Liver hemangiomas are generally benign tumors that do not require treatment. However, intervention is necessary in certain cases. Today, surgical and interventional methods are at the forefront. This review addresses the pathological features of liver hemangiomas, discusses their blood supply and treatment criteria, and evaluates the current status and advances in interventional therapies. In this context, the development of minimally invasive techniques is of great importance.
| What You Need to Know About Non‑Surgical Treatment of Liver Hemangioma | |
| Definition | Non‑surgical treatment methods for liver hemangiomas, benign vascular tumors of the liver. |
| Indications | Symptomatic hemangiomas (pain, mass effect), rapidly growing lesions, hemangiomas at risk of complications. |
| Contraindications | Asymptomatic and small hemangiomas, patients with severe liver disease. |
| Treatment Methods | Microwave ablation (MWA), transarterial embolization (TAE), stereotactic radiosurgery, proton therapy. |
| Pre‑procedure Preparation | Blood tests, liver function tests, imaging studies (MRI, CT), medication review. |
| Procedure Duration | Varies by method, between 30 minutes and 3 hours. |
| Anesthesia Type | Local anesthesia, sedation, or general anesthesia (depending on method). |
| Complications | Infection, bleeding, liver injury, radiation side effects, post‑embolization pain. |
| Recovery Time | Usually a few days to a few weeks. |
| Success Rate | High, but may vary depending on hemangioma size and location. |
| Alternative Treatments | Observation with regular follow‑up, surgical resection, pharmacological therapy (rarely). |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
Epidemiology and Pathological Features of Liver Hemangiomas
Liver hemangiomas are the most common benign tumors of the liver. Discovered incidentally, they are usually asymptomatic and do not require intervention. Studies have shown a wide prevalence of these tumors:
- Prevalence ranges from 0.4% to 7.3%.
- Morbid rate is approximately 2.5%.
Typically detected during routine exams or when causing nonspecific symptoms like abdominal pain, hemangiomas rarely require treatment. They can occur at any age but are most common between 30 and 50 years old, with women at higher risk (female-to-male ratio up to 6:1).
Although the exact cause is unknown, embryonic malformation of vascular channels is implicated. Vascular malformations form the basis of these lesions:
- Abnormal capillary networks in the embryo lead to venous malformations.
- These consist of thin-walled lumina lined by a single layer of endothelial cells.
Sex hormones, particularly estrogen and progesterone, may promote growth. Pregnancy and oral contraceptives can stimulate tumor enlargement by increasing hormone levels. Histologically, hemangiomas contain abnormal vascular sinusoids without hepatocytes, Kupffer cells, or bile ducts. Secondary changes such as necrosis, fibrosis, and calcification may be seen, supporting their classification as malformations rather than true neoplasms.
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Clinical Presentation of Liver Hemangiomas
Most liver hemangiomas are asymptomatic. However, large or multiple hemangiomas may cause:
- Abdominal pain,
- Nausea,
- Vomiting,
- Loss of appetite.
These symptoms indicate the need for treatment. Rare complications include rupture, leading to acute pain and hemorrhagic shock, with high mortality. Kasabach-Merritt syndrome is another serious complication characterized by:
- Severe thrombocytopenia,
- Coagulopathy,
- Hemorrhagic purpura.
Diagnosis relies on ultrasound, CT, and MRI, but coexisting conditions like hepatitis B or cirrhosis can complicate interpretation. Atypical hemangiomas may mimic malignancy, requiring careful differentiation.
Indications for Treating Liver Hemangiomas
Liver hemangiomas usually do not require treatment. Indications for intervention include:
- Symptomatic lesions causing pain or mass effect,
- Risk of rupture or hemorrhage,
- Kasabach-Merritt syndrome,
- Progressive growth (>2 cm annual increase),
- Diagnostic uncertainty,
- Severe anxiety affecting quality of life (rarely as surgical option).
Prophylactic treatment of asymptomatic hemangiomas is generally not recommended except in exceptional cases, such as during pregnancy with large lesions or in physically active patients with exophytic hemangiomas. Treatment decisions should balance risks and benefits on an individual basis.
Importance of Transarterial Embolization
Transarterial embolization (TAE) is preferred for its minimal invasiveness. It targets the tumor’s arterial supply using chemotherapeutic agents and lipiodol, selectively occluding feeding vessels. The hemangioma shrinks and regresses over time. Super-selective angiographic techniques ensure high precision.
Ablation Techniques
- Radiofrequency Ablation (RFA): Uses high-frequency currents via electrodes to thermally destroy tumor tissue.
- Microwave Ablation (MWA): Employs electromagnetic waves to rapidly heat and necrotize tumor cells, especially useful in high-bleeding-risk areas.
These ablation methods are used when surgery is contraindicated or patients are not surgical candidates. They can be tailored to lesion size and location.
Percutaneous Methods
- Percutaneous Sclerotherapy: Injection of sclerosing agents directly into the tumor to induce fibrosis.
- Percutaneous Argon-Helium Cryotherapy: Uses freezing to form ice crystals in tumor cells, disrupting their structure.
Percutaneous methods are effective for small, superficial hemangiomas, offering faster recovery and shorter hospital stays.
Evaluating Interventional Treatment Outcomes
Response to interventional therapies varies by hemangioma vascularity. Highly vascular lesions respond well to embolization and ablation with lower complication rates, while poorly vascularized lesions may show less effect. Detailed diagnostic evaluation before treatment is crucial. Tumor type and vascular characteristics guide therapy choice.
Treatment Options by Vascular Supply
Liver hemangiomas are benign lesions with limited need for treatment, but the correct interventional approach is critical when indicated. Options vary by blood supply:
- Hepatic artery embolization: For lesions fed by the hepatic artery.
- Portal vein–fed hemangiomas: Conventional embolization is unsuitable.
- Combined therapies: May include RFA for enhanced efficacy.
Accurate pre‑treatment imaging to determine vascular supply is essential for targeted therapy and minimizing complications.
Additional Resources and Documents
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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