Diagnosis and surgical decision-making in hepatic hemangioma: From venous malformation overlap to artificial intelligence-assisted multimodality imaging

Abstract

Hepatic hemangioma (HH) represents the most frequent non-cystic benign liver lesion. However, when its diagnosis is ambiguous, it can severely impact clinical decisions, from avoiding unnecessary biopsies to planning complex surgeries. In this narrative review, we explore how adult HH conceptually overlaps with low-flow venous malformations and assess the evolving roles of imaging, artificial intelligence (AI), and therapeutic strategies. To gather evidence, we searched the PubMed and Web of Science databases through March 2026 for English studies covering hepatic lesions, various imaging techniques [ultrasound, contrast-enhanced ultrasound (CEUS), computed tomography, magnetic resonance imaging (MRI)], radiomics, and local treatments. Most typical hemangiomas are easily identified noninvasively. The real diagnostic challenge lies in giant, sclerosed, or flash-filling lesions that resemble cancer, a problem magnified in patients suffering from cirrhosis or extrahepatic malignancies. Currently, MRI is the preferred modality to resolve these uncertainties, supplemented by the dynamic real-time insights of CEUS. Although AI and radiomics present new ways to analyze tricky lesions, current research is held back by retrospective data, inconsistent labeling, and a lack of strong external validation. Ultimately, clinical outcomes could be improved by prioritizing an accurate initial diagnosis. By combining advanced imaging and safely validated AI with the principles of vascular anomalies, clinicians can better manage surveillance, avoid biopsies, and confidently choose between conservative local therapies and major liver resections.

Key Words: Hepatic hemangioma; Hepatic venous malformation; Differential diagnosis; Magnetic resonance imaging; Radiomics; Surgical management

Core Tip: This review reframes the evaluation of hepatic hemangioma (HH) as a diagnosis-driven clinical problem rather than redefining the lesion itself. A key innovation lies in connecting modern concepts of vascular anomalies, particularly the possible biological overlap between selected adult HHs and low-flow venous malformations, with multimodality imaging and treatment selection. This article highlights the importance of magnetic resonance imaging and contrast-enhanced ultrasound in addressing atypical lesions, advises against premature biopsy, and presents artificial intelligence as a decision support tool for indeterminate lesions that may resemble malignancy.

INTRODUCTION

Hepatic hemangioma (HH) is the most prevalent benign non-cystic liver lesion, often discovered incidentally during abdominal imaging. In most adults, a confident diagnosis can be achieved without biopsy when the lesion exhibits classic enhancement behavior and marked T2 hyperintensity. However, diagnostic uncertainty remains in several clinically significant scenarios, including patients with known extrahepatic malignancies, chronic liver disease, atypical enhancement patterns, multiple lesions, and sclerosed or giant lesions[1-5]. For surgeons, the primary challenge is not merely identifying the common lesion, but also avoiding unnecessary hepatectomy while ensuring that malignancy is not overlooked.

A secondary challenge is conceptual rather than solely radiographic. Although the term “cavernous hemangioma” has traditionally dominated hepatobiliary surgery and radiology, contemporary research on vascular anomalies increasingly suggests that many adult lesions resemble low-flow venous malformations (VMs) more than proliferative vascular tumors. Zhou et al[6] evaluated a multidisciplinary clinical grading system for HH based on symptoms, lesion size, anatomical location, and tumor growth. Zhang et al[7] subsequently discussed the potential implications of this grading system for reducing overtreatment and refining surgical indications. Broad narrative reviews often fail to explore these diagnostic tensions in sufficient depth. Consequently, this diagnosis-focused narrative review addresses four critical questions: (1) Should adult HH and hepatic VM be conceptually distinguished? (2) How should modern ultrasound, contrast-enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI) be integrated to evaluate atypical lesions? (3) What contributions can artificial intelligence (AI) and radiomics make to lesion characterization? and (4) How do changes in diagnostic labeling influence decisions regarding observation, percutaneous therapy, and surgery?

LITERATURE SEARCH STRATEGY

A focused, evidence-informed search was conducted in PubMed and Web of Science for English-language studies published through March 2026. Search terms included “hepatic hemangioma”, “liver hemangioma”, “hepatic venous malformation”, “focal liver lesion”, “contrast-enhanced ultrasound”, “MRI”, “CT”, “radiomics”, “artificial intelligence”, “embolization”, and “sclerotherapy”. Reference lists of key guidelines and reviews were manually screened. This article aims to serve as a practical narrative synthesis rather than a formal systematic review; thus, studies were prioritized based on their relevance to diagnostic ambiguity, vascular anomaly classification, and downstream management implications. Clinically influential studies were defined as guidelines or consensus documents, original clinical or molecular studies, systematic reviews, meta-analyses, and widely cited narrative reviews that directly informed diagnostic uncertainty, lesion classification, imaging-based differentiation, or treatment decision-making. Non-English articles, studies without accessible full text, isolated case reports without broader diagnostic or management relevance, studies focused exclusively on non-hepatic vascular lesions, and articles lacking sufficient methodological or clinical detail were excluded. As this was not designed as a formal systematic review, duplicate independent screening and quantitative risk-of-bias assessment were not performed.

WHY NOMENCLATURE MATTERS: HH OR HEPATIC VM?

Classic adult HH consists of dilated blood-filled vascular spaces lined by flattened endothelium, historically supporting the term “cavernous hemangioma”. However, contemporary terminology delineates hemangioma as a vascular tumor characterized by proliferative behavior, while VM refers to a structural, low-flow vascular anomaly. Literature regarding extrahepatic vascular anomalies has traditionally maintained a separation between these categories, and recent liver-specific studies suggest that this distinction holds clinical significance within the liver as well. For hepatobiliary surgeons, this differentiation carries both semantic and therapeutic implications.

Ugwu et al[8] identified a recurrent somatic GJA4 c.121G>T mutation in hepatic lesions historically diagnosed as HH, linking these lesions genetically to cutaneous VMs. More recently, Amarneh et al[9] re-examined pathology-proven adult lesions and proposed that many lesions previously labeled as HHs may biologically overlap with hepatic VMs; their cohort revealed that most cases had originally been classified as hemangiomas before undergoing systematic re-evaluation. While these findings do not necessitate the immediate abandonment of the term HH in routine radiologic practice, they advocate for a more nuanced approach to terminology concerning lesion biology, interventional therapy, and research classification.

This distinction bears particular importance for three reasons. First, it prevents the conflation of adult incidental HH with infantile HH, a biologically distinct proliferative vascular tumor of infancy that can be multifocal or diffuse and may cause high-output heart failure or other systemic complications[10,11]. Second, the VM perspective provides a biologically coherent rationale for percutaneous sclerotherapy in selected giant symptomatic lesions[12]. Third, any AI or radiomics dataset that combines adult HH, hepatic VM, infantile hemangioma, and sclerosed end-stage lesions under a single label risks introducing classification noise into model training (Table 1). Figure 1 illustrates this paradigm shift from a historical umbrella diagnosis to biologically informed entities.

Figure 1 Emerging conceptual framework for adult hepatic vascular anomalies. The figure contrasts the traditional umbrella term “cavernous hemangioma” with a biologically informed framework that recognizes possible overlap with low-flow venous malformation in selected adult lesions. This distinction may inform terminology, research classification, and selected interventional strategies. Gemini was used to assist in the design and visual optimization of the graphical abstract. The tool helped to optimize color palettes to better communicate the concepts visually. It was not used to generate or alter any empirical data.

Table 1 Terminology and entity distinctions relevant to a diagnosis-focused review of hepatic hemangioma.

Entity	Typical setting	Key diagnostic clue	Management implication
Adult hepatic hemangioma (routine radiology term)	Incidental lesion in adults; usually asymptomatic	Marked T2 hyperintensity and progressive nodular fill-in on dynamic imaging	Most lesions can be observed; biopsy is usually unnecessary when imaging is classic
Hepatic venous malformation (vascular anomaly framing of many adult ‘cavernous hemangiomas’)	Symptomatic or giant adult lesion; slow-flow ectatic vascular spaces	Overlap of imaging/pathology with adult HH; recent GJA4-linked studies support VM biology	Introduces percutaneous sclerotherapy and vascular-anomaly-based terminology into management discussions
Infantile hepatic hemangioma	Infancy; may be focal, multifocal, or diffuse	Biologically proliferative vascular tumor with pediatric presentation	Different natural history and treatment pathway from adult incidental HH
Sclerosed/hyalinized hemangioma	Older or involuted lesion; often atypical imaging	Reduced T2 brightness, incomplete fill-in, retraction or rim-like enhancement	Major mimic of malignancy; often drives escalation to MDT review or surgery if unresolved.

HH: Hepatic hemangioma; VM: Venous malformation; MDT: Multi-disciplinary team.

MULTIMODALITY IMAGING DIAGNOSIS

Ultrasound usually serves as the first-line modality. In a typical adult lesion, grayscale ultrasound reveals a well-defined, homogeneously hyperechoic mass with posterior acoustic enhancement. Color Doppler often provides limited information due to slow intralesional flow. Superb microvascular imaging can identify strip-rim or nodular-rim vascularity and may offer valuable insights in lesions ≥ 2 cm or those exhibiting rapid enhancement patterns[2,13]. CEUS is advantageous as it displays enhancement in real time, confirming the classic pattern of peripheral nodular enhancement followed by progressive centripetal fill-in. This technique is particularly useful when MRI is contraindicated or when CT findings are inconclusive. However, CEUS interpretation requires contextual understanding: Small flash-filling hemangiomas may enhance rapidly and homogeneously in the arterial phase, while atypical or fibrotic lesions may not exhibit complete fill-in[2-5]. On unenhanced CT, a HH typically appears hypoattenuating compared to liver parenchyma. The most recognized contrast-enhanced pattern is discontinuous peripheral nodular enhancement in the arterial phase, accompanied by progressive centripetal fill-in during portal venous and delayed imaging. MRI remains the primary problem-solving modality, integrating dynamic behavior with tissue characterization. Typical lesions are hypointense on T1-weighted imaging and markedly hyperintense on T2-weighted sequences, creating the characteristic “light bulb” appearance. In most instances, the combination of intense T2 signal and blood-pool-like progressive enhancement is more informative than any single phase alone; when first-line ultrasound or CT findings conflict with clinical risk, prioritizing MRI as the problem-solving modality is advisable[1-5,14,15]. Atypical lesions present significant challenges. Flash-filling hemangiomas may appear uniformly hyperenhancing in the arterial phase, leading to confusion with focal nodular hyperplasia (FNH), hepatocellular carcinoma (HCC), or hypervascular metastasis. Giant lesions may exhibit thrombosis, fibrosis, or cystic changes, resulting in incomplete central fill-in. Sclerosed or hyalinized hemangiomas can be particularly misleading, as they may lose significant T2 hyperintensity, develop capsular retraction, or display only faint peripheral enhancement, thereby resembling cholangiocarcinoma or metastasis[4,14-16]. In oncology patients, metastasis poses the most critical diagnostic challenge. In a gadoxetic acid-enhanced MRI study, Motosugi et al[17] demonstrated that a bright T2 signal strongly indicates hemangioma, while ring-like arterial enhancement suggests metastasis. However, hepatobiliary-phase interpretation with gadoxetic acid requires caution. As hemangiomas do not contain functioning hepatocytes, they usually appear hypointense on hepatobiliary-phase images. In flash-filling or high-flow hemangiomas, arterial hyperenhancement followed by relative hypointensity during the transitional or hepatobiliary phase may simulate washout, creating a pseudo-washout appearance that can raise unnecessary concern for HCC or hypervascular metastasis. This finding should therefore not be interpreted in isolation; marked T2 hyperintensity, blood-pool-like enhancement behavior, absence of targetoid diffusion restriction, clinical context, and, when needed, CEUS or MRI with an extracellular contrast agent should be considered before escalating to invasive diagnosis or treatment. Diffusion-weighted MRI can also provide assistance, although mean apparent diffusion coefficient (ADC) values overlap; Hardie et al[18] reported that ADC standard deviation offers better differentiation of hemangioma from metastasis than mean ADC alone. As biopsy of suspected vascular lesions may be unnecessary and potentially hazardous when imaging can clarify the diagnosis, it should not typically be the preferred next step in most indeterminate cases. A second-line MRI, CEUS, prior imaging comparison, and multidisciplinary review usually offer safer clarification than tissue sampling[3,5] (Tables 2 and 3).

Table 2 Multimodality imaging clues for typical and atypical hepatic hemangioma.

Lesion	Typical ultrasound/CEUS pattern	Typical CT/MRI pattern	Main diagnostic pitfall
Typical HH	Well-defined hyperechoic lesion; CEUS shows peripheral nodular enhancement with progressive fill-in	T1 hypointense, markedly T2 hyperintense; peripheral nodular arterial enhancement with delayed centripetal fill-in	Usually, few pitfalls when the imaging pattern and clinical context are both classic
Flash-filling HH	May enhance rapidly and almost homogeneous on CEUS	Uniform arterial hyperenhancement, sometimes with less obvious delayed fill-in	Can mimic FNH, HCC, or hypervascular metastasis if delayed phases and T2 signal are underweighted
Sclerosed/hyalinized hemangioma	Often nonspecific or heterogeneous	Reduced T2 hyperintensity, incomplete enhancement, fibrosis, retraction	Frequently mistaken for cholangiocarcinoma or metastasis

HH: Hepatic hemangioma; CT: Computed tomography; MRI: Magnetic resonance imaging; CEUS: Contrast-enhanced ultrasound; FNH: Focal nodular hyperplasia; HCC: Hepatocellular carcinoma.

Table 3 Common mimics that should not be prematurely labeled as hepatic hemangioma.

Mimic	Typical ultrasound/CEUS pattern	Typical CT/MRI pattern	Clue arguing against classic HH
Focal nodular hyperplasia	May be iso- or mildly hyperechoic; spoke-wheel vascularity can be present	Homogeneous arterial enhancement; often iso/hyperintense on hepatobiliary phase	Presence of functioning hepatocytes and hepatobiliary phase uptake argues against HH
Hepatocellular carcinoma	Variable; often not classically hyperechoic in cirrhosis	Arterial phase hyperenhancement with washout/capsule; diffusion restriction more common	Cirrhotic background, washout, growth, and capsule should override a hemangioma default assumption
Hypervascular metastasis	Often multiple; CEUS may show rim or targetoid enhancement	Ring-like or targetoid arterial enhancement, lower T2 signal, restricted diffusion, no progressive blood-pool matching	Known malignancy, multiplicity, interval growth, and ring enhancement make HH less likely

HH: Hepatic hemangioma; CT: Computed tomography; MRI: Magnetic resonance imaging; CEUS: Contrast-enhanced ultrasound.

DIFFERENTIAL DIAGNOSIS IN HIGH-RISK CLINICAL SCENARIOS

Not every diagnostic issue presents with the same pre-test probability. In a healthy adult with an incidental 1.5 cm hyperechoic lesion and classic MRI findings, the diagnosis of HH is typically secure. However, any new arterially enhancing lesion in a patient with cirrhosis or any small lesion in an individual with known colorectal or neuroendocrine cancer requires a more rigorous differential diagnosis. The same imaging pattern may carry different implications based on the clinical context.

The primary radiologic differentials include FNH, HCC, and hypervascular metastases. FNH generally enhances homogeneously in the arterial phase and retains contrast during hepatobiliary-phase imaging due to the presence of functioning hepatocytes; a central scar and spoke-wheel arterial supply can further support this diagnosis. In contrast, HCC—especially in individuals with cirrhosis—is characterized by arterial-phase hyperenhancement, washout, capsular appearance, diffusion restriction, interval growth, and clinical risk factors. Metastases are more likely than HH to exhibit targetoid or ring enhancement, lower T2 signals, more pronounced diffusion restrictions, and lack of progressive blood-pool matching on delayed images[3-5,17,18]. Sclerosed lesions warrant special consideration. They often reside at the intersection of indeterminate imaging and overtreatment. A lesion characterized by diminished T2 signal, peripheral rim enhancement, capsular retraction, and absence of convincing progressive fill-in should be viewed as indeterminate rather than automatically classified as “atypical hemangioma” simply due to the commonality of hemangiomas. In such situations, radiologic-pathologic correlation, short-interval follow-up, or resection may be appropriate if imaging remains inconclusive and management would be impacted. The key consideration is that diagnosis should progress in a stepwise fashion rather than be concluded prematurely.

EMERGING AI AND RADIOMICS IN FOCAL LIVER LESION CHARACTERIZATION

AI has garnered significant attention as the characterization of focal liver lesions fundamentally involves a pattern-recognition task across multiple phases, sequences, and clinical scenarios. Vetter et al[19] systematically reviewed the use of AI for classifying focal liver lesions on ultrasound. Popa et al[20] further concluded that fully automated diagnosis of focal liver lesions is technically feasible, although substantial methodological heterogeneity remains. The most promising AI application for HH may be the differentiation of small or visually indeterminate lesions from metastases or other hypervascular lesions. Park et al[21] demonstrated that T2-weighted MRI radiomics models achieved excellent differentiation between small metastases and hemangiomas, successfully classifying numerous visually indeterminate lesions in validation sets. Ozaki et al[22] found that deep-learning reconstruction enhanced the qualitative and quantitative performance of diffusion-weighted MRI for distinguishing metastasis from hemangioma, although overall diagnostic accuracy was comparable to that of standard compressed-sensing reconstruction. Broader radiomics studies have also shown that quantitative T2-based features can aid in distinguishing benign from malignant primary solid liver lesions or differentiating HCC from blood-rich benign lesions that may mimic flash-filling hemangioma during conventional visual assessment[22,23]. Currently, however, AI should be viewed as a supportive tool in decision-making rather than a replacement for autonomous diagnosis, and existing models should not supplant guideline-based imaging interpretation or multidisciplinary review. Barriers to clinical implementation include not only technical challenges but also ontological issues: Label ambiguity, underrepresentation of atypical variants, limited pathology confirmation, and inadequate calibration across scanners and institutions. Moreover, real-world translation remains uncertain because few prospective studies have evaluated how AI or radiomics outputs can be integrated into routine hepatobiliary imaging workflows or multidisciplinary decision-making. For MRI-based radiomics, reproducibility remains particularly challenging, as extracted features may vary according to scanner vendor, acquisition protocol, reconstruction method, and manual vs semi-automated segmentation strategy. Therefore, future studies should prioritize standardized imaging protocols, transparent segmentation procedures, external multicenter validation, and prospective workflow-integration designs before these tools can be considered clinically established. Future models should clarify how reference standards are determined, integrate image-derived features with clinical metadata such as cirrhosis status, known extrahepatic malignancy, lesion growth history, serum tumor markers, and prior imaging findings, and undergo external testing specifically in visually indeterminate diagnostic gray zones where human readers encounter the most difficulty (Table 4).

Table 4 Representative artificial intelligence and radiomics studies relevant to hepatic hemangioma differential diagnosis.

Ref.	Task and modality	Main message	Key limitation
Popa et al[20], 2023	Systematic review of automated focal liver lesion diagnosis across US/CT/MRI	Automated diagnosis is feasible, but no modality or model family clearly dominates	Heterogeneous studies; many older single-center datasets
Arribas Anta et al[50], 2025	Narrative review of AI for focal hepatic lesion detection/characterization	AI is strongest as decision support for lesion characterization and workflow assistance	Mostly retrospective evidence; limited real-world implementation data
Pomohaci et al[51], 2025	Systematic review of AI in liver imaging	Liver lesions are the commonest AI target, but external validation and code sharing remain uncommon	Broad liver scope; not restricted to HH-specific questions
Park et al[21], 2026	T2-weighted MRI radiomics for small metastasis vs hemangioma	Excellent discrimination, including visually indeterminate lesions in validation sets	Retrospective study; validation still scanner- and center-dependent
Ozaki et al[22], 2026	Deep-learning reconstruction for DWI differentiation of metastasis vs hemangioma	Improved image quality and lesion conspicuity; diagnostic accuracy similar to standard reconstruction	Small sample size; single-vendor technical ecosystem
Starmans et al[23], 2024/Yang et al[52], 2025	T2-based radiomics for benign vs malignant liver lesions and blood-rich lesion classification	Quantitative T2 features can complement conventional reading when blood-rich benign lesions mimic malignancy	Broader lesion groups rather than pure HH-focused cohorts

HH: Hepatic hemangioma; AI: Artificial intelligence; US: Ultrasound; CT: Computed tomography; MRI: Magnetic resonance imaging; DWI: Diffusion weighted imaging.

HOW DIAGNOSTIC CLASSIFICATION CHANGES MANAGEMENT

The importance of accurate diagnosis extends beyond the avoidance of unnecessary biopsies, as diagnostic certainty directly influences whether observation, percutaneous intervention, or surgery is appropriate. In this context, diagnosis acts as a gatekeeper for treatment rather than a preliminary step disconnected from management.

The shift in terminology from HH to hepatic VM has increased the visibility of percutaneous sclerotherapy in the adult giant-lesion literature. Ghaemi et al[12] outlined a technically reproducible bleomycin-based percutaneous sclerotherapy technique for giant hepatic VM, positioning it as an alternative to transarterial embolization for selected symptomatic patients. A 2025 meta-analysis comparing percutaneous sclerotherapy with transarterial chemoembolization reported similarly high technical success rates and largely comparable radiological outcomes, with infrequent major complications[24]. An updated 2026 meta-analysis concerning hepatic VM also found no significant efficacy differences between transarterial embolization and percutaneous sclerotherapy, indicating that sclerotherapy might offer shorter hospital stays and reduced costs[25]. Although these data are predominantly retrospective, they highlight that terminology impacts the range of procedures considered.

Surgical decision-making is equally reliant on diagnosis. If imaging identifies a superficial or exophytic lesion distant from major vascular and biliary structures, minimally invasive surgery becomes more feasible. Conversely, if a lesion is central, giant, or remains radiologically indeterminate, open surgery may be more appropriate. Comparative studies consistently favor laparoscopy over open surgery in selected patients, resulting in less blood loss, faster recovery, and shorter hospital stays[26-28]. For giant lesions necessitating hemihepatectomy, robotic and laparoscopic methods seem to enhance postoperative recovery compared to open surgery, although the open approach retains advantages in terms of operative time and technical flexibility for challenging central tumors[28]. Propensity-matched data suggest that robot-assisted liver resection may reduce postoperative stays compared to conventional laparoscopy while maintaining similar complication rates, although cost and access remain significant constraints[29]. The critical point is that treatment comparisons should not be considered in isolation from diagnostic certainty and anatomical context. A lesion that is likely a sclerosed hemangioma will not be managed in the same way as a classic peripheral hemangioma, and a lesion identified as a VM may lead an experienced center to prefer sclerotherapy over direct resection. Laparoscopic ultrasound-guided microwave ablation (MWA) may also be considered among local treatment options in carefully selected symptomatic patients, particularly when formal resection is expected to be relatively morbid or when a parenchyma-sparing approach is preferred. However, its use requires secure benign diagnosis, careful assessment of lesion size and proximity to major vessels or bile ducts, and appropriate local expertise. Given the limited and heterogeneous evidence base, MWA should be regarded as a selective adjunct rather than a replacement for established options such as observation, embolization, sclerotherapy, or surgery. Most asymptomatic lesions still warrant observation; however, intervention decisions become more nuanced when diagnosis, symptom attribution, and lesion biology are evaluated together[30,31]. Observation cohorts and growth analyses indicate that many HHs remain stable or exhibit slow enlargement, suggesting that lesion size alone is a poor isolated criterion for intervention[32-35]. Major reviews and management syntheses support reserving resection for cases of persistent symptoms, diagnostic uncertainty, compression, Kasabach-Merritt syndrome, or concerns related to rupture[36-40]. When surgery is indicated, classic operative series suggest that parenchyma-sparing techniques—particularly enucleation where anatomy permits—are favorable compared to formal resection[41-43] (Table 5).

Table 5 How diagnostic classification influences interventional and surgical decision-making.

Comparison	Evidence summary	Practical implication for a diagnosis-focused review
Observation vs intervention	Many asymptomatic HHs remain stable or enlarge slowly, and lesion size alone is a poor isolated indication for treatment	Observation is generally preferred when diagnostic certainty is high and symptoms are absent or not clearly attributable to the lesion. Intervention is considered when symptoms, compression, complications, or diagnostic uncertainty affect management
Percutaneous sclerotherapy vs transarterial embolization/chemoembolization	Recent pooled analyses suggest similarly high technical success and comparable clinical or radiological response, with low major complication rates	If giant adult lesions are framed as low-flow venous malformations, sclerotherapy becomes a rational alternative rather than a marginal option
Percutaneous sclerotherapy vs surgical resection	Retrospective data suggest both can be effective for selected large lesions, with different trade-offs in efficacy, invasiveness, and resource use	Atypical or indeterminate lesions still require secure diagnosis before non-surgical treatment is chosen
Laparoscopic vs open resection	Meta-analysis and propensity-matched cohorts generally favor laparoscopy in selected peripheral lesions due to reduced blood loss, shorter stay, and faster recovery	Minimally invasive surgery is an anatomic consequence of diagnosis; it is not a universal answer for every giant or central lesion
Robotic vs laparoscopic/open resection	Robotic approaches may shorten postoperative recovery in selected patients, but cost, access, and lesion complexity remain major determinants	Robotics is most persuasive when preoperative imaging defines anatomy precisely and malignancy has been reasonably excluded

HH: Hepatic hemangioma.

A PRACTICAL DIAGNOSIS-FIRST FRAMEWORK

A practical diagnosis-first strategy for HH can be summarized in six steps. First, the clinical context must be established, including age, symptom burden, cirrhosis status, known extrahepatic malignancy, pregnancy or infancy, and prior imaging history. Second, it is essential to determine whether the lesion exhibits a classic phenotype on first-line imaging. If the lesion is small, strongly T2-bright, and shows progressive blood-pool-like fill-in, further work-up is often unnecessary. Third, escalation to MRI or CEUS should occur when the lesion is flash-filling, giant, multiple, dependent on background liver, or observed in an oncology patient. Fourth, reclassification of the lesion type is necessary to avoid forcing all vascular lesions into a single category, distinguishing between adult incidental HH/possible VM, infantile HH, sclerosed end-stage lesions, or non-hemangiomatous mimics. Fifth, biopsy should be avoided unless imaging remains unresolved and tissue analysis will clearly impact management. Sixth, when considering intervention for a giant symptomatic adult lesion, discussions should include not only resection and embolization but also whether the lesion behaves as a low-flow VM and the availability of local expertise in percutaneous sclerotherapy. Figure 2 summarizes this six-step diagnosis-first framework.

Figure 2 A practical diagnosis-first framework for hepatic hemangioma. The flowchart illustrates a six-step multidisciplinary diagnostic and management strategy. The framework highlights the importance of clinical context (Step 1), specific indications for escalation to advanced multimodality imaging (Steps 2-3), the necessity of reclassifying lesion types (Step 4), stringent criteria for biopsy (Step 5), and customized interventional or surgical management based on lesion biology (Step 6). HH: Hepatic hemangioma; MRI: Magnetic resonance imaging; CEUS: Contrast-enhanced ultrasound; VM: Venous malformation.

EVIDENCE GAPS AND FUTURE DIRECTIONS

Three evidence gaps warrant emphasis. The first is the need for terminology harmonization. Future imaging, pathology, and AI studies should specify whether lesions were labeled according to imaging consensus, histology, or vascular anomaly criteria, as hemangioma and VM are not necessarily interchangeable in adult liver disease. The second gap involves the prospective multicenter validation of diagnostic tools, particularly CEUS-based pathways and MRI/radiomics models for small indeterminate lesions. The third gap highlights the necessity for studies that directly link diagnostic phenotype to management selection, rather than evaluating embolization, sclerotherapy, or surgery in isolation from lesion classification. Contemporary interventional reports suggest that transarterial embolization, combined with percutaneous techniques and CT-guided bleomycin-based sclerotherapy, can alleviate symptoms and reduce lesion burden in selected patients; however, multicenter comparative data remain limited[44-46]. Future surgical and interventional studies should also document the imaging pitfalls that have redirected management, such as the pseudo-washout of high-flow hemangiomas on gadoxetic acid MRI, and the role of CEUS or broader benign-liver-lesion diagnostic algorithms prior to intervention[47-49].

CONCLUSION

A diagnosis-focused synthesis is now more valuable than another broad overview of HH. The most significant current advances do not pertain to a single modality; rather, they arise from the combination of clearer vascular anomaly concepts, more disciplined multimodality imaging, and cautious integration of AI and radiomics. MRI remains the principal problem-solving technique, while CEUS provides important real-time information, and AI may soon assist with the small, visually indeterminate lesions that frequently confound human readers. Correct classification of typical adult HH, lesions more accurately described as hepatic VMs, and malignant mimics has clinically significant implications, as it shapes surveillance strategies, facilitates biopsy avoidance, informs interventional choices, and guides surgical planning.