Hepatic Hemangioma: Pitfalls & Mimics, Part II

In this video lecture, we focus on variants and malignant mimics of hemangioma and discuss how to characterize these masses on ultrasound, CT and MRI.

Key points include:

• The ultrasound “target” sign is typical for hepatic metastases and appears as a lesion with a hypoechoic periphery and echogenic center.
• Hemangiomas in a fatty liver may appear hypoechoic and mimic a more serious tumor but can be definitively characterized with MRI.
• Sclerosed or hyalinized hemangiomas contain fibrous tissue and therefore have variable enhancement and diminished T2 hyperintensity.
• Hemangiomas can be associated with arterioportal shunts and may be surrounded by areas of transient hepatic enhancement difference (THED) and peritumoral sparing of fatty infiltration.
• Differential diagnostic considerations for hepatic hemangioma include hypervascular liver metastases (including melanoma and pancreatic neuroendocrine tumor), intrahepatic mass-forming cholangiocarcinoma, and hepatic angiosarcoma.
• Irregular rim enhancement is not the same as interrupted peripheral nodular enhancement and should raise suspicion for malignancy in a solid mass.
• Metastatic tumors may progressively fill in and mimic hemangioma, but often show less pronounced “evil grey” T2 hyperintensity isointense to spleen, restrict diffusion, and have atypical enhancement.
• Mass-forming, peripheral intrahepatic cholangiocarcinoma can mimic hemangioma as both tumors demonstrate gradual progressive enhancement, but cholangiocarcinoma enhancement will be heterogeneous and not usually isointense to blood pool.
• Intrahepatic cholangiocarcinoma is heterogeneously T2 hyperintense often with central hypointensity and overlying capsular retraction but may not have associated biliary ductal dilatation.

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