English

Abstract

The Editor, Sir, Haemangiomas were first described by Payne in 1869 (1). In the literature, their coexistence with various diseases of the female genital tract has been reported (2–5). Our case differs in that a postmenopausal woman had a mucinous cystadenoma in one ovary and an incidentally discovered cavernous haemangioma with focal positivity for progesterone receptor (PR) in the other ovary. An 81-year old woman had right lower quadrant pain. Transabdominal sonography revealed a 10 cm right ovarian cystic and septated mass. No left adnexal lesion was reported. There was no sign of ascites. The serum cancer antigen (CA) 125 level of the patient was 144.9 IU/mL (ref 0–35), serum Ca-19–9 level was 24.9 IU/mL (ref 0–39). Magnetic resonance images revealed a well circumscribed, slightly lobulated contoured, T1 SE hypo-, T2 SE hyperintense, multilocular cystic lesion in the right half of the pelvis (Figs. 1A–D). The left ovary measured 34 × 14 × 35 mm with slight spiculations and was isointense to myometrium on T1 SE and T2 SE weighted sequences (Fig. 1A–B). With injection of contrast material, slightly heterogeneous parenchymal contrast enhancement less than the myometrium was observed (Fig. 1A–D). Fig. 1 Magnetic resonance imaging shows right ovarian lesion to be a multilocular cyst; (A) homogeneous hypo-signal intensity on T1-weighted images and (B) high signal intensity on T2-weighted images. Left ovary has slight spiculations isointense on T1 and T2 ... The result of the right ovary was reported as a mucinous cystadenoma on frozen section (Fig. 2). Fig. 2 Histologically, the right ovarian cyst was lined by mucinous epithelium (HE × 20). On the cut surface of the left ovary (4 × 3 × 1.5 cm in size), a haemorrhagic nodular lesion, 2.5 × 1.5 cm in size, was noted. Microscopic sections revealed dilated, thin-walled vascular structures, variable in diameter, and the walls of which were comprised a single layer of endothelial cells not showing atypia (Fig. 3). Fig. 3 Near the ovarian stroma, dilated thin walled vessels were lined by a single layer of endothelial cells, containing red blood cells in their lumen (HE × 4). Based on macroscopic, morphologic and immunohistochemical findings of factor 8 (FVIII), CD 34, smooth muscle actin (SMA) expression, the case was reported as ovarian cavernous haemangioma. Oestrogen receptor (ER) was negative; however, some endothelial cells were positive for PR (Fig. 4). Fig. 4 Immunohistochemical findings; (A): strong positivity for factor 8 and (B): CD 34 in cells lining the cavernous vessels; (C): immunoreactivity for smooth muscle action in the walls of the vessels; (D): focal positivity for progesterone receptor in the ... Ovarian tumour coexisting with an incidental haemangioma has been previously reported (2–5). A review of the literature reveals that the present case was different in terms of capillary haemangioma in a postmenopausal patient with positive PR receptor (Table). Table Clinicopathologic features of patients with ovarian haemangioma and coexistent lesions reported in the literature The ovarian hilus had a histological appearance that is often confused with haemangiomas due to its rich vascular structure. A mass composed of large vascular channels, nodular formation and minimal amounts of stroma might be helpful to distinguish haemangiomas from dilated, hilar vascular structures (6). In the present case, the mass was composed of dilated blood vessels with little stroma and this helped to establish the diagnosis of haemangioma. The pathogenesis of stromal luteinization remains complicated and it is still controversial whether luteinized stromal cells promote the development of haemangiomas (7). Some authors have studied immunohistochemical expression of ER and PR, and they have found different results (3, 7). In the present case, luteinization was not observed. Moreover, endothelial cells were negative for ER, but some endothelial cells were positive for PR. Radiological appearance for the left ovary was inconclusive; the presence of an enlarged ovary (8) and visualization of contrast uptake on preoperative magnetic resonance imaging in a postmenopausal woman supported rich vascular structure. In postmenopausal women, enlarged ovaries with or without contralateral lesions should be evaluated cautiously.