A liver mass is a benign collection of immature blood vessels within the liver.

Also known as a liver hemangioma, a

liver mass is a condition that usually causes no symptoms and may be discovered during the administration of
testing or procedures for an unrelated condition. There is no indication that the presence of an untreated liver
hemangioma may cause the development of liver cancer. Treatment for masses which cause complications is
dependent on several factors that include the location of the mass and the overall health of the individual.

With no known, definitive cause for the formation of a liver hemangioma, it has been asserted that the condition is
congenital, meaning it is present at the time of birth. A small percentage of those with a liver hemangioma may
experience a progression of their condition. As a liver hemangioma progresses, it may increase in size or multiply,
leading to the formation of additional masses, resulting in the development of complications and, ultimately,
requiring treatment.

Individuals with a liver mass are generally asymptomatic, meaning they exhibit no symptoms. When a liver mass
causes symptom manifestation, an individual may experience a variety of signs. Abdominal discomfort, nausea,
and vomiting may be indicative of the presence of a liver mass. Additionally, those with a liver hemangioma may
experience the feeling of being full after consuming small amounts of food. For others with a liver hemangioma,
their appetite may be absent altogether.

There are several imaging tests used to confirm the presence of a liver hemangioma. Individuals may undergo
testing that includes magnetic resonance imaging (MRI), a computerized tomography (CT) scan, and an ultrasound
of the abdominal area. Additional testing procedures may be dependent on the individual and the seriousness of
his or her condition.

In most cases, individuals with a liver hemangioma who are not experiencing any symptoms or complications may
not require treatment. For those whose condition is more serious, treatment is dependent on the location and size
of the hemangioma, the number of masses, and the overall health of the individual. Treatment may include
surgery, transplantation, or radiation therapy.

Surgical procedures used to treat a liver mass may include the removal of the hemangioma or a portion of the liver
along with the hemangioma. For some individuals, a hepatic artery ligation or arterial embolization may be an
appropriate treatment option. A hepatic artery ligation involves closing off the hepatic artery to block blood flow
to the hemangioma. An arterial embolization utilizes the injection of medication into the hepatic artery to restrict
blood flow to the mass. Restricting the hemangioma’s blood supply removes the nutrients necessary to promote
growth, thus shrinking the mass.

Though rare, individuals with an unusually large liver mass may need to undergo a liver transplant to prevent
further complication. Candidates for liver transplantation are those for whom traditional treatment options are not
viable. During the transplantation process, the diseased liver is removed and replaced with one from a donor. Liver
transplantation surgery carries considerable risks and these should be discussed with a health care provider prior
to pursuing this treatment option.

Radiation therapy may be utilized in some cases to target and eradicate the cells of the hemangioma. The radiation
therapy process involves the administration of highly concentrated energy, such as X-ray, to the affected area.
Individuals who undergo radiation therapy may experience a variety of side effects that may include fatigue, and
redness or irritation at the administration site.

Even though there is no known cause for the formation of a liver hemangioma, there are some factors believed to
contribute to its development. Individuals between the ages of 30 and 50 may have a greater chance for being
diagnosed with a liver hemangioma, since those within this age group are most frequently diagnosed with the
condition. It has been asserted that high estrogen levels may contribute to the development of a liver
 hemangioma, therefore, women who have had hormone replacement therapy or who have been pregnant are at
an increased risk for being diagnosed with a liver mass.

Definition
By Mayo Clinic staff
Liver hemangioma (he-man-jee-O-muh) is a noncancerous (benign) mass that occurs in the liver. A liver
hemangioma is made up of a tangle of poorly formed blood vessels. Liver hemangioma is sometimes called hepatic
hemangioma or cavernous hemangioma.

Most cases of liver hemangioma are discovered during a test or procedure for some other condition. Most people
who have a liver hemangioma never experience signs and symptoms and never need treatment.

While it may be unsettling to know you have a mass in your liver, even if it's a benign mass, there's no evidence
that an untreated liver hemangioma can lead to liver cancer.

Symptoms
By Mayo Clinic staff
In most cases, liver hemangioma doesn't cause any signs or symptoms.

When a liver hemangioma causes signs and symptoms, they may include:

 Pain in the upper right abdomen

 Feeling full after eating only a small amount of food

 Lack of appetite

 Nausea

 Vomiting

 Clinical Manifestations
 Signs & Symptoms
 Abdominal bruit
 Abdominal Mass
 Abdominal Mass in Children
 Mass in RUQ
 Upper Abdominal Mass
 Hepatic bruit/sign
 Hepatic Mass
 Hepatic Mass/child
 Hepatomegaly
 Liver Mass
 Palpable Liver
Introduction

Background
Hemangioma is the most common benign tumor affecting the liver.1Hepatic hemangiomas are mesenchymal in
origin and usually are solitary. Some authorities consider them to be benign congenital
hamartomas. Hemangiomas are composed of masses of blood vessels that are atypical or irregular in arrangement
and size. Etiology remains unknown.

Pathophysiology
Although no definite familial or genetic mode of inheritance has been described, Moser et al reported a large
family of Italian origin in which 3 female patients in 3 successive generations had large symptomatic hepatic
hemangiomas.2 The authors postulated that restriction of the disease to the female sex could be explained by sex-
dependent differences in penetrance, the expression of a presumed liver-hemangioma gene, or the production of
proliferative factors, such as female sex hormones.

Several pharmacologic agents have been postulated to promote tumor growth. Steroid therapy 3 , estrogen
therapy, and pregnancy4 can increase the size of an already existing hemangioma. One study prospectively
evaluated 94 women with hepatic hemangiomas, with a mean follow-up period of 7.3 years (range, 1-17 y). 5 An
increase in the size of the hemangiomas was seen in 23% of women who received hormonal therapy as opposed to
10% of control subjects (P=0.05). Hemangiomas have also been reported in pregnant women following ovarian
stimulation therapy with clomiphene citrate and human chorionic gonadotropin. 6

Frequency
United States
The reported incidence rate of hepatic hemangiomas is approximately 2%. The prevalence rate at necropsy is as
high as 7.4%. The widespread use of noninvasive abdominal imaging modalities has led to increased detection of
asymptomatic lesions in vivo.

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

Age
Hepatic hemangiomas can occur at all ages. Most hepatic hemangiomas 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.7,8

Clinical

History

 Hemangiomas present a diagnostic challenge because they can be mistaken for hypervascular
malignancies of the liver and can coexist with (and occasionally mimic) other benign and malignant
hepatic lesions, including focal nodular hyperplasia, hepatic adenoma, hepatic cysts,
hemangioendothelioma, hepatic metastasis, and primary hepatocellular carcinoma.
 Hepatic hemangiomas can occur as part of well-defined clinical syndromes.
 o In Klippel-Trenaunay-Weber syndrome, hepatic hemangiomas occur in association with
congenital hemiatrophy and nevus flammeus, with or without hemimeganencephaly.
o In Kasabach-Merritt syndrome, giant hepatic hemangiomas are associated with
thrombocytopenia and intravascular coagulation.
o Osler-Rendu-Weber disease is characterized by numerous small hemangiomas of the face, nares,
lips, tongue, oral mucosa, gastrointestinal tract, and liver.
o Von Hippel-Lindau disease is marked by cerebellar and retinal angiomas, with lesions also in the
liver and pancreas.
o Multiple hepatic hemangiomas have been reported in patients with systemic lupus
erythematosus.9
 Clinical features
o Hepatic hemangiomas are more common in the right lobe of the liver than in the left lobe. 
o Hemangiomas of the liver are usually small and asymptomatic. They are most often discovered
when the liver is imaged for another reason or when the liver is examined at laparotomy or
autopsy. Larger and multiple lesions may produce symptoms. Goodman noted that symptoms
are experienced by 40% of patients with 4-cm hemangiomas and by 90% of patients with 10-cm
hemangiomas.10
o Right upper quadrant pain or fullness is the most common complaint. In some cases, pain is
explained by thrombosis and infarction of the lesion, hemorrhage into the lesion, or compression
of adjacent tissues or organs. In other cases, pain is unexplained.
o The only findings upon physical examination are, infrequently, an enlarged liver or the presence
of an arterial bruit over the right upper quadrant.
o Rarely, hemangiomas may present as a large abdominal mass. Other atypical presentations
include the following: (1) cardiac failure from massive arteriovenous shunting, (2) jaundice from
compression of the bile ducts, (3) gastrointestinal bleeding from hemobilia, 11 and (4) fever of
unknown origin.12
o An illness that resembles a systematic inflammatory process has been described with findings of
fever, weight loss, anemia, thrombocytosis, increased fibrinogen level, and elevated erythrocyte
sedimentation rate.13
 Complications
o Complications depend on the size and location of the tumor.
o Rarely, large tumors rupture spontaneously or after blunt trauma. Patients may present with
signs of circulatory shock and hemoperitoneum.
o Early satiety, nausea, and vomiting may occur when large lesions compress the stomach,
producing gastric outlet obstruction.
o One case has been reported of lower extremity edema caused by compression of the inferior
vena cava by a cavernous hemangioma of the caudate lobe of the liver.
 Infantile hemangiomas8
o Hepatic hemangiomas may be seen in 5-10% of children aged 1 year. They typically regress
during childhood.
o Reports have 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 thyroid hormone. 14

Physical
Infrequently, patients may present with an enlarged liver, an abdominal mass, or an arterial bruit over the right
upper quadrant.   
 
Cutaneous hemangiomas are a common finding. It is unclear whether or not they are associated with hepatic
hemangiomas.15
Causes
Oral contraceptives and steroids may accelerate the growth of a hemangioma. Whether or not these drugs actually
induce the formation of the hemangioma is unclear.

Differential Diagnoses

Other Problems to Be Considered

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

Workup

Laboratory Studies

 Routine laboratory tests

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

Imaging Studies

 The modalities used to aid in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic
contrast-enhanced computed tomography (CT) scanning, nuclear medicine studies using technetium-99m
(99m Tc) – labeled RBCs, magnetic resonance imaging (MRI), hepatic arteriography, and digital subtraction
angiography.
 Ultrasonography
o This is the most commonly used initial diagnostic tool. It is widely available and inexpensive.
Hepatic hemangiomas usually are echogenic, but their sonographic appearance is variable and
nonspecific.
o 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.
o The use of microbubble-enhanced ultrasonography has been studied. Lesions show peripheral
puddles and pools of enhancement that expand in a centripetal pattern during the portal venous
phase of enhancement.16 With delayed imaging, the lesion may completely "fill in." 17 However,
complete enhancement might not occur in large lesions where central thrombosis or scarring
may be present.
o In one study, the addition of a contrast agent to routine ultrasonography improved sensitivity
from 78% to 100% and specificity from 23% to 92%. 18 Unfortunately, contrast-enhanced
ultrasonography is available at relatively few medical centers. 19
o In general, the finding on ultrasonography of a suspected hemangioma should be diagnostically
integrated with CT scan or MRI to ensure a correct diagnosis.
 Computed tomography
o Dynamic contrast-enhanced CT scanning is preferred to routine CT scanning. When requesting a
CT scan to investigate a liver mass, the physician should inform the radiologist about the need for
 nonenhanced, arterial, portal venous, and delayed imaging (the so-called triple phase CT with
delayed imaging).
o First, the liver is imaged by CT before the administration of intravenous contrast. The next series
of images is obtained about 30 seconds after the injection of contrast, at the time that contrast is
entering the liver via the hepatic artery. Portal venous imaging occurs 60 seconds later, as
contrast is returning to the liver from the mesenteric veins via the portal vein. Finally, delayed
images are obtained several minutes later.
o 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.
o 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 imaging20,21
o MRI is highly sensitive and specific in the diagnosis of hepatic hemangioma. Typically,
hemangiomas have low signal intensity on T1-weighted images and high signal intensity on T2-
weighted images. When gadolinium is used as an intravenous contrast agent, hemangiomas
enhance in a fashion similar to that seen on dynamic CT. The sensitivity for detection of hepatic
hemangioma is upwards of 90%.22
o Giant cavernous hemangiomas (ie, >5 cm in diameter) may exhibit internal fluid levels on MRI
and CT scan images.23 This finding is attributed to the separation of blood cells and serous fluid
because of extremely slow blood flow through the tumor.
 Nuclear medicine studies
o Planar scintigraphic studies using Tc-99m pertechnetate-labeled red blood cells have been used
for many years to help in diagnosing hepatic hemangiomas. Sensitivity for hemangiomas greater
than 2 cm in diameter was said to be as high as 82%, with a specificity of up to 100%. 24
o Single-photon emission computerized tomography (SPECT) using Tc-99m pertechnetate-labeled
RBCs is more accurate than planar imaging in helping to diagnose hepatic
hemangioma.25However, it is not available at all medical centers.
o SPECT is more specific than MRI, but it is less sensitive. This is particularly true for lesions near
the heart or major blood vessels.25
o 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.26
 Arteriography
o 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.
o Branches of the hepatic artery may be displaced and crowded together or stretched around the
lesion, with normal vascular tapering.
o 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
o 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.27
o 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
 Imaging of hemangiomas less than 2 cm
o Diagnostic accuracy diminishes for all imaging modalities when assessing a liver lesion that is less
than 2 cm in diameter.
o MRI and 99mTc-RBC SPECT are the most accurate radiologic studies to establish the diagnosis of
a small hepatic hemangioma.
 The authors continue to regard MRI as the diagnostic test of choice for hepatic hemangioma at most
centers. Nuclear medicine studies may be used to confirm the diagnosis when a probable hemangioma is
detected on ultrasonography. Nuclear medicine studies may also help to clarify the nature of a lesion
when the diagnosis is equivocal on CT or MRI.

Procedures

 Liver biopsy
o 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.
o 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. 28 However, the authors do not
recommend its performance.
o Some authorities contend that either percutaneous liver biopsy or laparoscopic liver biopsy may
be reasonable to perform in cases where a small liver lesion must be differentiated
fromhepatocellular carcinoma. However, since 2001, hepatologists and surgeons have been
increasingly resistant to include liver biopsy in the diagnostic workup of suspected hepatocellular
carcinoma. The diagnosis of most hepatocellular carcinomas can be made by using a combination
of CT and MRI.29 Liver biopsy is only used when radiologic study results and alpha fetoprotein
testing are equivocal.

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

Pathology 

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

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

Histologically, the tumor is thin walled. Its vascular spaces are lined by a single layer of endothelial cells that are
separated by fibrous septa.30,31