How are large hepatic hemangiomas treated?

Updated: Jun 17, 2019
  • Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD  more...
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Answer

Hepatic hemangiomas have been treated with a wide array of therapies. Traditionally, surgical resection and surgical enucleation are the treatments of choice. [50] 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. [51]

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. [52]

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. [53, 54] A 2011 review described only 46 published cases of spontaneous rupture over the last century. [55] The risk for traumatic rupture is also low, [56] with only 51 cases described over the last century. [55] 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. [57] 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. [57]


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