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  Table of Contents    
CASE REPORT  
Year : 2016  |  Volume : 59  |  Issue : 2  |  Page : 220-222
Cavernous hemangiomatous polyp of uterus: A report of case and review of literature


Department of Pathology, University of Florida College of Medicine, Jacksonville, FL 32209, USA

Click here for correspondence address and email

Date of Web Publication9-May-2016
 

   Abstract 

Cavernous hemangiomatous polyp of uterus is a rare vascular malformation of the uterus. Common sites of malformation in uterine wall include serosa, myometrium, and endometrium and most common presentation is diffuse involvement of uterus. Patients usually present with obstetric and gynecological complications ranging from menorrhagia, intermenstrual bleeding, infertility, and pregnancy-associated complications which includes maternal and fetal demise due to excessive bleeding. Uterine hemangiomas occur at all age groups without preponderance in any decades and are classified into congenital and acquired. Congenital hemangiomas may be associated with hereditary diseases whereas acquired hemangiomas are thought to be associated with both physical changes and hormone alterations.

Keywords: Cavernous hemangioma, polyp, uterus

How to cite this article:
Shahid M, Nisar N, Saremian J. Cavernous hemangiomatous polyp of uterus: A report of case and review of literature. Indian J Pathol Microbiol 2016;59:220-2

How to cite this URL:
Shahid M, Nisar N, Saremian J. Cavernous hemangiomatous polyp of uterus: A report of case and review of literature. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Dec 16];59:220-2. Available from: http://www.ijpmonline.org/text.asp?2016/59/2/220/182024



   Introduction Top


Vascular malformation of the uterus and cervix is uncommon. Common sites of involvement in uterine wall include serosa, myometrium, and endometrium. Most common presentation is diffuse involvement of myometrium. Patients usually present with obstetric and gynecological complications ranging from menorrhagia, intermenstrual bleeding, infertility, and pregnancy-associated complications which includes maternal and fetal demise due to excessive bleeding.[1],[2],[3],[4] Uterine hemangiomas are classified into congenital and acquired. Congenital hemangiomas may be associated with hereditary diseases, including Klippel–Trenaunay syndrome, hereditary hemorrhagic telangiectasia, tuberous sclerosis, blue rubber bleb nevus syndrome, Maffucci syndrome, and Kasabach–Merritt syndrome. Acquired hemangiomas are thought to be associated with both physical changes and hormone alterations.[2] Here, we report a case of cavernous hemangiomatous polyp of the uterus which presented as postmenopausal bleeding.


   Case Report Top


The patient is a 57-year-old postmenopausal female, Gravida 2 Para 2, presented with uterine bleeding for last 1 year. She achieved menopause 5–6 years back and was not on any hormonal treatment. Her both previous pregnancies had resulted in full-term normal spontaneous vaginal deliveries. She has an average build and medium height and general examination of heart, chest, and abdomen did not reveal any abnormality. Her last pap smear 3 months back which was negative for intraepithelial lesion or malignancy. Speculum examination of vagina revealed atrophic changes and 1 cm × 2 cm exophytic, pink, nonfriable vaginal mass 2 cm inferior to cervix on the right vaginal wall. Bimanual examination revealed an anteverted, smooth, and multiparous uterus. Transvaginal ultrasonography findings were anteverted uterus measuring 7.58 cm × 4.77 cm × 4.90 cm with endometrial thickness of 1.65 mm. Endometrial cavity was distorted by 2.02 cm × 2.65 cm hyperechoic mass and a provisional diagnosis of endometrial polyp was made. The myometrium was normal. The patient underwent hysteroscopic removal of endometrial polyp. Microscopic examination revealed large cystically dilated blood vessels with thin walls lined by a single layer of flat endothelial cells in a background of atrophic endometrium [Figure 1]. Immunohistochemistry showed positivity for CD31, CD 34, and factor VIII antigen supporting histological diagnosis of cavernous hemangiomatous polyp [Figure 1].
Figure 1: Section shows polypoid tissue fragments with cystically dilated vascular spaces filled with blood and few endometrial glands in background (H and E, ×5), CD 31 positivity (IHC, ×10), CD 34 positivity (IHC, ×10), Factor VIII antigen positivity (IHC, ×10)

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   Discussion Top


Vascular tumors are rare in female genital tract, particularly in uterus uterine hemangiomas were first described in 1897, and were an incidental discovery at an autopsy after a young woman developed anemia and dyspnea and died 24 hours after delivering twins.[1] Clinically significant vascular lesions which have been described in the uterus include capillary and cavernous hemangiomas, arteriovenous malformations, angiomyomas, and hemangioendotheliomas.[1] Cavernous hemangiomatous polyp of the uterus is a rare vascular neoplasm in which there is proliferation of arterial and venous vessels of various sizes with cavernous like arteriovenous fistulas in uterine wall which replaces the normal myometrium.[3],[5],[6] Review of literature of uterine hemangioma reveals youngest patient was a 14-year-old girl who underwent hysterectomy for life-threatening bleeding [7] and the oldest patient was a 49-year-old woman who underwent hysterectomy for menorrhagia and dysmenorrheal.[2] This case presented as a postmenopausal bleeding, and only a few cases have been described in literature in postmenopausal females. The clinical symptoms are varied which ranges from asymptomatic to abdominal pain, excessive vaginal bleeding, anemia, infertility, and maternal and pregnancy-associated complications.[2] However, in gynecological practice, these patients usually present with recurrent menorrhagia, as seen in our case.

Uterine body is the most common site for hemangioma, but they can also involve uterine corpus or the cervix. Hemangiomas can be diffuse or localized. Most common presentation of a localized hemangioma is as an endometrial polyp or a localized mass in the myometrium. Diffuse hemangioma commonly present as transmural involvement of uterine wall from endometrium to the serosa.[8] Histologically, uterine hemangiomas can be divided into a capillary or a cavernous type. The capillary type is composed of small-sized capillary vessels and is usually confined to the endometrium, whereas the cavernous type demonstrates large dilated vascular channels and diffusely involves the uterus.[6] There are theories supporting the role of hormones in pathogenesis of acquired hemangioma, however, their direct association was not confirmed by immunohistochemical stains for estrogen and progesterone receptors. Indirect evidence suggests that estrogen may have a prominent role in angiogenesis and vasculogenesis through various angiogenetic factors resulting in the formation of hemangioma although direct association is still unclear.[2]

Differential diagnosis of uterine hemangioma includes lesions with vascular dilatation such as lymphangioma, arteriovenous malformation, and adenomatoid tumor. Uterine hemangioma can be diagnosed by ultrasonography that reveals a thickened uterine wall which is composed of cavernous fluid filled spaces with a turbulent flow in these spaces.[4] Other diagnostic modalities which can aid ultrasonography in diagnosis are Doppler, magnetic resonance imaging, and computed tomography imaging.

Treatment for uterine hemangiomas remains controversial. Conservative treatments include carbon dioxide laser excision, knife excision, cryotherapy, radiotherapy, electrocauterization, internal artery ligation, uterine artery embolization, local excision, conization, and laser ablation.[8],[9],[10] Hysterectomy may be considered for hemangioma, if they are refractory to conservative treatments.[10] Conservative management is the treatment of choice in young females before hysterectomy. Our patient presented with postmenopausal bleeding not responding to medical treatment and underwent hysteroscopic polypectomy. Cavernous hemangiomatous polyp can present as postmenopausal bleeding and polypectomy can be treatment of choice if rest of uterus does not have any pathology. It is important for a pathologist to recognize this entity, not only because of its potential for life-threating complications, but also because of the need for individualized treatment.[2],[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Johnson C, Reid-Nicholson M, Deligdisch L, Grinblat S, Natarajan S. Capillary hemangioma of the endometrium: A case report and review of the literature. Arch Pathol Lab Med 2005;129:1326-9.  Back to cited text no. 1
    
2.
Chou WY, Chang HW. Uterine hemangioma: A rare pathologic entity. Arch Pathol Lab Med 2012;136:567-71.  Back to cited text no. 2
    
3.
Malhotra S, Sehgal A, Nijhawan R. Cavernous hemangioma of the uterus. Int J Gynaecol Obstet 1995;51:159-60.  Back to cited text no. 3
    
4.
Lotgering FK, Pijpers L, van Eijck J, Wallenburg HC. Pregnancy in a patient with diffuse cavernous hemangioma of the uterus. Am J Obstet Gynecol 1989;160:628-30.  Back to cited text no. 4
    
5.
Sharma JB, Chanana C, Gupta SD, Kumar S, Roy K, Malhotra N. Cavernous hemangiomatous polyp: An unusual case of perimenopausal bleeding. Arch Gynecol Obstet 2006;274:206-8.  Back to cited text no. 5
    
6.
Lee EJ, Kim SH, Kim YH. Uterine cavernous haemangioma in a post-menopausal woman: CT and MRI findings mimicking uterine myoma with degeneration. Br J Radiol 2011;84:e68-71.  Back to cited text no. 6
    
7.
Ali SS, Muzaffar S, Kayani N, Setna F. Capillary haemangioma of the uterus: A rare cause of menorrhagia. Aust N Z J Obstet Gynaecol 2003;43:85-6.  Back to cited text no. 7
    
8.
Virk RK, Zhong J, Lu D. Diffuse cavernous hemangioma of the uterus in a pregnant woman: Report of a rare case and review of literature. Arch Gynecol Obstet 2009;279:603-5.  Back to cited text no. 8
    
9.
Gupta R, Singh S, Nigam S, Khurana N. Benign vascular tumors of female genital tract. Int J Gynecol Cancer 2006;16:1195-200.  Back to cited text no. 9
    
10.
Benjamin MA, Yaakub HR, Telesinghe P, Kafeel G. A rare case of abnormal uterine bleeding caused by cavernous hemangioma: A case report. J Med Case Rep 2010;4:136.  Back to cited text no. 10
    

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Correspondence Address:
Mohammad Shahid
University of Florida College of Medicine, Jacksonville, First Floor, Clinical Center, 655 West Eight Street, C504 Jacksonville, FL 32209
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.182024

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