Multimodal ultrasonographic features and diagnostic performance of hepatic hemangioma

Abstract

Abstract: Objective To perform a comprehensive analysis of multiple ultrasonographic modalities and provide a more accurate andObjective basis for the qualitative diagnosis of hepatic hemangioma (HH). Methods A total of 122 patients with pathologically confirmed HH and 80 patients with hepatocellular carcinoma (HCC) admitted between January 2022 and August 2024 were enrolled. The ultrasonographic features of HH and HCC under different imaging modalities were compared, and their diagnostic performance for HH was evaluated. Results Compared with the HCC group, HH lesions more frequently exhibited homogeneous internal echotexture, a distinct marginal fissure sign, and reticular internal echoes (P<0.05). The incidence of posterior acoustic enhancement and non-calcified posterior acoustic shadowing was also significantly higher in the HH group (P<0.05). In addition, HH lesions were more deformable under probe compression, indicating a softer and more compressible texture, whereas HCC lesions were firm and resistant to deformation. On color Doppler flow imaging (CDFI), HH lesions showed sparse blood flow signals predominantly with a “track-like” pattern, while HCC lesions demonstrated abundant blood flow and a central flow pattern. The venous-like low-velocity spectrum was more common in HH, and the peak flow velocity was significantly lower than that of HCC (P<0.05). Shear wave elastography (SWE) revealed that both the Young’s modulus value and tumor-to-liver elasticity ratio of HH were significantly lower than those of HCC (P<0.05). HH lesions predominantly displayed blue/green low-elasticity patterns with a “high-peripheral-low-central” distribution, consistent with the histological characteristics of central cavernous dilation and peripheral fibrosis. In contrast, HCC lesions primarily presented a mosaic pattern, reflecting heterogeneous stiffness due to necrosis and neovascularization. On contrast-enhanced ultrasound (CEUS), HCC lesions mainly exhibited a “fast-in and fast-out” enhancement pattern, whereas HH lesions typically showed peripheral nodular enhancement in the arterial phase, centripetal filling, and the “black hole sign”. During the portal phase, the time required for HH lesions to achieve 50% centripetal filling was significantly longer than that of HCC (P<0.05), and HH maintained iso- or hyper-enhancement in the delayed phase. The combined multimodal diagnostic approach integrating B-mode structural features, CDFI hemodynamics, SWE elasticity parameters, and CEUS perfusion patterns markedly improved the differentiation between HH and HCC. Conclusion HH exhibits characteristic imaging features across B-mode, CDFI, SWE, and CEUS modalities. Multimodal ultrasonographic analysis significantly enhances the sensitivity and specificity for diagnosing HH, providing a more comprehensive and reliable imaging basis for differentiating benign and malignant hepatic lesions.

Key words: Hepatic hemangioma, Hepatocellular carcinoma, Color doppler flow imaging, Shear wave elastography, Contrast-enhanced ultrasound

SHI Jing, ZHOU Feng-sheng, ZHU Qiao-ying, ZHAN Li-li. Multimodal ultrasonographic features and diagnostic performance of hepatic hemangioma[J]. Chinese Hepatolgy, 2025, 30(12): 1664-1667.

References

[1] Kacała A, Dorochowicz M, Matus I, et al. Hepatic hemangioma: review of imaging and therapeutic strategies[J]. Medicina (Kaunas), 2024, 60(3):449.
[2] Erickson L A, Gupta S, Torres-Mora J. Hepatic hemangioma[J]. Mayo Clin Proc, 2023, 98(3):489-491.
[3] Li W, Li R, Zhao X, et al. Differentiation of hepatocellular carcinoma from hepatic hemangioma and focal nodular hyperplasia using computed tomographic spectral imaging[J]. J Clin Transl Hepatol, 2021, 9(3):315-323.
[4] Hu S, Lyu X, Li W, et al. Radiomics analysis on noncontrast CT for distinguishing hepatic hemangioma (HH) and hepatocellular carcinoma (HCC)[J]. Contrast Media Mol Imaging, 2022, 2022:7693631.
[5] Wang Z, Yao J, Jing X, et al. A combined model based on radiomics features of Sonazoid contrast-enhanced ultrasound in the Kupffer phase for the diagnosis of well-differentiated hepatocellular carcinoma and atypical focal liver lesions: a prospective, multicenter study[J]. Abdom Radiol (NY), 2024, 49(10):3427-3437.
[6] Yokomine M, Horinouchi T, Yoshizato T, et al. Fetal hepatic hemangioma diagnosed in utero using Doppler microvascular imaging[J]. Kurume Med J, 2024, 70(1.2):69-72.
[7] Nahar N, Khan N, Chakraborty R K, et al. Color Doppler sonography and resistivity index in the differential diagnosis of hepatic neoplasm[J]. Mymensingh Med J, 2014, 23(1):35-40.
[8] Han H, Ji Z, Huang B, et al. The preliminary application of simultaneous display of contrast-enhanced ultrasound and micro-flow imaging technology in the diagnosis of hepatic tumors[J]. J Ultrasound Med, 2023, 42(3):729-737.
[9] Ding W, Meng Y, Ma J, et al. Contrast-enhanced ultrasound-based AI model for multi-classification of focal liver lesions[J]. J Hepatol, 2025, 83(2):426-439.
[10] Chai W, Xie L, Zhao Q, et al. Ultrasound and contrast-enhanced ultrasound findings after percutaneous irreversible electroporation of hepatic malignant tumors[J]. Ultrasound Med Biol, 2020, 46(3):620-629.
[11] de Lange C, Thrane K J, Thomassen K S, et al. Hepatic magnetic resonance T1-mapping and extracellular volume fraction compared to shear-wave elastography in pediatric Fontan-associated liver disease[J]. Pediatr Radiol, 2021, 51(1):66-76.
[12] Wang Y, Jia L, Wang X, et al. Diagnostic performance of 2-D shear wave elastography for differentiation of hepatoblastoma and hepatic hemangioma in children under 3 years of age[J]. Ultrasound Med Biol, 2019, 45(6):1397-1406.
[13] 江爱芳, 陈华芳, 张聪. 肝血管瘤超声造影表现分析[J]. 实用肝脏病杂志, 2025, 28(2):282-285.
[14] 国际肝胆胰协会中国分会肝血管瘤专业委员会. 肝血管瘤诊断和治疗多学科专家共识(2019年版)[J]. 临床肝胆病杂志, 2019, 35(9):1928-1932.
[15] Wakui N, Takayama R, Kamiyama N, et al. Diagnosis of hepatic hemangioma by parametric imaging using sonazoid-enhanced US[J]. Hepatogastroenterology, 2011, 58(110-111):1431-1435.
[16] 李洪波, 张学功, 牟玉华, 等. 肝血管瘤血流动力学特征与个性化介入治疗的临床研究[J]. 中国微创外科杂志, 2011, 11(10):944-946,952.
[17] 王常鹤, 朱璇, 邓静, 等. 超声剪切波弹性成像联合AAR、APRI和FIB-4指数诊断慢性乙型肝炎患者肝纤维化程度效能研究[J]. 实用肝脏病杂志, 2025, 28(1):32-35.
[18] Soh E G, Lee Y H, Kim Y R, et al. Usefulness of 2D shear wave elastography for the evaluation of hepatic fibrosis and treatment response in patients with autoimmune hepatitis[J]. Ultrasonography, 2022, 41(4):740-749.
[19] Li J, Li H, Xiao F, et al. Comparison of machine learning models and CEUS LI-RADS in differentiation of hepatic carcinoma and liver metastases in patients at risk of both hepatitis and extrahepatic malignancy[J]. Cancer Imaging, 2023, 23(1):63.
[20] Strobel D, Jung E M, Ziesch M, et al. Real-life assessment of standardized contrast-enhanced ultrasound (CEUS) and CEUS algorithms (CEUS LI-RADS?/ESCULAP) in hepatic nodules in cirrhotic patients-a prospective multicenter study[J]. Eur Radiol, 2021, 31(10):7614-7625.