Hepatic hemangiomas: spectrum of US appearances on gray-scale, power Doppler, and contrast-enhanced US

Abstract

Because US plays a key role in the initial evaluation of hepatic hemangiomas, knowledge of the entire spectrum of US appearances of these tumors is important. Most hemangiomas have a distinctive US appearance, and even with those with atypical appearances on conventional gray-scale US, specific diagnoses can be made using pulse-inversion harmonic US with contrast agents. In this essay, we review the spectrum of US appearances of hepatic hemangiomas on conventional gray-scale, power Doppler, and pulse-inversion harmonic US with contrast agents.

Fig. 1

A 36-year-old man with a hepatic hemangioma showing typical US features including uniform hyperechogenicity, well-defined margins and posterior sonic enhancement (arrows).

Fig. 2

A 46-year-old man with a hepatic hemangioma in the right lobe. Transverse US shows a well-defined large mass of heterogeneous echogenecity with hypoechoic foci. A thin echogenic rim seen around the tumor (arrowheads) suggests hepatic hemangioma.

Fig. 3

A 42-year-old man with a hepatic hemangioma in the right lobe. Oblique sagittal US shows a well-defined hyperechoic lesion with a hypoechoic central portion.

Fig. 4

A 60-year-old woman with a hepatic hemangioma in the left lobe. Transverse US demonstrates contour bulging; the mass is subtly hypoechoic (arrows) relative to normal liver parenchyma and lacks an echogenic border.

Fig. 5

A 66-year-old man with a diffuse hemangioma in the right lobe. A. Transverse US shows a large heterogeneous mass (arrows). The major portion of the lesion shows hyperechogenicity, especially in the periphery, and within it scattered hypoechoic foci are noted (arrowheads). Although the lesion abuts the right portal vein, there is no evidence of invasion of this vessel. B. Celiac angiogram shows diffuse enhancement with scattered foci of contrast material puddling.

Fig. 6

A 49-year-old man with a hepatic hemangioma in the left lobe. Sagittal US shows a small isoechoic mass detectable only by its echogenic border (arrows) and subtle contour bulging.

Fig. 7

A 34-year-old woman with an exophytic hepatic hemangioma in the caudate lobe. Transverse US shows a large square-shaped mass surrounded by the left lobe of the liver (lv), aorta (a), inferior vena cava (v), and right portal vein (p). The lesion shows heterogeneous echogenicity and has a multiple internal hypoechoic portion.

Fig. 8

A 51-year-old man with a hepatic hemangioma in the right lobe. Transverse US shows increased liver echogenicity, suggestive of diffuse fatty infiltration, and an atypical echo-poor hemangioma. There is no discernable echogenic border.

Fig. 9

A 51-year-old man with a hepatic hemangioma in the left lobe. A. Transverse US shows a slightly hyperchoic mass with a well-defined margin (arrow). B. Enhanced CT of the liver during the portal venous phase shows bright dot-like enhancement (arrow) in the periphery of the lesion.

Fig. 10

A 55-year-old woman with a hepatic hemangioma in the right lobe. A. Sagittal US shows a well-defined hypoechoic mass (arrow). B. Enhanced CT scan of the liver obtained during the hepatic arterial phase shows diffuse rapid enhancement of the tumor (arrow) with peritumoral wedge-shaped parenchymal enhancement (arrowheads), suggesting associated arterioportal shunt.

Fig. 11

A 54-year-old woman with a hepatic hemangioma in the right lobe. A. Unenhanced power Doppler US shows a hypoechoic mass with an echogenic border (arrows). The lesion shows minimal power Doppler signal in its periphery (open arrow) and optimized parameters (a pulse repetition frequency of 1,000 Hz and a medium wall filter). B, C. Dynamic contrast-enhanced power Doppler US scans obtained 30 seconds (B) and 90 seconds (C) after the initiation of contrast injection show dot-like enhancement (small arrows) at the periphery of the mass. However, unlike centripetal fill-in enhancement, characteristic of hemangioma, the enhanced area revealed by power Doppler US is smaller 90 seconds after enhancement than at 30. Even with the use of microbubble agents, power Doppler US is, therefore, due to its insensitivity to slow flow, able to characterize hepatic hemangiomas to only a limited extent.

Fig. 12

A 52-year-old man with two hepatic hemangiomas in the left lobe. A. Pulse-inversion harmonic US scans obtained prior to contrast injection show a hypoechogenic hepatic hemangioma (arrow) in the medial segment of the left lobe. Serial contrast-enhanced US scans obtained 14, 62, and 139 seconds after injection show peripheral globular enhancement with progressive centripetal fill-in (arrowheads). B. Serial dynamic contrast-enhanced T1-weighted MR images obtained immediately, 60, and 180 seconds after the administration of gadolinium-DTPA depict early peripheral nodular and globular enhancement with progressive centripetal fill-in (arrowheads), characteristic of hepatic hemangiomas. The enhanced areas seen on MR images are nearly identical to those seen on serial contrast-enhanced pulse-inversion harmonic US scans.