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Case Clinic:
Liver hemangiomas

Munich Re’s medical experts respond to challenging underwriting scenarios

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    November 2023

    This series presents individual medical cases that feature challenging conditions, uncommon diseases, or an unusual presentation of symptoms. Below we summarize a case, explain our research and analysis, and suggest an underwriting recommendation. Munich Re’s team of global medical directors routinely conducts rigorous analyses of the latest medical advances so that primary insurers and society alike can benefit from evidence-informed risk assessments. It is our hope that exploring compelling cases will foster a greater understanding of medical research and awareness of new medical innovations and emerging risks while ultimately expanding insurability.

    Case: Liver hemangiomas

    The Munich Re medical team investigated the insurability of a person with liver hemangiomas. The team asked the question, “Does the lesion need to be fully removed with benign pathology before any offer can be made?”  

    Munich Re medical's response

    • A hemangioma is a cluster of blood vessels that resembles a mass. Often considered a congenital anomaly, it can occur anywhere in the body but is frequently seen on the skin. When located in the liver, it is referred to as a liver hemangioma, hepatic hemangioma, or cavernous hemangioma. 
    • Hemangiomas are the most common benign tumor of the liver, seen in up to 20% of the general population.1 With the increase in abdominal imaging such as CT scans, MRIs, and ultrasounds, many more are being discovered incidentally when a person has no symptoms. Most are asymptomatic with excellent prognosis, although a few may have symptoms such as pain. Liver hemangiomas are often solitary, but sometimes multiple lesions are present. The majority are followed by serial imaging, with surgical resection being rare. 

    • Bleeding from a rupture of blood vessels is rare, but can occur. Once hepatic cellular carcinoma is ruled out, the overall prognosis for most patients is excellent, as the majority remain asymptomatic with stable lesions. Size is an important prognostic factor along with stability on surveillance imaging.

    Final recommendation

    Munich Re determined that a careful review of the serial imaging studies is required for any applicant with a history of liver hemangioma(s). No further imaging may be needed for small, asymptomatic lesions < 5 cm. For lesions > 5 cm, repeat imaging, preferably with a contrast-enhanced MRI, should be done in six to twelve months.2 If the lesion remains stable (i.e. growth rate < 3 mm/year), then no further imaging is needed and the risk may be accepted at standard.
    Contact the author
    Gina Guzman
    Dr. Gina Guzman
    Vice President & Chief Medical Officer
    Munich Re Life North America
    References
    1. Xie, Qs., Chen, Zx., Zhao, Yj. et al. Outcomes of surgery for giant hepatic hemangioma. BMC Surg 21, 186 (2021). https://doi.org/10.1186/s12893-021-01185-4 2. Leon, M., Chavez, L., & Surani, S. (2020). Hepatic hemangioma: What internists need to know. World Journal of Gastroenterology, 26(1), 11-20. https://doi.org/10.3748/wjg.v26.i1.11