Case of ovarian cavernous hemangioma

Case report

A 46 year-old woman without any pathological background except multiple uterine leiomyomas was undergone to a total hysterectomy and bilateral adnexectomy. During study of surgical specimen, a little reddish nodule of 9 mm was discovered in the hilum of the left ovary. 

Microscopically, this nodule was made of dilated thin-walled vascular channels, filled of blood.

Image taken with a Moticam X3

These vessels were lined by flattened endothelium. 

Image taken with a Moticam X3

Diagnosis

Neither cellular atypia nor mitotic figures were seen. This lesion was diagnosed as ovarian cavernous haemangioma, with CD31 immunostain expression.

Differential diagnosis

• Hemangiosarcoma: Despite being vascular lesions, Hemangiosarcoma is more cellular, with atypia, mitotic figures and necrosis.

• Proliferation of dilated blood vessels in ovarian hilum: Microscopically the image could be similar but in this case there no a well-defined structure as nodule or tumour.

• Adenomatoid tumour: It is an uncommon tumour that may develop in Fallopian tube or ovary, which actually has a mesothelial origin. The channels in this case express immunohistochemical markers of mesothelial origin, such as Calretinin, Thrombomodulin, D2-40 and are negative for CD31 and CD34.

• Serous cystadenoma: Epithelial tumour where there walls are lined usually by ciliated columnar epithelial cells instead of flattened cells. CD31 and CD34 immunostains are obviously negative.

Discussion

Ovarian haemangiomas are uncommon neoplasias in which only less a few tens have been documented. They can appear at any age. Usually are asymptomatic and mainly they are discovered as incidental finding in surgical procedures performed by other reasons. Exceptionally, some ovarian haemangiomas can reach large volumes and cause abdominal pain or ascites and pleural effusion (Pseudo Meigs’ symdrome). Grossly, ovarian haemangiomas can have variable size that is between 0.3 – 24 cm.

Microscopically there are two subtypes of haemangioma: capillary or cavernous. The ovarian haemangiomas use to be of cavernous type. Histologically they are made of blood-filled dilated vascular channels, lined by flattened endothelial cells and express endothelial immunohistochemical markers such as CD31 or CD34.

The pathogeny remains unknown although some theories have been proposed related to hormones or some infections. This entity is still controversial about if they are hamartomas, congenital vascular malformations or true tumours.

References

Mona Dahal et al. "Ovarian Hemangioma: a rare entity". International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2018; 7:2490-2492 

Katayoun Ziari et al. "Ovarian Hemangioma: a Rare Case Report and Review of the literature". Iran J Pathol. 2016; 11:61 – 65

Sun Suk Kim et al. "Ovarian Cavernous Hemangioma Presenting as a Large Growing Mass in a Postmenopausal Woman: A Case Report and Review of the Literature". Journal of Menopausal Medicine 2015; 21:155-159

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Angel Garcia, MD PhD 
Head of Gynecopatholgy Unit
Staff member of Pathology
Associate Professor of Pathology
Department of Pathology
Vall d’Hebron University Hospital
Autonomous University of Barcelona