Q. Could my liver hemangioma actually be liver cancer?

Answered by
Dr. Arshad Hussain Shah
and medically reviewed by iCliniq medical review team.
Published on Jun 07, 2018 and last reviewed on: Oct 25, 2019

Hello doctor,

I started having right sided pain in the rib area around one year and three months ago. It got really bad last week and I went to a doctor. They did an ultrasound and found several hyperechoic nodular foci on the liver. He said this could simply represent hemangiomas but could be mucinous metastases. I started panicking as I have always had bad health anxiety. I went to get a CT scan and could not do a contrast so found well defined "mildly hypodense mass" measuring 44.6x32.9 mm. I started to get really bad - not sleeping, not eating, losing weight, bad headaches, ringing in ears, muscle twitches, shaking, etc. They scheduled me for biopsy and when I got there the surgeon said they pulled up my old CT from six years ago and the mass had not changed. So, it was most likely hemangioma and not going to do a biopsy.

I still kept on the downward spiral as I did not believe them. I was told an MRI with contrast was the best test for liver lesions so I paid and had that done. Also had a brain MRI done because I thought I definitely had stage 4 cancer. All of this was one year back. MRI showed multiple liver lesions with largest 30.5x23.9 mm. T2 hyperintense and several others. All identified as behaving as hemangiomas and simple cysts. Not being satisfied with that I had a colonoscopy and upper endoscopy done. Both alright. Decided to go to liver specialist and they did another MRI with 9 cc Multihance. Findings were all clear except liver with "multiple lobulated T2 hyperintense hepatic lesions" largest being 3.1x2.5 mm. All consitent with hemangiomas. "No suspicious hepatic lesions".

The specialist also told me if I had stage 4 I would be in very bad shape with no treatment. I started back working out and put all my weight back on up to 200 lbs and feeling better except same pain in right side rib area every day. Got another six month follow up MRI last month and nothing had changed. Last week, I started having pain again in right rib area and started internet searching again and finding most hemangiomas are single not multiple and most metastases are multiple, which mine are. Also that hemangiomas are mostly in women not men. So now I am back to not sleeping, not eating, and feeling like I have some type of stage 4 cancer. Never had any cancer diagnosis though and none in my family. Eat good, worked out twice a day, only drink water, maintain a healthy weight. Even though I know in almost a year and a half with no treatment and stage 4 I would be bad shape or actually dead as the average lifespan of stage 4 metastases without treatment is 8.7 years, but I do not really believe that because they are not oncologists. I looked up and saw that NET's could be slow-growing cancers and maybe I have that. I just need an independent second opinion on what could cause right side pain besides what is showing up in all the tests I have had done. Also if having three MRI's with contrast saying the same thing is specific enough to rule out liver metastases. Online it shows MRI with contrast has a 97 % specificity when done one time so is three times even better to rule it out? Why would a male in great shape otherwise develop hemangiomas throughout the liver? Would a PET scan be better than MRI at this point? Thanks.

Dr. Arshad Hussain Shah

Medical Oncology
#

Hello,

Welcome to icliniq.com.

Do not worry and do not panic. All your reports (attachment removed to protect patient identity) are pointing towards hemangiomas. It is easy to differentiate between cancer and hemagioma by a radiologist on CT scan, MRI, or ultrasound. Your reports are clearly indicating cystic lesions (hemangiomas).

If these liver lesions were cancerous, usually they will be symptomatic - progressive weight loss, poor appetite, jaundice and deranged liver function tests, sometimes dark urine, etc.

Any cancerous liver lesion will progressively increase in size. Even slow-growing metastatic neuroendocrine in liver is usually stage 4 neuroendocrine tumor.

Your blood report is showing normal liver parameters, CT scan/MRI showing cystic/hemangiomas in liver. Any radiologist can easily differentiate between hemangioma and metastasis. So, your radiologist has mentioned clearly benign cystic lesions.

Also, you have no weight loss, poor appetite, and your liver parameters in blood test are normal. Also, colonoscopy and gastroscopies are normal (there was no need to go for endoscopy).

So, relax and do not worry at all. But keep following up with the hepatologist for these hemangiomas.

Internet search information will confuse you. If any questions, contact me for free for one more time in the next few days.

For further queries consult a medical oncologist online --> https://www.icliniq.com/ask-a-doctor-online/medical-oncologist

Thank you doctor,

I have a poor appetite when I start worrying about metastases but other than that my weight has been the same, actually increased since last year. My serotonin levels were also fine. I just stay worried because I am a male and hemangiomas normally are for females so having so many of them is just really worrisome that they are missing something and why do I have them, but as time goes by it gets easier. I do see where up to 20 % of the population can have them but do not get screened. So, they never know. I still get the intermittent right side pain some days so it is a constant reminder. I had never contacted an oncologist though and so to hear that is refreshing as I just hear from my regular doctor and liver doctor that the average total life span of stage 4 metastatic cancer is about 8.7 months untreated, (not years like I said above sorry) and I am going on 15 months now. So, I would be dead or in bad condition, but I am still working out and working every day. Also, my complete blood workups would surely show at least one enzyme or tumor marker off or blood cell counts off I would think. Just the anxiety wears me down. Thanks again.

Dr. Arshad Hussain Shah

Medical Oncology
#

Hello,

Welcome back to icliniq.com.

Multiple hemangiomas or large hemangioma can cause abdominal pain and discomfort.

Hemangiomas are more in females that does not mean that they are not in males.

Poor appetite can be due to many reasons even anxiety is one of the causes.

For more information consult a medical oncologist online --> https://www.icliniq.com/ask-a-doctor-online/medical-oncologist

I have a few more questions for you and would like you to look at the last 2 reports I had done comparing all of my MRIs. All of them are saying nothing has changed over a year and even the largest one as far back as 2012 and that there are no suspicious lesions. I still have the pain though in right and left rib area which by what everything I'm looking up is liver? something these last 2 reports, I had 2nd opinions read the scans, showed and even the one from Feb is my liver size was 17.5 cm, and 18 and 17.8 and 17.6. which by what I'm finding is considered just outside of the normal range. it is concerning that the original reports, especially the Emory University ones as I respect their expertise and that's where my liver specialist is out of, only showed "liver is normal in size". also the original Anderson. radiology MRI and CT showed "normal size liver". How do I distinguish these 2 different readings and coukd it be that size is "normal" for my larger body cavity? also if not normal could that explain my pain in ribs? also could the hemangiomas volume expand the liver size being they are technically tumors? with all my liver bloodwork normal and tumor markers normal and no hepatitis or cirrhosis why would my liver be larger if it is so? Thank you.

Dr. Arshad Hussain Shah

Medical Oncology
# Hemangiomas can some times present with large sized liver. Which can cause pain , fullness and discomfort on the right side of upper abdomen . Even sometimes hemangiomas can increase in size ( yearly 0.1 to 0.3 cm approximately ) , mostly in young people who are less than 30 years of age .
For Liver - MRI study is better Diagnostic tool as compared to ultrasound and CT scan . Your reports are showing that there is no suspicious lesion in the liver and the lesions are unchanged hemangiomas when compared to previous reports . Your liver is functioning well as Liver FUnction test is normal .
If there would have been any suspected cancerous lesion . It would interfere with liver function and will destroy the Liver in months .
Usually suspected Liver lesions ( cancer) can not stay same sized even for few months and they usually produce signs and symptoms eg progressive weight loss , nausea , loss of appetite , jaundice , fatigue even can cause bleeding . Your liver enzymes ALT , AST , alkaline phosphate and all other liver parameters are normal .
Your pain can be related to stomach upset , musculoskeletal disorder , anxiety or even due to liver hemangiomas
So Don't worry just keep regular follow up with your Hepatologist . He will monitor your Liver regularly
Hemangiomas are the most common benign ( non Cancerous ) tumours of liver . Most the of people live with them life long without any kind of intervention
Thank you. That is what I thought. i was just wondering why all the reports said normal size of liver and showed measurements of 17 cm+ but when I looked it up over 17 cm was considered large? I was thinking that could be because for my chest size 48 and only 32 waist that maybe according to my body size it is not really large so that's why the reports say "normal size and contour" of liver? I did also look up a German study on liver size of over 2000 people and showed the avg for male was 15.1 +/- 1.5 cm so mine would put me just outside the upper variance range correct? And with several hemangiomas the largest being almost 4cm, those would have to increase volume I would think, like you already said. But thank you again. All of this is just so confusing to me esoecially when I start searching the internet, which I am trying to do less.

Dr. Arshad Hussain Shah

Medical Oncology
# Don't worry about this hepatomegaly ( little large sized liver ) . it is due to burden of hemangioma on liver . Also your liver function test is normal so don't worry
Now your liver will be monitored every every 3 to 6 months for any change in size of hemangioma size , liver size . change in the lesions . They will compare always old and new scans . Also your liver function tests will be monitored
Just a follow up as I found a radiologist reading from the 2012 CT scan and it also showed my liver at 17.5 cm so even as far back as 2012 my liver was the same size which gives me some comfort. Also this 2012 reading that I attached states "Foci of hypodensity are seen in the pepatic parenchyma, consistent with known multiple hepatic hamangiomas", which would seem to suggest these things have been there going on 6 years almost now. The reason I am following up is today I received a breath test back that was positive for SIBO (small intestine bacteria growth) is what they said. They called me in an antibiotic which I will start, however my searching the internet again has gotten me all worked up. It lists a lot of benign things this SIBO can be but at the bottom it shows things like small bowel tumors or lymphoma, which is what I have thought I've had all along based on my symptoms. My question is would any of the tests I had including all my blood tests, Colonoscopy, Upper Endoscopy, CT's with barium of abdomen, and multiple contrast MRI's have picked up something in my small bowel like a tumor or picked up swollen lymph nodes in small bowel? These 2nd opinion reports I had done and attached remark that "No small or large bowel dilation" and "No evidence of bowel obstruction" does that mean the small intestines can be visualized? If I had a small bowel tumor and it had metastasized to the liver in 2012 or late 2016 would I be having other symptoms? Would the liver lesions be much bigger? Would an MRE of the specific small bowel be a test I should ask for? Thank you.

Dr. Arshad Hussain Shah

Medical Oncology
# Usually small bowel tumours are rare , Anatomically the lumen of small bowel is small as compared to large bowels So these these tumors present with early symptoms and signs . The most common symptoms and signs of small bowel tumors are bowel obstruction , central abdominal pain , abdominal distention , weight loss , recurrent vomiting and constipation
There are number of different type of small bowel tumors e.g adenocarcinoma , carcinoid ,GIST , lymphoma ,neuroendocrine tumors . But all of them are rare in clinical practice .Small bowel tumors produce early signs and symptoms as mentioned above
Your previous scans have not picked up any small bowel pathology .Usually It is difficult to pick up small bowel tumor or lesion on imaging scans eg CT Scan abdomen or MRI unless its size is large . The tests which can pick up small bowel tumours easily are capsule endoscopy , balloon assisted enteroscopy and C.T enterography
Just SIBO positive alone does not justify to go for these tests
Usually if small bowel tumors will be left untreated for 3 or 4 months , They will definitely cause obstruction in most of the cases and there is no recommended screening for these tumors in most of the countries
SIBO is a common bowel infection , so it needs antibiotics for eradication . Nothing to worry about anything serous
So just to clarify in my mind if I had a small bowel tumor that had already metastasized to my liver from over a year ago or especially back to 2012 I would be having much worse problems, showing anemia in my blood work, severe bowel obstruction, or even be dead at this point with no treatment? I have had no constipation just a lot of gas, sour like stomach which make a lot of noise after I eat, and the right and left UQ pain that I have been experiencing for almost a year and a half now, with somewhat loose stools but go regular every morning. Some low back pain. No blood in stool or fatigue or extreme weight loss and still able to work every day and exercise twice a day. Bottom line I guess is that I just want to find out if this SIBO thing would be tied into these liver lesions/hemangiomas in any way that it would be a stage 4 cancer? They did prescribe me Rifaximin that I start today. Thanks again.

Dr. Arshad Hussain Shah

Medical Oncology
# Malignant small bowel tumour if left untreated for long time. It will definitely metastasize to other organs and cause infiltration to near by organs . Even it can will cause bowel obstruction just in few months of appearance
So nothing to worry about and don't link your SIBO with small bowel tumour . Cancers have specific presentations and features
Your signs and symptoms and radiological findings don't raise suspicious about malignancies
Continue treatment for SIBO as prescribed by your doctor .
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