Liver Lesion on Ultrasound: Hemangioma, FNH or Adenoma, and Which Need Surgery

What a “hyperechoic lesion” means

It describes how the lesion looks on ultrasound; it is not a diagnosis. “Hyperechoic” means that it reflects ultrasound more strongly than the surrounding liver and looks brighter on the screen. A typical hemangioma often looks like this, but other lesions, including some metastases, can be hyperechoic too.

A typical ultrasound appearance of a hemangioma is enough only under certain conditions: the liver is healthy, there is no history of cancer, and the lesion is small (under 2–3 cm, depending on the guideline), uniform and well defined. In other cases, and whenever the appearance is atypical, contrast-enhanced imaging is needed, most often MRI, or CT or contrast-enhanced ultrasound^[1][2].

Hemangioma: the most common finding

A hemangioma is the most common benign liver tumor, a cluster of blood vessels^[1]. It usually causes no symptoms and is found by chance.

If the diagnosis is confirmed and the liver is healthy, a hemangioma without symptoms needs neither treatment nor regular follow-up^[1][2]. A large size alone is not a reason for surgery, and discomfort often persists after surgery. Surgery is rare and reserved for complications: bleeding, a blood clotting disorder, or compression of nearby organs or vessels^[2]. If the diagnosis is uncertain, the case is discussed by a multidisciplinary team and clarified with further tests.

Can a hemangioma turn into cancer? A hemangioma is not considered a precancerous condition: it follows a benign course^[1][2]. The real concern is not the hemangioma itself but whether it really is one.

Focal nodular hyperplasia (FNH)

FNH is the second most common benign liver lesion: an area of overgrowth of normal liver cells around an abnormal blood vessel^[1]. It occurs mainly in women and usually causes no symptoms. Unlike a hemangioma, FNH usually does not look hyperechoic on ultrasound, so it is most often recognized on MRI^[1].

If FNH is confirmed by its typical appearance on contrast-enhanced MRI, treatment and regular follow-up are usually not needed, and hormonal contraceptives do not have to be stopped^[1][2]. The risk of FNH turning into cancer is practically nil^[2].

Liver adenoma: when a surgeon is needed

Hepatocellular adenoma is less common, occurs mainly in women and is linked to hormonal contraceptives and obesity^[1]. It is the lesion that needs attention, because large adenomas can bleed and some can turn into cancer^[1].

Management depends on the size, sex and subtype of the adenoma^[1][2]:

• women are advised to stop hormonal contraceptives and lose weight if needed, and to repeat contrast-enhanced MRI after 6 months;
• if the adenoma is still 5 cm or larger after that, or keeps growing, removal is usually recommended;
• an adenoma under 5 cm is not left without follow-up: it is monitored with MRI on a schedule set by the doctor, and separately during pregnancy;
• in men, removal is usually recommended regardless of size, because their risk of malignant change is higher;
• one subtype (with β-catenin activation) turns into cancer more often, so its removal is discussed regardless of size. This subtype is identified by tissue analysis, not by imaging.

Sudden severe pain in the upper right abdomen in someone with a known adenoma is a reason to seek urgent help: it may be bleeding. The decision on surgery is made by a multidisciplinary team. How liver surgery is done is described on the page on benign liver tumors. I perform liver surgery together with a team of surgical oncologists.

When a liver lesion is assessed more carefully

Everything above applies to a healthy liver. If a person has cirrhosis or chronic hepatitis B, a new liver lesion is first assessed as possible liver cancer, and even a hemangioma in these patients is followed up at first. If there is a history of cancer, a new lesion is first assessed as a possible metastasis^[1][2]. More on this in the article can liver metastases be operated on.

What to do if a liver lesion was found on ultrasound

1. Tell your doctor about your healthWhether you have had cancer, hepatitis or cirrhosis, and whether you take hormonal contraceptives. This decides how thorough the work-up should be.
2. Clarify the diagnosisIf the ultrasound appearance is atypical or there are risk factors, contrast-enhanced liver MRI is most often needed.
3. If a hemangioma or FNH is confirmedUsually nothing needs to be done, and regular ultrasounds are not needed either.
4. If it is an adenoma or the diagnosis is uncertainShow your scans to a surgeon: the online consultation is free. We discuss a plan after a full work-up.

Sources

1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016;65(2):386–398. PMID 27085809
2. Frenette C, Mendiratta-Lala M, Salgia R, et al. ACG Clinical Guideline: Focal Liver Lesions. Am J Gastroenterol. 2024;119(7):1235–1271. PMID 38958301

This article is for general information and does not replace a consultation: what the lesion is can only be determined from your scans.