Ovarian hemangioma: Differential diagnosis of ovarian cancer

Abstract

Introduction and importance

Ovarian cavernous hemangioma is a rare benign vascular tumor primarily found as either an isolated ovarian mass or as diffuse abdominopelvic hemangiomatosis. Its discovery is often incidental, but symptomatic presentations can occur, including ovarian torsion, can occur without any specification.

Case presentation

We present the case of a 55-year-old menopausal woman with chronic pelvic pain. Initial diagnostic imaging and tumor markers suggested ovarian malignancy. Subsequent investigations, including ultrasound and MRI, revealed a vascularized adnexal mass with characteristics mimicking malignancy. Surgical exploration through laparoscopy unveiled an 8 cm multicystic solid-cystic lesion with histopathological analysis confirming a 9 cm cavernous hemangioma.

Clinical discussion

Histologically, the lesion displayed features consistent with a benign vascular malformation. Literature review indicates variability in presentations and diagnostic challenges in distinguishing these lesions from malignant ovarian tumors. Treatment involved successful cystectomy via laparoscopic surgery, ensuring ovarian preservation so as not to increase the cardiovascular risk due to bilateral annexectomy.

Conclusion

Ovarian cavernous hemangiomas pose diagnostic challenges due to their rarity and potential mimicry of malignancy. Timely recognition through imaging modalities, especially MRI, and confirmation via histopathological examination remain pivotal. Ovarian-sparing surgical interventions are recommended, particularly for younger patients without suspicious tumor features. Despite their rarity, awareness of these lesions is crucial for accurate diagnosis and appropriate management.

Highlights

• •Rare Vascular Tumor: Discusses the rarity of ovarian cavernous hemangioma, presenting as either isolated ovarian masses or diffuse abdominopelvic hemangiomatosis.
• •Diagnostic Challenges: Explores the diagnostic challenges due to its varied presentations, often mimicking ovarian malignancy, and the significance of imaging modalities, especially MRI, in accurate diagnosis.
• •Pathophysiology Insights: Provides insights into the unclear pathophysiology, discussing potential factors such as transforming growth factor-beta1, hormonal stimulation, and debates on the nature of these lesions (true tumors, hamartomas, or stimulated vessels).
• •Treatment Strategies: Discusses treatment modalities, emphasizing the importance of ovarian-sparing surgery, especially in younger patients without suspicious tumor features, and highlights successful laparoscopic cystectomy as a feasible intervention.

1. Introduction

Hemangiomas are benign vascular tumors. They are most commonly found in the skin and liver and can be diagnosed from early childhood to old age. Their occurrence in the ovaries is rare and often asymptomatic [15]. However, they can be associated with thrombocytopenia, acute abdominal pain, vomiting, ascites, and an elevation in CA125 [14]. In such cases, they can mimic ovarian cancer [16,17]. The cavernous type is the most frequent.

We present a case of a 55-year-old patient who sought consultation due to chronic pelvic pain. Ovarian cancer was suspected initially, but upon histopathological examination, it was revealed to be a cavernous hemangioma.

Hemangiomas typically aren't found in the ovaries, so the presentation of symptoms mimicking ovarian cancer can lead to misdiagnosis. In this particular case, a patient's chronic pelvic pain triggered suspicion of ovarian cancer, but the histopathological analysis after examination revealed a different diagnosis—cavernous hemangioma.

This work was reported in line with the SCARE criteria [18].

2. Observation: a case study

This concerns patient M.M., a 55-year-old, blood type O-positive, with no significant medical history but a gravidity of 4 and parity of 4 (four deliveries with four living children), menopausal for the past 5 years. She presented with chronic pelvic pain persisting for a year. On examination, the patient was conscious, with a soft and depressible abdomen. Palpation revealed an indolent Left iliac fossa mass with no guarding. Speculum examination displayed no bleeding from the cervix.

Ultrasound examination (Fig. 1) revealed a normal-sized uterus with a normal echo structure and a thin endometrium. There was an echogenic, septated, left ovarian image measuring 82*55 mm with vascularized vegetations in Doppler Ultrasound and thickened walls, classified as ORADS 4. The right ovary showed no anomalies, and there was no fluid collection.

Fig. 1.

a: Ultrasound Doppler vascularisation.

b: Ultrasound measurement.

Pelvic MRI (Fig. 2) indicated a multicystic, fluid-filled mass in the left ovary with some tissue components enhancing with contrast-enhanced T2-weighted images curve, measuring 825,852 mm, classified as ORADS 4. There were multiple subendometrial spots in the transitional zone, which had a normal thickness of <12 mm and hyperintense signals on T2, with the largest measuring 6 mm, suggestive of subendometrial cysts.

Fig. 2.

MRI sagittal and axial cut.

Tumor markers showed CA125 at 9.14 U/ml and CA19-9 at 18.48 U/ml, raising suspicion for ovarian cancer also those markers can be elevated in nonmalignant cases.

The patient underwent laparoscopy revealing a normal-sized and structured uterus, normal digestive system, and liver with no anomalies. Both fallopian tubes appeared healthy, and the right ovary showed no abnormalities. There was no peritoneal carcinomatosis and there were no metastatic lesions in the surface of the intestinal tract, perineum, and omentum. However, the left ovary displayed an 8 cm multiloculated solid-cystic cyst with a whitish vegetation on the wall measuring 15 mm. Procedures included cytology, left-sided annexectomy, and multiple biopsies.

The operative report described a multicystic tumor formation with a fibrous capsule. This formation consisted of vascular sections, often of considerable size, occasionally interconnected and anastomosed, containing dilated lumens filled with clot material. Their walls showed dystrophic smooth muscular tissue, remodelled by fibro-hyalinosis. The ovarian parenchyma showed dystrophic changes with corpora albicantia and non-specific fibro-hyalinosis. These features were consistent with a large cavernous hemangioma measuring 9 cm.

This case study highlights the complexity of diagnosing ovarian lesions, where clinical and radiological findings initially suggested ovarian cancer, but the histopathological analysis following surgery revealed a rare presentation of a cavernous hemangioma in the ovary.

3. Discussion

The discussion focuses on ovarian cavernous hemangioma, a rare benign vascular tumor primarily located unilaterally on the periphery of the ovary [13]. Payne first described it in 1869. Most reported cases occur in menopausal women, with an onset age ranging from 4 months to 81 years [1].

The exact pathophysiology remains unclear, although some authors suggest the involvement of transforming growth factor beta1 and hormonal stimulation. Typically asymptomatic [2], these cysts are often incidentally discovered during abdominal or pelvic examinations [13]. However, complications may arise, leading to acute ovarian torsion, painful manifestations, ascites, or an abdominal pelvic mass [3].

Ultrasound reveals a highly vascularized adnexal mass, often resembling malignant characteristics. MRI plays a crucial role in characterizing the mass, where T2-weighted images showing isointensity to cerebrospinal fluid [4], significantly intensifying on contrast-enhanced T1-weighted images, strongly indicate an ovarian vascular tumor [12].

Debate persists regarding whether ovarian hemangiomas constitute true tumors, hamartomas, or stimulated vessels. Some propose they could be congenital malformations or neoplasms [5], possibly influenced by pregnancy, hormonal factors, or infection. The hypothesis of estrogenic effects on vascular growth is supported by the presence of estrogen receptors in most hemangiomas [11]. Others suggest ovarian hemangiomas might arise from reactive stromal luteinization culminating in hyperandrogenism and hyperestrogenism [6].

Histological examination confirms the diagnosis, differentiating between cavernous or capillary types (Fig. 3) [7]. Histologically, these benign lesions result from vascular malformation, particularly flawed vascular canalization, forming abnormal vascular channels [8].

Fig. 3.

Histology. Dilated or cystic vessels more or less anastomosed.

Treatment typically involves cystectomy via laparotomy or laparoscopy. Ovarian-sparing surgery is recommended for young women, especially in non-suspicious tumor cases [9].

Prognosis for ovarian hemangiomas is generally favorable. Despite their rarity and potential complications, timely diagnosis and appropriate surgical intervention lead to positive outcomes [10].

4. Conclusion

Ovarian cavernous hemangioma is rare and can manifest either as an isolated ovarian mass or as diffuse abdominopelvic hemangiomatosis. These growths are typically discovered incidentally but can occasionally lead to symptomatic presentations, such as ovarian torsion.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Not applicable. Our institution requires no ethical approval for case reports.

Funding

Not applicable.

All authors read and approved the final manuscript.

Author contribution

Montacer Hafsi; conception and design, acquisition of data, drafting the article, revising it critically for important intellectual content final approval of the version to be published.

Marwa Moussi conception and design, acquisition of data, drafting the article, revising it critically for important intellectual content final approval of the version to be published.

Souhir Najar final approval of the version to be published.

Faten Dridi final approval of the version to be published.

Smaoui Maroua final approval of the version to be published.

Mechaal Mourali final approval of the version to be published.

Guarantor

The corresponding author is the guarantor of submission.

I, Montacer Hafsi hereby affirm that this manuscript is original, has not been published previously, and is not under consideration for publication elsewhere. All authors have contributed significantly to this work and have reviewed and approved the final version of the manuscript for submission. We confirm that all sources used have been properly cited and that any conflicts of interest have been disclosed.

Registration of research studies

None.

Declaration of competing interest

All authors declare that they have no conflicts of interest.

Data availability

Not applicable.