Answer for BIR CoW 19 Oct 2025
HEPATIC HEMANGIOMA
Findings
Evidence of well defined lobulated T1 Hypointense/T2 Hyperintense lesion showing internal T2 Hyperintense areas with subtle areas of diffusion restriction noted involving segment 2 and 3 of left lobe of liver. The lesion measures~ 6.8(anteroposterior) x7.4 (transverse) x 7.6(cranio caudal) cm On contrast administration, the lesion shows peripheral nodular discontinuous enhancement with progressive peripheral enhancement and centripetal filling in. On delayed imaging, the lesion shows contrast retainment. IMPRESSION: Well defined lobulated T1 Hypointense/T2 Hyperintense lesion showing internal T2 Hyperintensity areas with subtle areas of diffusion restriction and peripheral nodular discontinuous enhancement with progressive peripheral enhancement and centripetal filling in involving segment 2 and 3 of left lobe of liver - Features of Hepatic hemangioma.
Discussion
Hepatic hemangiomas, the most prevalent benign liver tumors, are characterized as slow-flow venous malformations with an incidence rate ranging between 0.4% and 20.0% Cavernous hemangiomas represent the most frequent pathological subtype. Notably, there is a predilection for women, with reported female-to-male ratios reaching as high as 5:1. The vast majority of hepatic hemangiomas are asymptomatic, maintain a stable size, do not affect liver function, and are incidentally detected during routine abdominal imaging Giant hemangiomas, particularly those that exhibit progressive growth, pose a higher risk of serious complications, including local compression effects due to the tumor’s volume, hemorrhage, Kasabach–Merritt Syndrome, or Budd–Chiari syndrome SUBTYPES OF HEMANGIOMA Typical hepatic hemangioma Atypical hepatic hemangioma 1. Giant hepatic hemangioma 2. Flash filling hepatic hemangioma: up to 16% of all hepatic hemangiomas 3. Calcified hepatic hemangioma 4. Hyalinised/sclerosed hepatic hemangioma ULTRASOUND: On greyscale ultrasound, hepatic hemangiomas typically present as hyperechoic, well-circumscribed lesions with a uniform appearance, or as hypoechoic masses featuring a hyperechoic rim. The hyperechoic pattern observed in ultrasound images of hepatic hemangiomas is linked to their histological makeup, where the echogenicity results from the numerous interfaces between the endothelium-lined sinuses constituting the lesions and the encapsulated blood. In contrast, larger lesions might show heterogeneity, characterized by mixed echogenicity (both hypo- and hyperechoic) arising from potential necrosis, hemorrhage, or fibrosis, leading to classification as atypical hepatic hemangiomas. Doppler ultrasound assessments of most hepatic hemangiomas reveal minimal to absent Doppler flow signals CT: The characteristic imaging feature of a hepatic hemangioma on computed tomography (CT) scans is a well-circumscribed, hypodense lesion. Upon administration of contrast medium, it demonstrates peripheral nodular enhancement, followed by gradual and homogeneous centripetal fill-in. Atypical hepatic hemangiomas can present with a variety of enhancement patterns on CT imaging. In the context of hepatic steatosis (fatty liver), particular caution is warranted, as a typical hemangioma might appear hyperdense in comparison to the surrounding hepatic parenchyma. MRI: In magnetic resonance imaging (MRI), hepatic hemangiomas are typically characterized by a well-defined, homogenous morphology, manifesting as hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences, a feature often described as the “cotton-wool” appearance. The differentiation between malignancies and hepatic hemangiomas, both of which exhibit hyperintensity on T2-weighted images, can be facilitated by modulating the echo time (TE). While malignant lesions tend to exhibit a reduction in signal intensity, hepatic hemangiomas display an enhanced signal intensity
REFERENCES:
1. Kacała A, Dorochowicz M, Matus I, Puła M, Korbecki A, Sobański M, Jacków-Nowicka J, Patrzałek D, Janczak D, Guziński M. Hepatic Hemangioma: Review of Imaging and Therapeutic Strategies. Medicina (Kaunas). 2024 Mar 8;60(3):449. doi: 10.3390/medicina60030449. PMID: 38541175; PMCID: PMC10972168. 2. Weerakkody Y, Rasuli B, Le L, et al. Hepatic hemangioma. Reference article, Radiopaedia.org (Accessed on 05 Oct 2025) https://doi.org/10.53347/rID-7565
Findings
Evidence of well defined lobulated T1 Hypointense/T2 Hyperintense lesion showing internal T2 Hyperintense areas with subtle areas of diffusion restriction noted involving segment 2 and 3 of left lobe of liver. The lesion measures~ 6.8(anteroposterior) x7.4 (transverse) x 7.6(cranio caudal) cm On contrast administration, the lesion shows peripheral nodular discontinuous enhancement with progressive peripheral enhancement and centripetal filling in. On delayed imaging, the lesion shows contrast retainment. IMPRESSION: Well defined lobulated T1 Hypointense/T2 Hyperintense lesion showing internal T2 Hyperintensity areas with subtle areas of diffusion restriction and peripheral nodular discontinuous enhancement with progressive peripheral enhancement and centripetal filling in involving segment 2 and 3 of left lobe of liver - Features of Hepatic hemangioma.
Discussion
Hepatic hemangiomas, the most prevalent benign liver tumors, are characterized as slow-flow venous malformations with an incidence rate ranging between 0.4% and 20.0% Cavernous hemangiomas represent the most frequent pathological subtype. Notably, there is a predilection for women, with reported female-to-male ratios reaching as high as 5:1. The vast majority of hepatic hemangiomas are asymptomatic, maintain a stable size, do not affect liver function, and are incidentally detected during routine abdominal imaging Giant hemangiomas, particularly those that exhibit progressive growth, pose a higher risk of serious complications, including local compression effects due to the tumor’s volume, hemorrhage, Kasabach–Merritt Syndrome, or Budd–Chiari syndrome SUBTYPES OF HEMANGIOMA Typical hepatic hemangioma Atypical hepatic hemangioma 1. Giant hepatic hemangioma 2. Flash filling hepatic hemangioma: up to 16% of all hepatic hemangiomas 3. Calcified hepatic hemangioma 4. Hyalinised/sclerosed hepatic hemangioma ULTRASOUND: On greyscale ultrasound, hepatic hemangiomas typically present as hyperechoic, well-circumscribed lesions with a uniform appearance, or as hypoechoic masses featuring a hyperechoic rim. The hyperechoic pattern observed in ultrasound images of hepatic hemangiomas is linked to their histological makeup, where the echogenicity results from the numerous interfaces between the endothelium-lined sinuses constituting the lesions and the encapsulated blood. In contrast, larger lesions might show heterogeneity, characterized by mixed echogenicity (both hypo- and hyperechoic) arising from potential necrosis, hemorrhage, or fibrosis, leading to classification as atypical hepatic hemangiomas. Doppler ultrasound assessments of most hepatic hemangiomas reveal minimal to absent Doppler flow signals CT: The characteristic imaging feature of a hepatic hemangioma on computed tomography (CT) scans is a well-circumscribed, hypodense lesion. Upon administration of contrast medium, it demonstrates peripheral nodular enhancement, followed by gradual and homogeneous centripetal fill-in. Atypical hepatic hemangiomas can present with a variety of enhancement patterns on CT imaging. In the context of hepatic steatosis (fatty liver), particular caution is warranted, as a typical hemangioma might appear hyperdense in comparison to the surrounding hepatic parenchyma. MRI: In magnetic resonance imaging (MRI), hepatic hemangiomas are typically characterized by a well-defined, homogenous morphology, manifesting as hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences, a feature often described as the “cotton-wool” appearance. The differentiation between malignancies and hepatic hemangiomas, both of which exhibit hyperintensity on T2-weighted images, can be facilitated by modulating the echo time (TE). While malignant lesions tend to exhibit a reduction in signal intensity, hepatic hemangiomas display an enhanced signal intensity
REFERENCES:
1. Kacała A, Dorochowicz M, Matus I, Puła M, Korbecki A, Sobański M, Jacków-Nowicka J, Patrzałek D, Janczak D, Guziński M. Hepatic Hemangioma: Review of Imaging and Therapeutic Strategies. Medicina (Kaunas). 2024 Mar 8;60(3):449. doi: 10.3390/medicina60030449. PMID: 38541175; PMCID: PMC10972168. 2. Weerakkody Y, Rasuli B, Le L, et al. Hepatic hemangioma. Reference article, Radiopaedia.org (Accessed on 05 Oct 2025) https://doi.org/10.53347/rID-7565
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!