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# Benign liver lesions (haemangioma, focal nodular hyperplasia, adenoma)

Non-cancerous liver lumps, usually found by chance on a scan. Most need no treatment, but large adenomas can bleed or rarely turn into cancer.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Liver](https://durgical.com/en/anatomy/liver/)
- [Liver segment IV](https://durgical.com/en/anatomy/left-medial-segment-of-liver/)
- [Liver segment VI](https://durgical.com/en/anatomy/anterior-lateral-segment-of-liver/)
- [Liver segment VII](https://durgical.com/en/anatomy/posterior-lateral-segment-of-liver/)
- [Proper hepatic artery](https://durgical.com/en/anatomy/proper-hepatic-artery/)
- [Portal vein](https://durgical.com/en/anatomy/hepatic-portal-vein/)
- [Hepatic veins](https://durgical.com/en/anatomy/hepatic-veins/)
- [Gallbladder](https://durgical.com/en/anatomy/gallbladder/)

## Why it happens

- [Hyperplasia: physiologic and pathologic](https://durgical.com/en/general-pathology/hyperplasia-physiologic-and-pathologic/)
- [Benign vs malignant tumours: the comparison table](https://durgical.com/en/general-pathology/benign-vs-malignant-tumours-the-comparison-table/)
- [Actions of estrogen and progesterone](https://durgical.com/en/physiology/actions-of-estrogen-and-progesterone/)
- [Liver: lobule, acinus, hepatocytes, sinusoids, Kupffer cells](https://durgical.com/en/histology/liver-lobule-acinus-hepatocytes-sinusoids-kupffer-cells/)

## What it is

A group of non-malignant solid liver masses. The three most examined are haemangioma (a vascular malformation, the most common), focal nodular hyperplasia (a reactive nodule around an abnormal artery) and hepatocellular adenoma (a true benign tumour of hepatocytes linked to oestrogen). They are usually incidental findings on imaging.

## Who gets it

Very common with modern imaging. Haemangiomas are found in up to about 1 in 5 adults on imaging or autopsy, more in women. Focal nodular hyperplasia is the second most common, mostly in women aged 20 to 50. Adenomas are rare and occur mainly in women of reproductive age taking oral contraceptives, and increasingly with obesity and in men using anabolic steroids.

## Causes

- Haemangioma: congenital vascular malformation; may enlarge with oestrogen exposure or pregnancy
- Focal nodular hyperplasia: hyperplastic response of hepatocytes to an abnormal arterial blood supply
- Hepatocellular adenoma: oestrogen (oral contraceptives) and androgen/anabolic steroid exposure, obesity and metabolic syndrome, glycogen storage diseases

## Risk factors

- Female sex
- Long-term oral contraceptive use (adenoma)
- Anabolic steroid use (adenoma, especially in men)
- Obesity (adenoma)
- Glycogen storage disease type I (multiple adenomas)
- Pregnancy (growth of haemangioma or adenoma)

## Pathophysiology

Haemangiomas are blood-filled spaces lined by endothelium; slow blood flow explains the peripheral nodular contrast filling. Focal nodular hyperplasia is a nodule of normal hepatocytes arranged around a central fibrous scar containing a large artery that radiates outward (spoke-wheel pattern); it has no malignant potential. Adenomas are sheets of hepatocytes without portal tracts or bile ducts, supplied by thin-walled arteries, which explains their tendency to bleed; some molecular subtypes (beta-catenin activated) can transform into hepatocellular carcinoma.

## Classification

- Haemangioma: most common, no malignant potential
- Focal nodular hyperplasia: central stellate scar, no malignant potential, rarely bleeds
- Hepatocellular adenoma: subtypes HNF1A-inactivated, inflammatory, beta-catenin-activated (highest cancer risk) and unclassified
- Other benign lesions: simple cysts, nodular regenerative hyperplasia

## Symptoms and signs

- Usually none (found incidentally)
- Right upper quadrant fullness or discomfort with large lesions
- Sudden severe right upper quadrant pain and shock from adenoma rupture
- Early satiety from mass effect of large lesions
- In infants with large haemangiomas: heart failure or consumption coagulopathy

## Red flags

- Sudden right upper quadrant pain with low blood pressure (rupture and haemoperitoneum)
- Rapid growth of a lesion or growth during pregnancy
- Weight loss, raised alpha-fetoprotein or underlying cirrhosis (consider malignancy)
- An adenoma in a man (higher risk of cancer)

## Diagnosis

**Clinical**
Most are found incidentally. The history should cover contraceptive or steroid use, chronic [liver](https://durgical.com/en/anatomy/liver/) disease, cancer history and symptoms. A lesion in a cirrhotic liver is treated as hepatocellular carcinoma until proven otherwise.

**Tests**
Liver tests and alpha-fetoprotein are usually normal. Biopsy is rarely needed and is avoided in suspected haemangioma because of bleeding risk; it is used when imaging is inconclusive or to subtype adenomas.

**Imaging**
Ultrasound often finds the lesion first; haemangioma is typically well-defined and hyperechoic. Multiphase contrast CT or MRI characterises it: haemangioma shows peripheral nodular enhancement with progressive centripetal fill-in; focal nodular hyperplasia shows bright arterial enhancement with a central scar and retains hepatobiliary contrast on MRI; adenoma enhances in the arterial phase, may contain fat or blood, and does not retain hepatobiliary contrast. Contrast-enhanced ultrasound is another option.

## Differential diagnosis

- Hepatocellular carcinoma
- Liver metastases
- Liver abscess (pyogenic or amoebic)
- Hydatid cyst
- Focal fatty infiltration or sparing

## Goal of treatment

Characterise the lesion accurately, reassure when benign, and prevent bleeding or malignant change in high-risk adenomas.

## Treatment

**Conservative**
Haemangioma and focal nodular hyperplasia: no treatment or follow-up needed in most asymptomatic cases.

**Lifestyle**
Adenoma: stop oral contraceptives or anabolic steroids and lose weight if obese; many adenomas shrink.

**Surgical**
Resection for adenomas that persist above about 5 cm, any adenoma in a man, beta-catenin-activated subtype, or symptomatic or rapidly growing lesions; rarely for large symptomatic haemangiomas.

**Procedure**
Transarterial embolisation for a bleeding adenoma to stabilise the patient before surgery; ablation in selected cases.

**Follow-up**
Serial imaging for adenomas, including closer surveillance in pregnancy; urgent assessment of sudden abdominal pain.

## Complications

- Rupture and intraperitoneal bleeding (adenoma, rarely haemangioma)
- Malignant transformation of adenoma into hepatocellular carcinoma
- Consumption coagulopathy, a rare complication of giant haemangiomas (in infants the Kasabach-Merritt phenomenon comes from other vascular tumours, not true haemangiomas)
- Pain from thrombosis or bleeding inside the lesion

## Prognosis

Excellent for haemangioma and focal nodular hyperplasia. Adenomas usually do well once hormones are stopped or the lesion is resected; the main risks are bleeding and, for some subtypes, cancer.

## Prevention

- Avoiding anabolic steroids
- Choosing a contraceptive method without oestrogen after an adenoma is found
- Weight control

## Test yourself

Think of the answer, then tap the question to see it.

## What is the most common benign liver tumour?

Haemangioma.

## Which benign lesion has a central stellate scar?

Focal nodular hyperplasia.

## Which benign liver lesion is linked to oral contraceptives and can rupture?

Hepatocellular adenoma.

## Why is biopsy avoided in a suspected haemangioma?

Because of the risk of bleeding; imaging is usually diagnostic.

## Which adenoma subtype carries the highest risk of malignant change?

The beta-catenin-activated subtype.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/benign-liver-lesions/)

## Related conditions

- [Hepatocellular carcinoma](https://durgical.com/en/conditions/hepatocellular-carcinoma/)
- [Amoebic liver abscess](https://durgical.com/en/conditions/amoebic-liver-abscess/)
- [Pyogenic liver abscess](https://durgical.com/en/conditions/pyogenic-liver-abscess/)
- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)
- [Infantile hemangioma](https://durgical.com/en/conditions/infantile-hemangioma/)
- [Metabolic dysfunction-associated steatotic liver disease (MASLD/NAFLD)](https://durgical.com/en/conditions/metabolic-dysfunction-associated-steatotic-liver-disease/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Benign Liver Tumors - Hepatology - MSD Manual Professional Edition](https://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/liver-masses-and-granulomas/benign-liver-tumors) (MSD Manual Professional Edition, 2024).

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Source: https://durgical.com/en/conditions/benign-liver-lesions/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/benign-liver-lesions/