Shrinking hemangiomas amid advancing cirrhosis: A report of 2 cases

Hepatic hemangiomas are the most common benign tumors of the liver. They typically display stable imaging features in non-cirrhotic livers. However, in the setting of cirrhosis, their imaging appearance may change dramatically, posing notable diagnostic challenges during hepatocellular carcinoma (HCC) surveillance. The shrinkage and altered imaging characteristics of hemangiomas in cirrhotic livers likely reflect fibrotic remodeling and changes in hepatic perfusion rather than true lesion involution. We highlight how fibrotic compression, vascular redistribution, and capsular retraction may cause hemangiomas to appear smaller or display atypical features on imaging, posing a diagnostic challenge. These changes can even mimic malignancy transformation, reducing clinical confidence and leading to potential misdiagnosis. Clinicians must remain aware of these potential pitfalls to avoid unnecessary intervention, maintain appropriate management, and approximate the true progression of hemangiomas in the setting of cirrhosis. Here, we report 2 cases of hepatic hemangiomas in patients with cirrhosis that demonstrated apparent regression on serial MRI. In both cases, hemangioma size decreased over time in conjunction with advancing parenchymal fibrosis, increased nodularity, and signs of portal hypertension. Despite the reduction in size, neither patient showed imaging features concerning for malignancy, and both remained stable with respect to liver function.