the highest growth period in those younger than 30 years (0.46 ± 0.41 cm per year) and the slowest growth period in those older than 50 years (0.16 ± 0.42 cm per year).[33] Hemangiomas sized 8-10 cm grew at a rate of 0.80 ± 0.62 cm per year, whereas those larger than 10 cm grew at a slower rate of 0.47 ± 0.91 cm per year.[33]

Rarely, hepatic hemangiomas may present as a large abdominal mass. Other atypical presentations include:

In a case series, one patient presented with symptoms that resembled a systematic inflammatory process: fever, weight loss, anemia, thrombocytosis, increased fibrinogen level, and elevated erythrocyte sedimentation rate.[36]

The classic indications for either surgery or minimally invasive therapy are for relief of symptoms due to the hemangioma or 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; in one study, the risk of rupture was 3.2% for giant hemangiomas, particularly with exophytic lesions and those located peripherally.[18]

Approach Considerations

Radiologic imaging is the key to making a diagnosis of hepatic hemangioma. The key modalities include ultrasonography, dynamic contrast-enhanced computed tomography (CT) scanning, and magnetic resonance imaging (MRI). Less commonly used imaging modalities include nuclear medicine studies using technetium-99m (99mTc)–labeled red blood cells (RBCs), hepatic arteriography, and digital subtraction angiography (DSA).

See Imaging Studies for a brief summary of some of the radiologic characteristics of hepatic hemangioma.

Laboratory Studies

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.

In one study, patients with an hemangioma diameter greater than 4 cm had higher D-dimer levels than patients with smaller hemangiomas.[37] This suggests patients with large hemangiomas may be at higher risk for intratumoral thrombosis and other complications, as compared to patients with smaller lesions.[37]

Normal levels of alpha-fetoprotein, carbohydrate antigen (CA) 19-9, and carcinogenic embryonic antigen (CEA) bolster the clinical suspicion of a benign hepatic mass lesion.

Imaging Studies

Ultrasonography

Most hemangiomas are discovered as an incidental finding on ultrasound examination, appearing on 2-4% of adult abdomimial sonograms.[10] Classic sonographic characteristics include:

Ultrasound has a sensitivity as high as 97% and a specificity as high as 60% in the diagnosis of hepatic hemangioma.[38] The American College of Gastroenterology (ACG) and the European Association for the Study of the Liver (EASL) both state that the finding of a small lesion (< 2 cm for ACG; < 3 cm for EASL) with classic imaging characterstics in a patient without chronic liver disease or without an oncologic diagnosis can be considered to be diagnostic for hepatic hemangioma. Additional contrast-enhanced studies are not necessary in such patients.[8, 39]

Unfortunately, other benign and malignant lesions may be hyperechoic on ultrasonography, including focal hepatic steatosis, inflammatory hepatocellular adenomas, and mucinous colorectal metastases.[10] In general, the finding of a suspected hemangioma on ultrasonography should be diagnostically integrated with CT or MRI studies to ensure a correct diagnosis.

Contrast-enhanced ultrasound uses microbubbles to better delineate vascular lesions. Hepatic hemagiomas are characterized by peripheral puddles and pools of enhancement that expand in a centripetal pattern during the portal venous phase of enhancement.[40] With delayed imaging, the lesion may completely "fill in."[41] However, complete enhancement might not occur in large lesions in which central thrombosis or scarring may be present. The addition of a contrast material may improve the sensitivity and specificity of ultrasonography.[42] Unfortunately, contrast-enhanced ultrasonography is available at relatively few medical centers.[43]

Serial ultrasonographic examinations can be used to monitor any increase in the size of an hemangioma over time.



View Image

Hepatic Hemangiomas. Hemangioma of the liver as seen on ultrasonography. Image from Wikimedia Commons/James Heilman, MD (https://commons.wikimedia.org....



View Image

Hepatic Hemangiomas. (a): Transverse sonogram of the left lobe of liver presenting a typical hyperechogenic hemangioma. (b) and (c): Two different hyp....

Computed tomography scanning

Dynamic contrast-enhanced CT scanning is preferred over 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 (ie, the so-called triple-phase CT scan with delayed imaging).

First, the liver is imaged by CT scanning before the administration of intravenous contrast medium. The next series of images is obtained about 30 seconds after the injection of contrast; at the time, the contrast material is entering the liver via the hepatic artery. Portal venous imaging occurs 60 seconds later, as the contrast is returning to the liver from the mesenteric veins via the portal vein. Finally, delayed images are obtained several minutes later.

Classic CT imaging characteristics of hepatic hemangiomas:

See the image below.



View Image

Hepatic Hemangiomas. (A) On plain computed tomography (CT) scan, an oval, low-density lesion with clear boundaries and central liquefactive necrosis i....

Magnetic resonance imaging

MRI is highly sensitive and specific for the diagnosis of hepatic hemangioma.[45, 46]

Classical imaging characteristics of hepatic hemangiomas on MRI include:

The sensitivity for MRI detection of hepatic hemangioma is in the range of 92-100%, with a specificity in the range of 85.7-99.4%.[8]

Hemangiomas smaller than 2 cm may exhibit homogeneous enhancement in late arterial-phase imaging. These lesions can be mistaken for hepatocellular carcinoma or a hypervascular metastasis.[47]

Giant cavernous hemangiomas (ie, >5 cm in diameter) may exhibit internal fluid levels on MRI and CT scans.[48] This finding is attributed to the separation of blood cells and serous fluid owing to extremely slow blood flow through the tumor.

In the authors' opinions, MRI with arterial phase and delayed contrast medium is the test of choice for investigating a liver mass of unclear origin. This is particularly the case when hepatic hemangioma is suspected.



View Image

Hepatic Hemangiomas. Moderately (a) and heavily (b) T2-weighted magnetic resonance images show typical bright lesions. Image from BMC Gastroenterology....

Nuclear medicine studies

At this time, nuclear medicine studies are infrequently used to make a diagnosis of hepatic hemangioma.

For many years, planar scintigraphic studies using Tc-99m pertechnetate-labeled red blood cells (RBCs) were used to help diagnose hepatic hemangiomas. Their sensitivity for detecting hemangiomas larger than 2 cm in diameter was as high as 82%, with a specificity approaching 100%.[49]

More recently, single-photon emission CT (SPECT) scanning using Tc-99m pertechnetate-labeled RBCs is more accurate than planar imaging in helping to diagnose hepatic hemangioma.[50] However, this imaging modality is not available at all medical centers.

Arteriography

Arteriography is rarely used to diagnose hepatic hemangioma.

When patients do undergo arteriography, the classic imaging characteristics of hepatic hemangiomas include:

Procedures

Liver biopsy

Percutaneous biopsy is rarely used to make a diagnosis of hepatic hemangioma. However, biopsy might be needed when both hepatic hemangioma and malignancy are in the differential diagnosis of a small liver lesion.

One study reported the safe performance of ultrasonographically guided biopsy using an18-gauge core needle biopsy in 51 hemangiomas ranging in size from 7 to 114 mm.[51] However, the procedure can be complicated by bleeding. The ACG recommends against its performance if at all possible.[8]

Pathology

Macroscopically, hemangiomas are reddish-blue and well demarcated from surrounding tissue, ranging in size from 2 mm to more than 20 cm. On gross examination, these lesions often appear to have a flat surface or as bulging subcapsular lesions. Large tumors may become pedunculated. Hemangiomas are usually solitary, but multiple tumors are described in about 10% of patients.[2] Multiple and diffuse hepatic lesions are seen infrequently.

Microscopically, hemangiomas are composed of cavernous vascular channels. The channels are lined by single layers of flattened endothelium and are separated by fibrous septa.[52, 53] These vascular spaces may contain thrombin, calcifications, or prominent scarring with hyalinization (ie, a sclerosed hemangioma). Phleboliths are rare. Malignant transformation has not been reported.

Medical Care

Most hepatic hemangiomas are small and asymptomatic at the time of diagnosis, and they are likely to remain that way. In a 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.[54] 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. The American College of Gastroenterology (ACG) recommends against the performance of routine follow-up imaging studies for patients diagnosed with hepatic hemangioma, except in the setting of chronic hepatitis B.[8] In the authors' practices, patients typically undergo ultrasonography at 6 and 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.

Important exceptions

There are important exceptions to not following up with radiologic studies over the long term. Patients with new onset of abdominal pain deserve a follow-up imaging study. There is disagreement as to whether the patients who undergo treatment with estrogens or women who become pregnant need surveillance; indeed, a number of studies have reported accelerated hemangioma growth in patients in patients with high estrogen states.[55]

The ACG recommends against the monitoring of both pregnant women and patients with large hemangiomas (ie, > 10 cm). However, the authors of this chapter and others disagree.[56] Patients with large hemangiomas may deserve long-term follow-up, perhaps with annual ultrasonography, because of their probable increased risk of complications.

Medical treatment

There are no commonly accepted medical treatments for hepatic hemangioma. Case reports have described the use of:

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.

Surgical Care

Hepatic hemangiomas warrant therapy if they are causing significant symptoms.[59] Unfortunately, in some individuals, it is difficult to determine if the symptoms are caused by a hemangioma or by another process (eg, irritable bowel syndrome). Farges et al described 14 patients who underwent surgical or angiographic therapy for "incapacitating symptoms" that were believed to be related to a hepatic hemangioma, in which half of these patients remained symptomatic after therapy, implying that the hemangioma was not responsible for their complaints.[60]

Indications for surgery

Potential indications for surgical management of hepatic hemangiomas include:

Surgical resection

The size and location of a lesion will influence the surgeon's decision to perform either a formal segmental resection of a hemangioma or an enucleation of the tumor. Traditionally, centrally located tumors undergo formal anatomic resection, in which peripheral tumors are removed by enucleation. Centrally located hemangiomas can also be removed by enucleation, but such surgery is technically demanding.[61]

Both surgical resection and enucleation are safe and are well tolerated by patients. Mortality of 0% has been reported in large series. Typically, postoperative morbidity is minimal, and the average length of hospital stay is 6 days.[62] Still, serious postoperative complications have been reported in up to 7% of patients undergoing surgery.[63]

Most hemangioma surgeries are performed using an open approach, but laparoscopic surgery can be performed in some cases. Hepatic lobectomy may be necessary in the setting of large lesions.[21]

Hemangiomas rarely recur after successful resection in the absence of tumor-promoting factors (eg, estrogen therapy).[64]

Management of the ruptured hemangioma

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, whereas others have recommended transarterial embolization instead. Once the patient is stabilized, formal surgical resection of the hepatic hemangioma can be performed.[65]

Management of large hemangiomas

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 as 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.[66, 67]  In 2011, Donati et al described only 46 published cases of spontaneous rupture over the last century.[17] The risk for traumatic rupture was also low, with only 51 cases described over the last century.[17, 68] Congestive heart failure was even less frequently identified as a complication.

Orthotopic liver transplantation

On rare occasions, liver transplantation has been offered to symptomatic patients with large or diffuse lesions.[69, 70]

Alternative treatments

Less commonly used modalities for treating symptomatic hepatic hemangiomas include transarterial embolization of large feeding vessels[71, 72, 73, 74, 75] (discussed further below); radiofrequency ablation[76, 77, 78, 79, 80] ; hepatic irradiation[81, 82] ; and radiofrequency ablation.[76, 77, 78, 79, 80]

Transarterial embolization has been employed in cases in which surgical resection was not feasible on account of the massive or diffuse nature of the lesion, the tumor’s proximity to vascular structures, or the patient's comorbidities. As noted earlier, transarterial embolization has also been used on an emergent basis in cases of spontaneous hemorrhage and rupture.

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

What are hepatic hemangiomas?What is the pathophysiology of hepatic hemangiomas?What is the prevalence of hepatic hemangiomas in the US?Which patient groups have the highest prevalence of hepatic hemangiomas?What is the prognosis of hepatic hemangiomas?What are the possible complications of hepatic hemangiomas?Which clinical history findings are characteristic of hepatic hemangiomas?What are the clinical features of hepatic hemangiomas?Which physical findings are characteristic of hepatic hemangiomas?Which conditions should be considered in the differential diagnoses of hepatic hemangiomas?What is the role of lab testing in the workup of hepatic hemangiomas?Which imaging studies are performed in the workup of hepatic hemangiomas?What is the role of ultrasonography in the workup of hepatic hemangiomas?What is the role of a CT scan in the workup of hepatic hemangiomas?What is the role of an MRI scan in the diagnosis of hepatic hemangiomas?What is the role of nuclear imaging in the workup of hepatic hemangiomas?What is the role of arteriography in the workup of hepatic hemangiomas?Which imaging modalities are the most sensitive for the diagnosis of hepatic hemangiomas?How is hepatic angiosarcoma differentiated from hepatic hemangiomas on imaging?Which imaging modality is most accurate for assessing hepatic hemangiomas less than 2 cm?What is the role of liver biopsy in the workup of hepatic hemangiomas?Which histologic findings are characteristic of hepatic hemangiomas?How are hepatic hemangiomas treated?What is the role of radiologic studies in treatment monitoring of hepatic hemangiomas?What is the role of kinase inhibitors in the treatment of hepatic hemangiomas?What is the role of surgery in the treatment of hepatic hemangiomas?How are large hepatic hemangiomas treated?What is the role of surgical resection in the treatment of hepatic hemangiomas?What is the role of arterial embolization in the treatment of hepatic hemangiomas?What is the role of surgical ligation in the treatment of hepatic hemangiomas?What is the role of radiofrequency ablation in the treatment of hepatic hemangiomas?What is the role of hepatic irradiation in the treatment of hepatic hemangiomas?What is the role of liver transplantation in the treatment of hepatic hemangiomas?Which dietary and activity modifications are used in the treatment of hepatic hemangiomas?

Author

David C Wolf, MD, FACP, FACG, AGAF, FAASLD, 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

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Gilead; Intercept; Madrigal.

Coauthor(s)

Unnithan V Raghuraman, MD, FACG, FACP, FRCP, Consulting Staff, Department of Gastroenterology, St John Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Vivek V Gumaste, MD, Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center at Elmhurst; Program Director of GI Fellowship (Independent Program); Regional Director of Gastroenterology, Queens Health Network

Disclosure: Nothing to disclose.

References

  1. Dickie B, Dasgupta R, Nair R, et al. Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg. 2009 Jan. 44 (1):125-33. [View Abstract]
  2. Ishak KG, Rabin L. Benign tumors of the liver. Med Clin North Am. 1975 Jul. 59 (4):995-1013. [View Abstract]
  3. Leon M, Chavez L, Surani S. Hepatic hemangioma: What internists need to know. World J Gastroenterol. 2020 Jan 7. 26 (1):11-20. [View Abstract]
  4. Takahashi T, Kuwao S, Katagiri H, Kakita A. Multiple liver hemangiomas enlargement during long-term steroid therapy for myasthenia gravis. Dig Dis Sci. 1998 Jul. 43 (7):1553-61. [View Abstract]
  5. Glinkova V, Shevah O, Boaz M, Levine A, Shirin H. Hepatic haemangiomas: possible association with female sex hormones. Gut. 2004 Sep. 53 (9):1352-5. [View Abstract]
  6. Giannitrapani L, Soresi M, La Spada E, Cervello M, D'Alessandro N, Montalto G. Sex hormones and risk of liver tumor. Ann N Y Acad Sci. 2006 Nov. 1089:228-36. [View Abstract]
  7. Spitzer D, Krainz R, Graf AH, Menzel C, Staudach A. 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. [View Abstract]
  8. [Guideline] Frenette C, Mendiratta-Lala M, Salgia R, Wong RJ, Sauer BG, Pillai A. ACG Clinical guideline: focal liver lesions. Am J Gastroenterol. 2024 Jul 1. 119 (7):1235-71. [View Abstract]
  9. Klotz T, Montoriol PF, Da Ines D, Petitcolin V, Joubert-Zakeyh J, Garcier JM. Hepatic haemangioma: common and uncommon imaging features. Diagn Interv Imaging. 2013 Sep. 94 (9):849-59. [View Abstract]
  10. Bonatti M, Valletta R, Corato V, et al. I thought it was a hemangioma! A pictorial essay about common and uncommon liver hemangiomas' mimickers. Insights Imaging. 2024 Sep 19. 15 (1):228. [View Abstract]
  11. Maruyama S, Matono T, Koda M. The natural history and management of hepatic hemangioma. J Clin Med. 2023 Sep 1. 12 (17):5703. [View Abstract]
  12. Caseiro-Alves F, Brito J, Araujo AE, et al. Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis. Eur Radiol. 2007 Jun. 17 (6):1544-54. [View Abstract]
  13. 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. [View Abstract]
  14. Horta G, López M, Dotte A, et al. [Benign focal liver lesions detected by computed tomography: review of 1,184 examinations] [Spanish]. Rev Med Chil. 2015 Feb. 143 (2):197-202. [View Abstract]
  15. Dreyfus M, Baldauf JJ, Dadoun K, Becmeur F, Berrut F, Ritter J. Prenatal diagnosis of hepatic hemangioma. Fetal Diagn Ther. 1996 Jan-Feb. 11 (1):57-60. [View Abstract]
  16. 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. [View Abstract]
  17. 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. [View Abstract]
  18. 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. [View Abstract]
  19. Madhusudhan KS, Srivastava DN, Gamanagatti S. Giant hemangioma of liver presenting as deep vein thrombosis of the lower limbs. J Postgrad Med. 2009 Oct-Dec. 55 (4):290-1. [View Abstract]
  20. Bajenaru N, Balaban V, Săvulescu F, Campeanu I, Patrascu T. Hepatic hemangioma -review-. J Med Life. 2015. 8 Spec Issue (Spec Issue):4-11. [View Abstract]
  21. Xie QS, Chen ZX, Zhao YJ, Gu H, Geng XP, Liu FB. Outcomes of surgery for giant hepatic hemangioma. BMC Surg. 2021 Apr 8. 21 (1):186. [View Abstract]
  22. 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. [View Abstract]
  23. 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):306-12. [View Abstract]
  24. 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. [View Abstract]
  25. 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. [View Abstract]
  26. Starkey E, Shahidullah H. Propranolol for infantile haemangiomas: a review. Arch Dis Child. 2011 Sep. 96 (9):890-3. [View Abstract]
  27. Tsai MC, Liu HC, Yeung CY. Efficacy of infantile hepatic hemangioma with propranolol treatment: A case report. Medicine (Baltimore). 2019 Jan. 98 (4):e14078. [View Abstract]
  28. Yang K, Peng S, Chen L, Chen S, Ji Y. Efficacy of propranolol treatment in infantile hepatic haemangioma. J Paediatr Child Health. 2019 Oct. 55 (10):1194-200. [View Abstract]
  29. 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. [View Abstract]
  30. Lorette G, Georgesco G, Sirinelli D, Alison D, Delhommais A. [Cutaneous immature hemangioma and hepatic angioma: there is no frequent association] [French]. Ann Dermatol Venereol. 1996. 123 (12):789-90. [View Abstract]
  31. Goodman Z. Benign tumors of the liver. In: Okuda K, Ishak KG, eds. Neoplasms of the Liver. Tokyo, Japan: Springer-Verlag; 1987. 105-25.
  32. 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. [View Abstract]
  33. Jing L, Liang H, Caifeng L, et al. New recognition of the natural history and growth pattern of hepatic hemangioma in adults. Hepatol Res. 2016 Jul. 46 (8):727-33. [View Abstract]
  34. Mikami T, Hirata K, Oikawa I, Kimura M, Kimura H. Hemobilia caused by a giant benign hemangioma of the liver: report of a case. Surg Today. 1998. 28 (9):948-52. [View Abstract]
  35. Lee CW, Chung YH, Lee GC, Kim JY, Lee JS. A case of giant hemangioma of the liver presenting with fever of unknown origin. J Korean Med Sci. 1994 Apr. 9 (2):200-4. [View Abstract]
  36. Pol B, Disdier P, Le Treut YP, Campan P, Hardwigsen J, Weiller PJ. Inflammatory process complicating giant hemangioma of the liver: report of three cases. Liver Transpl Surg. 1998 May. 4 (3):204-7. [View Abstract]
  37. Maruyama S, Matono T, Koda M. Prevalence and characteristics of hepatic hemangioma associated with coagulopathy and its predictive risk factors. J Clin Med. 2022 Jul 26. 11 (15):4347. [View Abstract]
  38. Toro A, Mahfouz AE, Ardiri A, et al. What is changing in indications and treatment of hepatic hemangiomas. A review. Ann Hepatol. 2014 Jul-Aug. 13 (4):327-39. [View Abstract]
  39. [Guideline] European Association for the Study of the Liver (EASL). EASL Clinical practice guidelines on the management of benign liver tumours. J Hepatol. 2016 Aug. 65 (2):386-98. [View Abstract]
  40. 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. [View Abstract]
  41. Dietrich CF, Mertens JC, Braden B, Schuessler G, Ott M, Ignee A. Contrast-enhanced ultrasound of histologically proven liver hemangiomas. Hepatology. 2007 May. 45 (5):1139-45. [View Abstract]
  42. von Herbay A, Vogt C, Willers R, Häussinger D. 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. [View Abstract]
  43. 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. [View Abstract]
  44. Nino-Murcia M, Olcott EW, Jeffrey RB Jr, Lamm RL, Beaulieu CF, Jain KA. Focal liver lesions: pattern-based classification scheme for enhancement at arterial phase CT. Radiology. 2000 Jun. 215 (3):746-51. [View Abstract]
  45. 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. [View Abstract]
  46. 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. [View Abstract]
  47. Albiin N. MRI of focal liver lesions. Curr Med Imaging Rev. 2012 May. 8 (2):107-16. [View Abstract]
  48. Obata S, Matsunaga N, Hayashi K, Ohtsubo M, Morikawa T, Takahara O. Fluid-fluid levels in giant cavernous hemangioma of the liver: CT and MRI demonstration. Abdom Imaging. 1998 Nov-Dec. 23 (6):600-2. [View Abstract]
  49. Kinnard MF, Alavi A, Rubin RA, Lichtenstein GR. Nuclear imaging of solid hepatic masses. Semin Roentgenol. 1995 Oct. 30 (4):375-95. [View Abstract]
  50. Krause T, Hauenstein K, Studier-Fischer B, Schuemichen C, Moser E. Improved evaluation of technetium-99m-red blood cell SPECT in hemangioma of the liver. J Nucl Med. 1993 Mar. 34 (3):375-80. [View Abstract]
  51. Heilo A, Stenwig AE. Liver hemangioma: US-guided 18-gauge core-needle biopsy. Radiology. 1997 Sep. 204 (3):719-22. [View Abstract]
  52. Craig JR, Peters RL, Edmondson HA. Tumors of the liver and intrahepatic bile ducts. Atlas of Tumor Pathology. Washington, DC: Armed Forces Institute of Pathology; 1989. Second series, fasc. 26: 56-62.
  53. Ishak KG, Markin RS. Liver. Damjanov I, Linder J, eds. Anderson's Pathology. 10th ed. Mosby: St. Louis, Mo; 1996. 1834.
  54. 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. [View Abstract]
  55. Vilgrain V, Cauchy F, Dokmak S, Paradis V, Belghiti J. Benign liver lesions. In: Jarnagin WR, ed. Blumgart's Surgery of the Liver, Biliary Tract and Pancreas. 6th ed. Philadelphia, Pa: Elsevier; 2017. II: 1299.
  56. van Malenstein H, Maleux G, Monbaliu D, et al. Giant liver hemangioma: the role of female sex hormones and treatment. Eur J Gastroenterol Hepatol. 2011 May. 23 (5):438-43. [View Abstract]
  57. 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. [View Abstract]
  58. Yamashita S, Okita K, Harada K, et al. Giant cavernous hepatic hemangioma shrunk by use of sorafenib. Clin J Gastroenterol. 2013 Feb. 6 (1):55-62. [View Abstract]
  59. 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. [View Abstract]
  60. 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. [View Abstract]
  61. 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. [View Abstract]
  62. Arnoletti JP, Brodsky J. Surgical treatment of benign hepatic mass lesions. Am Surg. 1999 May. 65 (5):431-3. [View Abstract]
  63. 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. [View Abstract]
  64. 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. [View Abstract]
  65. 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. [View Abstract]
  66. 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. [View Abstract]
  67. Ribeiro MA Jr, Papaiordanou F, Gonçalves JM, Chaib E. Spontaneous rupture of hepatic hemangiomas: a review of the literature. World J Hepatol. 2010 Dec 27. 2 (12):428-33. [View Abstract]
  68. Plackett TP, Lin-Hurtubise KM. Hepatic hemangiomas and parachuting. Aviat Space Environ Med. 2008 Oct. 79 (10):986-8. [View Abstract]
  69. Tepetes K, Selby R, Webb M, Madariaga JR, Iwatsuki S, Starzl TE. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg. 1995 Feb. 130 (2):153-6. [View Abstract]
  70. 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. [View Abstract]
  71. Deutsch GS, Yeh KA, Bates WB 3rd, Tannehill WB. Embolization for management of hepatic hemangiomas. Am Surg. 2001 Feb. 67 (2):159-64. [View Abstract]
  72. Srivastava DN, Gandhi D, Seith A, Pande GK, Sahni P. 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. [View Abstract]
  73. Zeng Q, Li Y, Chen Y, Ouyang Y, He X, Zhang H. 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. [View Abstract]
  74. 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. [View Abstract]
  75. Rokitansky AM, Jakl RJ, Göpfrich 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. [View Abstract]
  76. 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. [View Abstract]
  77. 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. [View Abstract]
  78. 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. [View Abstract]
  79. 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. [View Abstract]
  80. 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. [View Abstract]
  81. 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. [View Abstract]
  82. Biswal BM, Sandhu M, Lal P, Bal CS. Role of radiotherapy in cavernous hemangioma liver. Indian J Gastroenterol. 1995 Jul. 14 (3):95-8. [View Abstract]
  83. Moser C, Hany A, Spiegel R. [Familial giant hemangiomas of the liver. Study of a family and review of the literature] [German]. Praxis (Bern 1994). 1998 Apr 1. 87 (14):461-8. [View Abstract]
  84. 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. [View Abstract]
  85. 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. [View Abstract]
  86. De Franco A, Monteforte MG, Maresca G, De Gaetano AM, Manfredi R, Marano P. [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. [View Abstract]
  87. 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. [View Abstract]
  88. Heo SH, Jeong YY, Shin SS, Chung TW, Kang HK. Solitary small hepatic angiosarcoma: initial and follow-up imaging findings. Korean J Radiol. 2007 Mar-Apr. 8 (2):180-3. [View Abstract]
  89. 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. [View Abstract]
  90. Bruix J, Sherman M, Llovet JM, et al, for the EASL Panel of Experts on HCC. 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. [View Abstract]
  91. 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. [View Abstract]
  92. 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. [View Abstract]
  93. Özmen 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. [View Abstract]
  94. Hsi Dickie B, Fishman SJ, Azizkhan RG. Hepatic vascular tumors. Semin Pediatr Surg. 2014 Aug. 23 (4):168-72. [View Abstract]
  95. 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. [View Abstract]
  96. 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. [View Abstract]
  97. Bai DS, Chen P, Qian JJ, et al. Modified laparoscopic hepatectomy for hepatic hemangioma. Surg Endosc. 2015 Nov. 29 (11):3414-21. [View Abstract]

Hepatic Hemangiomas. Hemangioma of the liver as seen on ultrasonography. Image from Wikimedia Commons/James Heilman, MD (https://commons.wikimedia.org/wiki/File:Hemangiomaliver.PNG).

Hepatic Hemangiomas. (a): Transverse sonogram of the left lobe of liver presenting a typical hyperechogenic hemangioma. (b) and (c): Two different hypoechogenic liver lesions suspected to be atypical hemangiomas, subsequently confirmed by computed tomography scanning. Image from BMC Gastroenterology (https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).

Hepatic Hemangiomas. (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. Image from PLoS One (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135158).

Hepatic Hemangiomas. Moderately (a) and heavily (b) T2-weighted magnetic resonance images show typical bright lesions. Image from BMC Gastroenterology (https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).

Hepatic Hemangiomas. Hemangioma of the liver as seen on ultrasonography. Image from Wikimedia Commons/James Heilman, MD (https://commons.wikimedia.org/wiki/File:Hemangiomaliver.PNG).

Hepatic Hemangiomas. (a): Transverse sonogram of the left lobe of liver presenting a typical hyperechogenic hemangioma. (b) and (c): Two different hypoechogenic liver lesions suspected to be atypical hemangiomas, subsequently confirmed by computed tomography scanning. Image from BMC Gastroenterology (https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).

Hepatic Hemangiomas. Moderately (a) and heavily (b) T2-weighted magnetic resonance images show typical bright lesions. Image from BMC Gastroenterology (https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-11-43).

Hepatic Hemangiomas. (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. Image from PLoS One (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135158).