With the improvement of medical imaging technology and people’s health awareness, asymptomatic hemangiomas of the liver are often found during medical examinations. For patients, the possibility of hepatocellular carcinoma is often the first consideration for an occupying lesion in the liver. Even if a diagnosis of benign hemangioma is made, it can bring some psychological pressure to patients, who are also eager to understand the clinicopathological features and principles of diagnosis and treatment of hepatic hemangioma. This article answers common clinical questions about the diagnosis and treatment of hepatic hemangioma. 1.Why do you have hepatic hemangioma? Hepatic hemangioma is the most common benign liver parenchymal tumor, with an incidence between 3% and 20%, and is more common in middle-aged women, with a male to female ratio of about 5-6:1. Hepatic hemangioma can occur at any age, but is relatively uncommon in children. The exact cause of hepatic hemangiomas is unclear. Histogenetically, most people believe that they originate from embryonic vascular misshapen buds in the liver and form as a result of tumor-like proliferation for some reason. Some studies have also found that some hemangiomas have estrogen receptors, so they may increase at an accelerated rate during female puberty, pregnancy, and contraceptive use, so changes in hormone levels may also be a cause of hemangiomas. 2. How to distinguish the “size” of hepatic hemangioma? The size of hepatic hemangioma varies greatly, ranging from less than 1cm to 20cm. With the development of medical imaging technology, small hemangiomas of about 1-2 cm are now often found in healthy people during medical examinations. There is no absolute standard to distinguish the size of hepatic hemangioma, and with reference to the standard of liver cancer, those below 5cm can be considered as “small hemangioma”, those between 5-10cm are “large hemangioma”, and those above 10cm can be called “giant hemangioma”. Giant hemangioma”. Some hemangiomas will slowly increase in size, but most of them will grow slowly and remain stationary for many years without any treatment. 3.What are the clinical manifestations of hepatic hemangioma? Can hepatic hemangioma rupture? Small hepatic hemangiomas have no obvious clinical symptoms, while large hemangiomas may have non-specific and vague conscious symptoms such as abdominal distension and upper abdominal discomfort. If a patient has significant epigastric pain, acid reflux, fullness and other discomfort, a gastroscopy or other examination should be performed to rule out gastric or intestinal pathology, as these epigastric symptoms are far more likely to be caused by gastrointestinal disease than by hemangioma. Many patients actually go to the hospital for examination when they suffer from chronic gastritis, cholecystitis, colitis, etc., and occasionally discover hepatic hemangiomas. Even large hemangiomas rarely rupture spontaneously, so hepatic hemangiomas generally do not have to worry about the possibility of rupture and hemorrhage. However, giant hemangiomas may rupture due to abdominal trauma. The pressure inside the giant hemangioma is so high that even if a fine needle is used for puncture or biopsy, there are reports of life-threatening hemorrhage. Therefore, puncture biopsy is generally not recommended. 4.How to diagnose hepatic hemangioma? Current imaging techniques can confirm the diagnosis of most hepatic hemangiomas. Most hemangiomas have typical imaging features in liver magnetic resonance imaging (MRI), liver CT, and liver ultrasound. Typical small hemangiomas detected by liver ultrasound on physical examination generally require only regular follow-up with ultrasound in experienced liver consultation centers and do not require additional imaging. A few atypical hepatic hemangiomas sometimes require both liver MRI and liver CT to assist in the diagnosis. Very few hepatic hemangiomas are difficult to distinguish from focal nodular hyperplasia of liver or even primary hepatocellular carcinoma on imaging, and pathological examination after surgical resection is required to confirm the diagnosis. 5.Can hepatic hemangioma become cancerous? The standard and official name of hepatic hemangioma is “hepatic cavernous hemangioma”. The tumor tissue consists of blood-filled cavities of varying sizes covered by flat endothelial cells, with narrow, fibrous intervals. To the naked eye, they appear to be “sponges” filled with blood. In true hepatic cavernous hemangioma, there is no fear of cancer. Some patients say they were previously diagnosed with hepatic hemangioma, but a few years later they were found to have “hepatocellular carcinoma”, so they consider whether the original hemangioma has become cancerous. In this case, there are two possibilities: first, the original diagnosis of “hepatic hemangioma” is a misdiagnosis, and the mass itself is liver cancer; second, the “hepatic hemangioma” is not a real spongy hemangioma, but a hepatic endothelium-related hepatic hemangioma such as Secondly, “hepatic hemangioma” is not a real cavernous hemangioma, but a disease related to hepatic endothelium, such as “hepatic epithelioid hemangioendothelioma” and “hepatic hemangioendothelial cell sarcoma”. 6.When does hepatic hemangioma need treatment and how to treat it? The vast majority of hepatic cavernous hemangiomas do not require any treatment, nor do they require any medication, because no medication can shrink or disappear the hemangioma. For clinically confirmed typical hemangiomas, outpatient ultrasound review is usually sufficient every 6 months. For atypical hemangiomas, the review should be done in about 3 months. Treatment is only needed if the patient has a huge hemangioma; or has obvious uncomfortable symptoms; or if it is difficult to identify with liver cancer. Treatment methods include surgical resection, interventional embolization, and even liver transplantation. Surgical resection is definitive and effective, and is the preferred method. There are also attempts to use non-surgical interventional embolization to treat hepatic hemangioma, but it has been proven that the hemangioma does not shrink after treatment, so it is basically no longer used. Once a hepatic hemangioma is clinically diagnosed and requires surgical resection, the timing of surgery should not be delayed because some giant hemangiomas that encircle the major blood vessels in the liver cannot be surgically resected in severe cases and liver transplantation can only be considered. We once treated a case of a huge hemangioma, about 50 cm in size, which occupied most of the abdominal cavity and finally had to undergo liver transplantation.