Focal Liver Lesions Haemangioma and Adenoma
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Direct answer
Focal liver lesions are discrete masses within the liver, and most benign ones are haemangiomas, focal nodular hyperplasia or hepatocellular adenomas. Haemangioma is the commonest benign solid liver tumour and is usually an incidental finding on ultrasound or cross-sectional imaging. Hepatocellular adenoma carries the highest risk of haemorrhage and malignant change among the three, so it is resected or followed closely.
What you must remember
- Haemangioma: the commonest benign solid liver tumour, usually asymptomatic, with peripheral nodular enhancement and centripetal fill-in on contrast imaging.
- Focal nodular hyperplasia: seen mainly in women of reproductive age, with a central stellate scar and uniform arterial enhancement.
- Hepatocellular adenoma: linked with oral contraceptives and anabolic steroids, and at risk of haemorrhage that rises with size.
- Adenoma size: lesions above about 5 cm carry the greatest risk of rupture and are usually resected.
- Technetium sulphur colloid: FNH often takes up the tracer because it contains Kupffer cells, while adenoma and haemangioma usually do not.
- Oral contraceptive history: stopping the drug is the first step in a young woman with an adenoma, and regression can follow.
- Malignant change: an adenoma can transform to hepatocellular carcinoma, so growth or new features prompt biopsy or resection.
- Initial imaging: ultrasound finds the lesion, and contrast-enhanced MRI, often with a hepatobiliary agent, characterises it.
Deciding which lesion you are looking at
Imaging separates the three lesions in most cases, and the table sets their typical features side by side. The clinical context of age, sex and oral contraceptive use is used alongside the scan, and the same lesion can look different on ultrasound and on MRI, so the most detailed study is the one that settles the question.
| Feature | Haemangioma | Focal nodular hyperplasia | Hepatocellular adenoma |
|---|---|---|---|
| Typical patient | Adults, often women | Women of reproductive age | Young women on oral contraceptives |
| Imaging clue | Peripheral nodular enhancement | Central stellate scar, arterial enhancement | Arterial enhancement, variable appearance |
| Key risk | Rarely symptomatic | Benign, rarely needs treatment | Haemorrhage and malignant change |
| Management | Observe | Observe unless symptomatic | Resect, especially above 5 cm |
The table shows that imaging features and clinical context work together, so a single scan finding is rarely enough. A haemangioma is recognised by its enhancement pattern, while an adenoma is recognised mainly by the risk factors around it.
Where the exam tries to catch you
The stem gives a liver lesion in a young woman or a patient with cirrhosis, and the trap is to name the malignant lesion first.
- Trap: biopsying a typical haemangioma Correct: the imaging pattern is diagnostic, and biopsy carries a risk of bleeding without benefit.
- Trap: resecting an FNH as if it were malignant Correct: FNH is benign and is observed unless it causes symptoms or diagnostic doubt.
- Trap: ignoring oral contraceptive use in a young woman with a liver mass Correct: the history suggests hepatocellular adenoma, and stopping the drug is the first step.
- Trap: calling any arterial-phase enhancing nodule HCC Correct: adenoma and FNH also enhance in the arterial phase, so cirrhosis and washout patterns matter.
Frequently asked questions
Which benign liver lesion carries the highest risk of rupture?
Hepatocellular adenoma carries the highest risk of rupture and haemorrhage among benign liver lesions, and the risk rises with size. Lesions above about 5 cm are usually resected, while smaller ones are observed.
What is the characteristic imaging feature of a haemangioma?
A haemangioma shows peripheral nodular enhancement on contrast imaging, followed by centripetal fill-in over time. This pattern is typical on contrast-enhanced CT or MRI, and biopsy is usually not needed to confirm it.
What is the typical imaging feature of focal nodular hyperplasia?
Focal nodular hyperplasia shows a central stellate scar with uniform arterial enhancement on contrast imaging. Technetium sulphur colloid scintigraphy often shows uptake, because the lesion contains Kupffer cells.
Why should oral contraceptives be stopped in hepatic adenoma?
Oestrogen in oral contraceptives promotes growth and raises the risk of haemorrhage in hepatic adenoma. Stopping the drug can cause the lesion to regress, which is why it is the first step in management.