In this presentation, an evidence based approach to diagnosis and management of liver hemangioma is explained. The presentation is based on UPTODATE.

1. LIVER HEMANGIOMA
NUCLEAR MEDICINE
APPLICATION
Ramin Sadeghi, MD

2. INTRODUCTION
The most common benign mesenchymal hepatic tumors
Are often solitary, but multiple lesions may be present in both the
right and left lobe of the liver in up to 40 percent of patients

3. CLINICAL SETTING
Most patients with hepatic hemangiomas are asymptomatic and have
an excellent prognosis.
Symptoms are more likely with large lesions.
The diagnosis is often considered in patients found to have a focal
liver lesion in whom hemangiomas need to be distinguished from
other tumors.

6. PREVALENCE AND PATHOGENESIS
Estimates of the prevalence of hepatic hemangiomas have ranged
from 0.4 to 20 percent
60 to 80 percent of cases are diagnosed in patients who are between
the ages of 30 and 50 years.
In adults, hemangiomas occur more frequently in women with a ratio
of 3:1
Lesions responsible for symptoms are more likely in young women

7. PATHOGENESIS
The etiology of hepatic hemangiomas is incompletely understood.
They are considered to be vascular malformations or hamartomas of
congenital origin that enlarge by ectasia rather than by hyperplasia or
hypertrophy.
Hormonal influence over tumor growth is suggested by enlargement
during pregnancy and estrogen and progesterone therapy and
regression after withdrawal of therapy

8. CLINICAL PRESENTATION
Hemangiomas are typically discovered incidentally at laparotomy,
autopsy, or during an imaging test performed for unrelated
conditions.
Lesions >4 cm are more likely to cause symptoms
The most common symptoms are abdominal pain and right upper
quadrant discomfort or fullness
Giant hemangiomas in children have been associated with high-
output cardiac failure and hypothyroidism.
The Kasabach-Merritt syndrome is a consumptive coagulopathy in
children that has been described in association with giant
hemangiomas

9. PRESENTATION
Physical findings are usually unremarkable, but occasionally reveal a
palpable liver or mass. A bruit is seldom heard over the hemangioma.
Liver function tests are usually normal, unless there has been a
complication such as thrombosis, bleeding, or compression of the
biliary tree. Alpha-fetoprotein is normal.

10. NATURAL HISTORY
Development of spontaneous rupture is rare.
 It usually occurs in large hemangiomas that are peripherally located; however,
follow-up of giant hemangiomas (tumors >5 cm in size) has shown that even these
rarely enlarge or rupture.
Traumatic rupture of cavernous hemangioma following blunt trauma
to the abdomen is also rare, but highlights that traumatic rupture of
the liver may be associated with underlying liver pathology
Iatrogenic rupture or intratumoral bleeding has been described
following liver biopsy or fine-needle aspiration

11. DIAGNOSIS
Usually is reached by imaging

12. US
Ultrasound typically reveals a well-demarcated, homogeneous,
hyperechoic mass.
Color Doppler is not useful
The diagnosis can be strongly suggested by ultrasound in
approximately 80 percent of patients with lesions <6 cm

14. FOLLOW UP FOLLOWING US
All patients with a history of liver disease or known or suspected
extrahepatic malignancy should undergo a confirmatory examination
such as a contrast-enhanced CT or MRI.
In patients with no evidence of liver disease or extrahepatic
malignancy and "typical" appearances of hemangioma on ultrasound,
an acceptable alternative is to repeat the ultrasound at three to six
months to document stability.

15. CT SCANNING
A non-contrast-enhanced CT scan of a hemangioma usually
demonstrates a well-demarcated hypodense mass
The administration of contrast results in a peripheral nodular
enhancement in the early phase, followed by a centripetal pattern or
"filling in" during the late phase.
The lesions classically opacify after a delay of three or more minutes
and remain isodense or hyperdense on delayed scans

17. MRI
MRI has emerged as a highly accurate, noninvasive technique for
diagnosing hemangiomas with a sensitivity of approximately 90
percent and a specificity of 91 to 99 percent
The typical MRI appearance is a smooth, well-demarcated,
homogeneous mass that has low signal intensity on T1-weighted
images and is hyperintense on T2-weighted images

19. TECHNETIUM-99M PERTECHNETATE-
LABELED RED BLOOD CELL POOL
STUDY
Sensitivity for lesions >2 cm in size varies from 69 to 92 percent.
Specificity approximates 100 percent.
False negatives can occur due to the presence of fibrosis or
thrombosis.
False-positive tests are rare, but include lesions such as
hypervascular malignancies and angiosarcomas.
Single-photon emission CT (SPECT) using 99mTc-RBC increases the
spatial resolution of planar scintigraphy, providing sensitivity and
accuracy close to that of MRI for lesions >1 cm

20. TECHNETIUM-99M PERTECHNETATE-
LABELED RED BLOOD CELL POOL
STUDY
The best use of 99mTc-RBC SPECT is for lesions >2 cm to confirm a
suspected hemangioma seen as a hyperechoic lesion in ultrasound
and to clarify the diagnosis when CT findings are unclear.

22. IMAGING IN PATIENTS WITH
CIRRHOSIS
The hyperechoic metastases and HCC may have similar sonographic
characteristics and are more likely in chirrhotic patients.
As a result, multiple imaging modalities and serum AFP determination
may be required to differentiate a benign hemangioma from a
malignant lesion in these settings

23. MANAGEMENT
Asymptomatic patients, particularly those with lesions <1.5 cm, can
be reassured and observed.
 We do not recommend follow-up imaging in patients with hemangiomas ≤5 cm in
size, provided there is certainty of the diagnosis based on radiologic and on clinical
details.
Radiologic follow-up of patients with lesions >5 cm, particularly
those in a sub capsular location.
 Our approach is to repeat imaging in 6 to 12 months for such lesions, using the
imaging modality that best showed the hemangioma previously (eg, computed
tomography scan or magnetic resonance imaging).
 If there is no change in the size of the lesion, we do not perform additional
imaging.

24. SURGERY
Patients who have pain or symptoms suggestive of extrinsic
compression of adjacent structures should be considered for surgical
resection.
However, it is important that all other causes of pain have been
evaluated and excluded prior to surgery.

25. RECOMMENDATIONS REGARDING
OCPS AND PREGNANCY
There is insufficient evidence to conclusively link estrogens to the
development or growth of hemangiomas
hemangiomas can be managed conservatively during pregnancy and
vaginal delivery is acceptable as complications from lesions under 10
cm are rare.