Can Liver Cancer Be Mistaken for Hemangioma?

Liver cancer can absolutely be mistaken for a hemangioma, and the reverse happens too. Because hemangiomas are by far the most common benign solid liver mass, radiologists encounter them constantly and are trained to recognize their typical appearance on imaging. The trouble is that several subtypes of hemangioma stray from the textbook look, and certain liver cancers can mimic hemangioma patterns convincingly enough to delay correct diagnosis by months or even years. One study of malignant tumors initially misdiagnosed as hemangiomas found that the error caused a median treatment delay of ten months, with some cases going unrecognized for as long as eight years.¹

Why Hemangiomas and Liver Cancers Look Alike on Imaging

Hemangiomas are benign tangles of blood vessels inside the liver. On a contrast-enhanced CT or MRI scan, a classic cavernous hemangioma shows a very recognizable pattern: bright spots at the periphery of the lesion during the early phase of contrast injection, which slowly fill inward over the next few minutes, eventually making the whole mass bright. Radiologists call this “discontinuous peripheral enhancement” with progressive fill-in, and when the pattern is textbook, the diagnosis is straightforward.

The problem is that this peripheral enhancement pattern is not exclusive to hemangiomas. Other benign and malignant liver lesions can display it too, and hemangiomas themselves do not always follow the script. A lesion that lights up at its edges during the arterial phase might be a typical hemangioma, an atypical hemangioma, or something else entirely.² On the cancer side, one of the hallmarks of hepatocellular carcinoma is that it enhances brightly during the arterial phase and then “washes out” on later phases, becoming darker than the surrounding liver. But the boundary between a hemangioma that fills in slowly and a cancer that washes out can be subtle, especially when the lesion is small or the imaging timing is slightly off.³

Hemangioma Subtypes That Fool Radiologists

Not all hemangiomas behave the same way on a scan. Two subtypes in particular are responsible for most of the diagnostic confusion.

Flash-filling (capillary) hemangiomas make up roughly one in six hepatic hemangiomas. Unlike the classic cavernous type that fills in gradually from the edges, a flash-filling hemangioma lights up intensely and uniformly during the arterial phase, looking almost identical to a hypervascular liver tumor such as hepatocellular carcinoma or a neuroendocrine metastasis.⁴ When a radiologist sees a lesion that enhances rapidly and homogeneously on arterial phase, the natural instinct is to consider malignancy. If subsequent imaging phases do not clearly show sustained enhancement or the classic hemangioma fill-in pattern, the lesion can end up flagged as suspicious. To make matters worse, some high-flow hemangiomas can show transient washout with certain contrast agents, directly mimicking the washout pattern used to diagnose hepatocellular carcinoma.⁵

Sclerosing hemangiomas are even trickier. These are hemangiomas in which the blood-filled spaces have been partially or completely replaced by scar tissue. Because the vascular channels are scarred shut, the lesion loses its typical blood-pool behavior on imaging. Instead of lighting up brightly on T2-weighted MRI (the way normal hemangiomas do, because they are full of slow-moving blood), sclerosing hemangiomas can appear relatively dark, which is more consistent with a solid tumor. Case reports describe sclerosing hemangiomas that so closely resembled cholangiocarcinoma or hepatocellular carcinoma that surgeons resected them under a tentative cancer diagnosis, only discovering the benign nature on pathology after the operation.⁶ In one such case, not only did imaging look malignant, but blood markers associated with liver cancer were also elevated, further pushing clinicians toward a cancer diagnosis.⁷

Giant hemangiomas, typically defined as those larger than about five centimeters, add another layer of complexity. As they grow, they can develop internal areas of bleeding, clotting, or tissue death that create an irregular, heterogeneous appearance on scans. A giant hemangioma with central necrosis can look worryingly similar to a large liver cancer with a necrotic core.⁸

When Cirrhosis Muddies the Picture

The diagnostic challenge becomes significantly harder when a patient has cirrhosis or chronic liver disease. Cirrhosis is the main risk factor for hepatocellular carcinoma, so any new or growing mass in a cirrhotic liver immediately raises suspicion for cancer. At the same time, hemangiomas still occur in cirrhotic livers. They tend to be smaller, and they can behave differently on imaging than hemangiomas in healthy livers.⁹

In a cirrhotic liver, hemangiomas tend to show less of the classic bright T2 signal (sometimes called “T2 shine-through”) that normally makes them easy to identify. When that reassuring brightness is reduced, the hemangioma starts to look more like a solid mass, and the radiologist has less to work with when trying to separate it from hepatocellular carcinoma.⁹ One study of hemangiomas in cirrhotic livers found that the average lesion was under a centimeter and that the large majority showed rapid, uniform enhancement rather than the gradual fill-in pattern, making them look almost indistinguishable from small hepatocellular carcinomas.¹⁰ Differentiating hemangioma from hepatocellular carcinoma in a cirrhotic patient is considered one of the harder calls in liver imaging.¹¹

Blood Tests Can Add to the Confusion

Clinicians sometimes look to blood markers for help. Alpha-fetoprotein (AFP) is the best-known blood marker associated with liver cancer, particularly hepatocellular carcinoma. An elevated AFP in the context of a liver mass generally pushes clinicians toward a cancer diagnosis. But AFP is not perfectly specific to cancer. In rare cases, hemangiomas themselves have been associated with sharply elevated AFP levels. One case report documented a patient with a cavernous hemangioma whose AFP was more than eighteen times the upper limit of normal. The AFP level dropped back toward normal after the hemangioma was surgically removed, confirming the benign mass as the source.¹²

This kind of scenario is uncommon, but it illustrates a broader point: no single test or marker definitively resolves the question. AFP can be elevated in hemangioma (rarely) and can be normal in some liver cancers. Imaging can be ambiguous. Each piece of evidence nudges the probability in one direction, but confident diagnosis often requires the full picture.

The Real-World Cost of Misdiagnosis

Misidentifying a liver cancer as a hemangioma delays treatment, sometimes significantly. Because hemangiomas are so common and typically require no treatment, a patient told they have a benign hemangioma may be placed on a relaxed surveillance schedule or no follow-up at all. If that mass is actually a cancer, the window for curative treatment can shrink or close. A study examining patients whose malignant liver tumors had initially been called hemangiomas found that the final correct diagnoses included hepatocellular carcinoma in the majority, along with cholangiocarcinoma, angiosarcoma, and various metastatic cancers.¹

A separate study found that false hemangioma diagnoses were far more likely to originate at low-volume centers, occurring at such facilities in three-quarters of cases. In that cohort, the average delay from first observation to correct diagnosis was about twenty-two months. Despite the delay, liver resection was still possible in most patients, and among those with hepatocellular carcinoma, the five-year survival rate after eventually receiving appropriate treatment was around 69 percent.¹³ That survival figure is reasonably encouraging, but it likely would have been better without the delay. The same study noted that a specific risk factor for liver cancer, such as hepatitis or cirrhosis, was present in over 70 percent of the misdiagnosed patients, suggesting that clinical context was not being weighted heavily enough in the initial interpretation.¹³

The inverse error, calling a hemangioma a cancer, carries its own costs. Patients may undergo unnecessary biopsies (which carry bleeding risk for a vascular lesion like a hemangioma), unnecessary surgery, or intense psychological distress while awaiting further workup. Neither direction of misdiagnosis is harmless.

Imaging Tools That Help Sort It Out

When standard CT or MRI leaves a lesion indeterminate, radiologists have several additional tools. Contrast-enhanced ultrasound (CEUS) has become an important second step. CEUS uses microbubble contrast agents that stay within the blood vessels, allowing real-time observation of how blood flows through a lesion. Official guidelines recommend CEUS as a follow-up to conventional ultrasound for indeterminate liver lesions, particularly because it is good at confirming benign diagnoses like hemangiomas without the cost and wait of additional CT or MRI scans.¹⁴ On CEUS, a typical hemangioma shows a characteristic pattern of peripheral nodular enhancement that fills inward, and it stays bright in the late phase rather than washing out. Malignant tumors, by contrast, tend to wash out in later phases, becoming darker than the surrounding liver tissue.¹⁵

Specialized MRI contrast agents also improve discrimination. Gadoxetic acid (sold under the brand name Eovist or Primovist) is taken up by functioning liver cells in a delayed “hepatobiliary phase,” which creates a unique contrast between normal liver tissue and masses that do not contain functioning hepatocytes. This phase can help separate hemangiomas from both primary liver cancers and metastases. Research has shown that combining specific MRI sequences during the hepatobiliary phase can match the accuracy of more complex multi-sequence protocols for telling hemangiomas apart from metastatic tumors.¹⁶ However, even gadoxetic acid is not foolproof: high-flow hemangiomas can show transient washout with this agent, temporarily mimicking hepatocellular carcinoma before the later phases clarify the diagnosis.⁵

Where AI Fits Into Liver Lesion Diagnosis

Artificial intelligence models trained on ultrasound images of liver tumors have shown surprisingly strong performance at discriminating between hemangiomas, cysts, hepatocellular carcinoma, and metastatic tumors. In one study comparing AI models to human physicians on the same set of ultrasound images, the best-performing AI achieved roughly 89 percent accuracy across all four tumor types, while human experts reached a median of about 67 percent and non-experts about 47 percent.¹⁷ For malignant tumors specifically, the AI’s accuracy was over 94 percent.

These numbers do not mean AI will replace radiologists, but they suggest a useful role as a second opinion. In busy or low-volume settings where radiologists see fewer complex liver cases, an AI tool could flag lesions that deserve closer scrutiny or additional imaging. Given that misdiagnoses are more common at low-volume centers, this is the exact setting where such tools could have the most impact.

Pediatric Cases and Prenatal Confusion

The diagnostic overlap between hemangioma and cancer also plays out in very young patients, though the specific tumor types are different. In infants and neonates, infantile hepatic hemangioma is the most common benign liver tumor, while hepatoblastoma is the most common malignant one.¹⁸ Both can present as large liver masses detected on prenatal ultrasound, and they share enough imaging features in utero that prenatal differentiation is genuinely difficult.¹⁹ AFP levels, which are normally very high in healthy newborns, are less useful as a discriminator in the neonatal period than they would be in adults. Postnatal imaging with MRI and clinical follow-up usually resolves the question, but the initial uncertainty can be deeply stressful for expecting parents.

What You Can Do if You Have an Uncertain Liver Mass

If you have been told you have a liver hemangioma and something about the situation feels incomplete, there are a few practical considerations worth knowing. First, context matters enormously. A small, classic-looking hemangioma in an otherwise healthy 35-year-old with no liver disease history and normal blood markers is overwhelmingly likely to be exactly what it looks like. Hemangiomas are found incidentally in a significant percentage of the population and rarely need any intervention.²⁰ But if you have underlying liver disease, hepatitis, heavy alcohol use, or other risk factors for liver cancer, the threshold for additional workup should be lower.

Second, if a lesion was diagnosed on conventional ultrasound alone, the confidence level is inherently lower than if it was characterized on contrast-enhanced CT, MRI, or CEUS. Ultrasound was the initial modality responsible for the false hemangioma diagnosis in the vast majority of misdiagnosed cases in the study of erroneous hemangioma diagnoses, while MRI was the least likely to produce a false diagnosis.¹³ If your diagnosis rests solely on a standard ultrasound, asking about follow-up imaging with contrast is reasonable.

Third, size changes matter. Hemangiomas can grow, especially in younger adults, with the highest prevalence and largest sizes observed in people in their forties.²¹ Some growth in a known hemangioma is not automatically alarming, but rapid growth, new symptoms like pain or unexplained weight loss, or a change in the lesion’s appearance on follow-up imaging should prompt re-evaluation. Radiologists reviewing atypical liver masses routinely consider a broad differential that includes both benign mimickers and cancers, but the process works best when clinical information, risk factors, and imaging are all integrated together rather than assessed in isolation.²²

1
PubMed Central. Malignant Tumors Misdiagnosed as Liver Hemangiomas
2
PubMed Central. Discontinuous peripheral enhancement of focal liver lesions on CT and MRI: outside the box of typical cavernous hemangioma
3
PubMed. Quantitatively defining washout in hepatocellular carcinoma
4
PubMed Central. Hepatic Hemangioma: Review of Imaging and Therapeutic Strategies
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PubMed Central. Transient washout of hepatic hemangiomas: Potential pitfall mimicking malignancy
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PubMed Central. Multiple sclerosing hemangiomas mimicking hepatocellular carcinoma: A case report
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PubMed Central. Diagnostic Pitfalls of Hepatic Sclerosed Hemangiomas: A Case Report
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PubMed Central. Giant hepatic hemangioma with internal necrosis discovered due to fever of unknown origin and treated successfully with surgical resection: a case report
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PubMed. Is magnetic resonance imaging of hepatic hemangioma any different in liver fibrosis and cirrhosis compared to normal liver?
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PubMed Central. Hepatic cavernous hemangioma in cirrhotic liver: imaging findings
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PubMed Central. Adult hepatic cavernous hemangioma with highly elevated α-fetoprotein: A case report and review of the literature
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PubMed. Impact on liver cancer treatment of a first erroneous diagnosis of hemangioma
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PubMed. Contrast-Enhanced Ultrasound of Focal Liver Lesions
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PubMed Central. Contrast-enhanced ultrasound in liver cancer
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PubMed Central. Differentiating Liver Hemangioma from Metastatic Tumor Using T2-enhanced Spin-echo Imaging with a Time-reversed Gradient-echo Sequence in the Hepatobiliary Phase of Gadoxetic Acid-enhanced MR Imaging
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SpringerLink / J Gastroenterol. Artificial intelligence (AI) models for the ultrasonographic diagnosis of liver tumors and comparison of diagnostic accuracies between AI and human experts
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PubMed. Coexisting Infantile Hepatic Hemangioma and Hepatoblastoma in a Neonate: A Case Report
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PubMed Central. Infantile hepatic hemangioma misdiagnosed by prenatal ultrasonography: a case report
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PubMed Central. Hepatic hemangioma: What internists need to know
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PubMed Central. Atypical Manifestation of Primary Hepatocellular Carcinoma and Hepatic Malignancy Mimicking Lesions