Liver hemangiomas are the most common benign neoplasms of the liver and are often diagnosed incidentally on abdominal imaging. Most liver hemangiomas are small (< 4 cm) indolent lesions that do not require further intervention or surveillance in the absence of symptoms. The management of giant liver hemangiomas (> 4 cm), however, remains controversial. The natural progression of giant hemangiomas is not well defined and the risk of life-threatening complications, namely rupture and bleeding, is not clearly established. The development of symptoms such as abdominal pain, mass effects or life-threatening events such as rupture, bleeding or consumptive coagulopathy is an indication for surgical resection or intervention. Asymptomatic giant hemangiomas present a management dilemma as the risk of life-threatening complications is unknown. Several single centers studies have demonstrated the safety of expectant management of even very large asymptomatic hemangiomas. There is no evidence to support using size alone as an indication for resection. Although morbidity and mortality of liver resection for hemangioma has improved, the risks of surgical intervention need to be balanced against the rare risk of adverse events during expectant observation.
