A hemangioma was found on ultrasound. Does it need to be removed?

Almost never. A hemangioma does not turn into cancer and rarely grows. If the diagnosis is confirmed by MRI and there are no complaints, neither treatment nor regular monitoring is needed.

Why is a liver adenoma a concern?

Large adenomas can bleed, and certain subtypes can turn into cancer. So removal is recommended for adenomas of 5 cm or more, in men, and for high-risk subtypes; small adenomas are monitored.

Can I take hormonal contraceptives with a liver lesion?

With an adenoma — no, they are stopped because they promote growth. With a hemangioma or FNH there are usually no restrictions; decide together with your doctor.

Can I get pregnant with a liver lesion?

With a hemangioma or FNH — yes. With an adenoma, pregnancy is planned together with the doctor: adenomas under 5 cm need close monitoring during pregnancy, and those of 5 cm or more are treated before pregnancy.

My liver cyst is growing. What should I do?

Asymptomatic simple cysts, even large ones, are usually not dangerous. If a cyst causes complaints, its wall is removed laparoscopically. Cysts with septa or a thickened wall need an MRI to rule out a cystic tumor.

Liver hemangioma, adenoma and cysts: when surgery is needed

A lesion in the liver found on ultrasound is frightening, but most such findings are benign: hemangiomas, focal nodular hyperplasia, simple cysts. Most of them need neither treatment nor even regular monitoring. What matters is establishing correctly that the lesion really is benign and not a tumor that should be removed. A contrast-enhanced MRI is usually enough for this; surgery is needed only in a small share of patients — mainly for liver adenomas and certain cystic tumors.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Types of benign liver lesions

A hemangioma is the most common benign liver lesion, a cluster of blood vessels; it does not turn into cancer. Focal nodular hyperplasia is an area of overgrowth of normal liver cells around an abnormal vessel; it does not become malignant either. Simple cysts are fluid-filled cavities that are very common.

Hepatocellular adenoma is less common, occurs mainly in women and is linked to hormonal contraceptives and obesity. This is the one that needs attention: large adenomas can bleed, and certain subtypes can turn into cancer. Cystic tumors of the bile ducts and parasitic cysts are considered separately.

All of this applies to a healthy liver. If a patient has cirrhosis or chronic hepatitis B (or advanced fibrosis with hepatitis C), a new liver nodule is first assessed as possible hepatocellular carcinoma — see the liver cancer page. Likewise, in people with a history of cancer, a new liver lesion is first assessed as a possible metastasis, and only then as a benign finding.

Are there symptoms

Usually there are none — the lesion is found by chance on ultrasound or CT. Large hemangiomas and cysts may cause a feeling of pressure or heaviness under the right ribs and early satiety. Sudden severe pain under the right ribs in a patient with a known adenoma may indicate bleeding and requires immediate medical attention.

Examinations needed

Contrast-enhanced liver MRI, including with a liver-specific contrast agent — the main test: in most cases a typical appearance distinguishes hemangioma, FNH and adenoma without a biopsy.
Contrast-enhanced ultrasound — when indicated, to clarify the nature of small lesions.
Contrast-enhanced CT — if MRI is not possible.
Blood tests, hepatitis markers and, when indicated, alpha-fetoprotein, especially with chronic liver disease.
Biopsy — only when imaging does not give a confident answer, mainly to determine the adenoma subtype.

When surgery is needed

Hemangiomas and FNH are usually neither removed nor monitored: surgery is considered only for marked symptoms clearly caused by the lesion, or for rapid growth. Simple cysts are removed or unroofed only when they are large and cause complaints.

For an adenoma, hormonal contraceptives are stopped first and weight is reduced. If after 6 months the adenoma is still 5 cm or larger, removal is recommended; in men and with the β-catenin-mutated subtype, the adenoma is removed regardless of size. Cystic bile duct tumors are removed because of the risk of malignancy.

If surgery is not needed or not possible

For most hemangiomas, FNH and simple cysts, the best decision is to do nothing, provided they look typical and cause no complaints. Small adenomas in women are monitored with MRI — after a year, then yearly. Bleeding from an adenoma is stopped by embolization through the blood vessels, and surgery is discussed once the patient is stable.

How the operation is performed

The lesion is removed by liver resection — anatomical or non-anatomical, preserving as much healthy tissue as possible. Large symptomatic cysts are treated by fenestration — removing the part of the cyst wall that bulges on the liver surface to reduce the risk of fluid building up again.

When the lesion’s location and the extent of resection allow, the operation is performed laparoscopically, through several small incisions.

Most liver lesions are not a reason for surgery but a reason for one good MRI. It often removes the need for further follow-up.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After laparoscopic resection or cyst fenestration, patients are usually discharged within a few days. The liver gradually regains its volume, and usually no special diet is needed.

Follow-up

After a typical hemangioma, FNH or simple cyst, no follow-up is needed. Adenomas that were not removed are monitored with MRI on the doctor’s schedule; women with an adenoma plan pregnancy together with their doctor. After an adenoma is removed, follow-up is usually not needed unless the subtype carried a risk.