Perfusion vascularity mismatch is characteristic of liver cavernous hemangiomas. The large blood volume and slow perfusion are responsible for this pattern. Often a large lesion demonstrate “cold” areas within the hemangioma, which are explained by slow or absent perfusion due to localized thrombosis. The authors present a polyvinyl- chloride worker with a large liver lesion whose Tc-99m RBC scintigraphy was consistent with cavernous hemangioma with a “cold” area. The lesion was diagnosed at surgery as hemangiosarcoma. It is concluded that malignant vascular lesions of the liver cannot be differentiated from the benign lesions by RBC imaging alone, because they may demonstrate similar patterns.