Surgical decisions regarding cavernous hemangioma of the liver require consideration of the natural history of the lesion. To provide background, we retrospectively evaluated 49 cases of such hemangiomas exceeding 4 cm in diameter. There were 36 female patients (including 4 infants) and 13 males. Their ages ranged from 1 month to 68 years and averaged 44 years. Surgical procedures that ranged from simple excision to hepatic lobectomy were performed on 13 patients. Four had postoperative complications. There were no surgical deaths or any late deaths attributable to hemangioma. The other 36 patients have been observed for up to 15 years (mean 5.5 years) without the need for surgery. None of the patients in this group died, and none has experienced intraperitoneal hemorrhage or intensification of symptoms, although the size of four lesions increased. The benign course should be considered when deciding on management of lesions that are asymptomatic or so large as to pose significant operative risk.