Liver haemangioma
A haemangioma is the most common benign tumour of the liver. It is a mass of abnormal blood vessels, present from birth in most cases, and in the overwhelming majority of people it causes no symptoms, needs no treatment and never becomes dangerous.
How it forms
A haemangioma is a congenital vascular malformation rather than a true tumour in the sense of uncontrolled growth. During development of the liver's blood supply, a cluster of vessels forms abnormally, producing a tangle of wide, thin-walled vascular channels lined by normal endothelial cells and separated by thin fibrous partitions. Blood flows slowly through these channels, which is what gives a haemangioma its characteristic appearance on contrast imaging — it fills gradually from the edge inwards rather than all at once.
Because the lining cells are normal, a haemangioma does not behave like a cancer. It does not invade surrounding tissue and it does not spread. The cells are not abnormal; their arrangement is.
Most haemangiomas remain the same size for life. A minority enlarge slowly. Oestrogen appears to influence growth in some cases, which is the basis for the observation that haemangiomas are found more often in women and may occasionally enlarge during pregnancy or with hormone use. This does not mean that hormones caused the lesion, and it is not by itself a reason to avoid pregnancy or stop contraception.
How it is found
Almost always incidentally, on an ultrasound, CT or MRI done for another reason. Most are small — under three centimetres. Lesions over ten centimetres are sometimes described as giant haemangiomas, although the term describes size alone and not danger.
Symptoms
Small haemangiomas produce no symptoms whatsoever. Large ones may cause:
- a dull ache or dragging sensation in the upper right abdomen
- early satiety, if the lesion presses on the stomach
- rarely, symptoms from pressure on adjacent structures
Spontaneous rupture is very rare and receives disproportionate attention. It is not a realistic concern for an ordinary haemangioma and is not a reason to operate on an asymptomatic lesion.
How the diagnosis is made
Imaging is usually conclusive and biopsy is rarely required. On ultrasound a small haemangioma appears as a well-defined, uniformly bright lesion. Where confirmation is needed, contrast-enhanced MRI is the test of choice: the pattern of peripheral nodular enhancement that fills in progressively over the delayed phases is highly characteristic. CT with contrast shows the same behaviour.
Needle biopsy is generally avoided. It is seldom necessary, and puncturing a vascular lesion carries a bleeding risk that imaging can usually make unnecessary.
Diagnostic difficulty arises mainly in two settings: when the patient has a known cancer elsewhere and a metastasis must be excluded, and when the lesion is atypical in appearance. In both, MRI resolves the question in most cases.
When treatment is needed — and when it is not
The correct management of the great majority of haemangiomas is to leave them alone and to say so clearly. Once the diagnosis is secure on good-quality imaging, repeated scanning is not required; it generates anxiety without changing anything.
Intervention is considered only when:
- symptoms are significant and genuinely attributable to the lesion
- the lesion is enlarging substantially on serial imaging
- the diagnosis remains uncertain despite adequate imaging
- rare complications occur, such as a consumptive coagulopathy (Kasabach–Merritt phenomenon), which is seen chiefly in very large lesions
Size alone is not an indication. A ten-centimetre haemangioma causing no symptoms in a person who feels well does not require an operation simply because of its dimensions.
Treatment options
Enucleation
Where surgery is indicated, enucleation is often preferred. The haemangioma is dissected out along the natural plane between the lesion and the surrounding liver, which preserves functioning liver tissue and limits blood loss. Suitable for lesions that are accessible and not intimately related to major vascular structures.
Liver resection
Formal removal of the segment or lobe containing the lesion, used when enucleation is not feasible because of position or relationship to the major vessels.
Other approaches
Arterial embolisation is occasionally used to reduce size or to control bleeding, usually as an adjunct rather than a definitive treatment. Both laparoscopic and robotic approaches are appropriate in selected cases, the decision resting on the position of the lesion and the safety of vascular control.
Recovery
After laparoscopic enucleation most people are in hospital two to four days and back to ordinary activity within two to three weeks. Open resection involves a longer stay and a recovery measured in six to eight weeks. The liver regenerates well, and removal of a segment does not compromise long-term liver function in a person with an otherwise healthy liver.
Follow-up
None is needed after successful treatment of a benign lesion. For lesions being observed rather than treated, a single confirmatory scan after an interval is often sufficient, after which no further imaging is required unless symptoms change.
When to seek a surgical opinion
An opinion is worthwhile if a haemangioma is causing symptoms that interfere with daily life, if it has grown appreciably, or if the diagnosis is in doubt — particularly where there is a history of cancer elsewhere. For the far more common situation of a small incidental haemangioma on a routine scan, the most useful thing a surgeon can offer is a clear explanation that nothing needs to be done.
Common questions
Is a haemangioma cancer?
No. It is a benign tangle of blood vessels, present in a substantial proportion of the population, and it has no potential to become cancer. It is the commonest solid lesion found in the liver and in most people it is entirely incidental.
Do I need it removed?
Almost certainly not. The great majority need no treatment at all, whatever their size. Treatment is considered only where a lesion causes genuine and persistent symptoms, and even then the decision is weighed carefully, because a large operation for a benign lesion needs a good reason.
Could it burst?
Spontaneous rupture is extremely rare — rare enough that it is not a sound basis for operating on a symptomless lesion. This is worth saying plainly, because fear of rupture is the commonest reason people ask for a haemangioma to be removed.
Is it safe to exercise or play contact sport?
Yes. Normal activity, exercise and sport are not restricted. There is no evidence that ordinary activity causes these lesions to bleed.
Can I take the contraceptive pill or HRT?
Generally yes. Oestrogen may cause some enlargement, and this is sometimes discussed, but for most women with a small or moderate haemangioma it is not a reason to avoid hormonal treatment. It is worth a conversation if the lesion is large.
Why was an MRI needed if the ultrasound already showed it?
Because the diagnosis needs to be certain. MRI shows a very characteristic pattern of filling that confirms a haemangioma beyond doubt, which means no further scans and no further worry. Where the ultrasound appearance is typical and the liver is otherwise normal, further imaging is sometimes unnecessary.
Do I need repeat scans?
Usually not, once the diagnosis is confirmed. These lesions are stable in most people, and repeated scanning generates anxiety without benefit. New or changing symptoms are a reason to reassess; the passage of time alone is not.
Could it be the cause of my pain?
Sometimes, but less often than assumed. A large lesion stretching the liver capsule or pressing on the stomach can cause discomfort. A small one is unlikely to be responsible, and other causes should be looked for before attributing symptoms to it — otherwise an operation may leave the pain unchanged.
Related conditions
Other conditions of the liver covered on this site:
- Liver cysts (simple hepatic cysts)
- Hydatid (echinococcal) cyst of the liver
- Focal nodular hyperplasia and hepatocellular adenoma
- Liver abscess
- Hepatocellular carcinoma (HCC)
- Intrahepatic cholangiocarcinoma
- Liver metastases
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and imaging.