Original Article An Audit of the Clinicopathological Spectrum of Benign Vascular Tumors of Female Genital Tract; with a Mini Narrative Review Shruthi S. Andola, Vatsala Kishore1, Kruthika S. Andola, Umadevi S. Andola, Sainath K. Andola1 Departments of Obstetrics and Gynecology and 1Pathology, M.R. Medical College, Kalaburagi, Karnataka, India ABSTRACT Background: Vascular tumors of the female genital tract (FGT) are very rare. The aim of this study was to analyze the spectrum of vascular tumors in FGT and to correlate their clinicopathological features. Materials and Methods: A retrospective study of 15years, including clinical features, imaging studies, gross and microscopic features of 24 cases of benign vascular tumors of FGT were reviewed. The age range was 20–95 years. Presenting complaints were abdominal pain/mass, postcoital bleeding, and vaginal and vulval mass. The duration of symptoms varied from 3months to 10years. A diagnosis of vascular tumor was not considered in any of these on clinical grounds. Results: The most common benign vascular tumor was hemangioma (7cases), followed by chorangioma (5cases). The most common sites of occurrence of these benign tumors were ovary and vulva (8cases each), the rarest site was cervix (1case). The clinical symptom of ovarian vascular tumors was abdominal pain and lump. Among the vascular tumors of ovary, the most common was lymphangioma (4cases) followed by hemangioma (3cases). The least common tumor was angiomyolipoma. The most common vulval tumors were hemangioma and lymphangioma circumscriptum. An unusual case of multiplicity and complexity was observed with 3 neoplasms, one malignant and two benign with additional caseating tuberculous lymphadenitis. Conclusion: Benign vascular tumors in the FGT can present with symptoms similar to gynecological tumors and epithelial malignancies leading to unwarranted radical surgery. The pathological examination is necessary in all such cases to exclude the possibility of malignancy. Angiomyofibroblastoma and aggressive angiomyxoma of the vulva are very rare and both share similar clinical and histopathologic features causing diagnostic problems. KEY WORDS: Angimyolipoma, angiomyofibroblastoma, female genital tract, hemangioma, lymphangioma cisrcumscriptum, vascular tumors INTRODUCTION diagnosis of 24 cases of benign vascular tumors of the FGT observed over a period of 15 years. The ovary itself is a highly vascularized organ but vascular tumors of female genital tract (FGT), especially those arising in the ovary, are very rare.[1] The majority of vascular MATERIALS AND METHODS tumors are incidental findings due to their small size All the cases diagnosed as vascular tumor of the FGT in the and asymptomatic nature. However, some cases present Department of Obstetrics and Gynaecology and Pathology clinically with features simulating other more common during a period of 15 years from 2000 to 2015, were gynecological tumors, even on radiological investigations retrieved from the files. like ultrasonography.[2] Most of the reports in the literature are short series of these neoplasms confined to one organ Address for correspondence of FGT.[2] Dr. Sainath K. Andola, Department of Pathology, M.R. Medical College, Kalaburagi - 585 105, Karnataka, India. This study describes the clinical profile, histopathological E-mail: [email protected] features, immunohistochemical findings, and differential This is an open access article distributed under the terms of the Creative Commons Access this article online Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, Quick Response Code and build upon the work non‑commercially, as long as the author is credited and the Website: new creations are licensed under the identical terms. www.jbcrs.org For reprints contact: [email protected] How to cite this article: *** DOI: *** © 2016 Journal of Basic and Clinical Reproductive Sciences | Published by Wolters Kluwer - Medknow 33 Andola, et al.: Benign vascular tumors of female genital tract The clinical features, imaging studies, laboratory The hemangiomas showed enlarged ovaries with a investigations, and gross findings were analyzed. honeycomb appearance. Histologically dilated vascular Histopathology slides were reviewed for morphological spaces containing blood were noted [Figure 2]. features, and special stains were done. A single case of AML was diagnosed. Cut section showed Immunohistochemistry was done in a case diagnosed as yellowish gray gelatinous appearance and histologically deep aggressive angiomyxoma (AAM). admixture of smooth muscle, fat, and vascular spaces seen [Figure 3 and Table 3]. RESULTS Of 8 vulval tumors, most frequent were lymphangioma circumscriptum (LC), hemangiomas, and superficial Maximum cases were hemangiomas (29.16%) [Table 1]. angiomyxoma (SAM) (2 cases each) followed by single cases of deep AAM and angiomyofibroblastoma (AMFB). The age ranged from 20 to 95 years with mean age of 43.4 years. Ovary and vulva were most frequently Both cases of LC presented as edematous, multiple, grouped involved (33.33%) [Table 2]. vesicles on mons pubis and labia majus. Microscopy revealed hyperkeratotic, hyperplastic squamous epithelium with Of 8 cases in the ovary, 4 were lymphangiomas, 3 were multiple fluid filled spaces lined by flat endothelial cells in hemangiomas, and a case of angiomyolipoma (AML) noted. superficial and deep dermis [Figure 4]. These cases presented with nonspecific symptoms which Both cases of SAM were pedunculated skin covered masses ranged from abdominal masses and/pain, postcoital bleeding, of 5 and 4 cm diameter, respectively, with the clinical and vulval or vaginal masses. A diagnosis of the vascular tumor diagnosis of condyloma. Microscopy revealed hypocellular was not considered in any of these cases on the clinical grounds. myxomatous tumor composed of spindle fibroblastic cells and numerous large caliber vessels having thickened The lymphangioma of ovary showed multiple cystic spaces endothelial lining [Figure 5a and b]. on cut surface. Microscopy revealed several cystic spaces lined by bland endothelial cells and lumen showed lymph fluid [Figure 1]. Table 1: Histological spectrum of benign vascular tumors Number Percentage Hemangioma 7 29.16 Lymphangioma 4 16.66 Angiomyolipoma 1 4.16 Superficial angiomyxoma 2 8.33 Deep aggressive angiomyxoma 2 8.33 Angiomyofibroblastoma 1 4.16 Lymphangioma circumscriptum 2 8.33 Figure 1: Gross specimen of ovary showing multiple cystic spaces, Chorangioma of placenta 5 20.83 microscopy-several cystic spaces lined by bland endothelial cells Total 24 100.00 containing lymph (H and E, ×200) Table 2: Anatomic and age distribution and surgical procedure of benign vascular tumors Anatomic site Histopathological diagnosis Surgical procedure Number of cases and age (years) Percentage Ovary n=8 (33.33%) Left Hemangioma Total abdominal hysterectomy with 2 (35, 38) 8.33 Lymphangioma bilateral salpinogo-oopherectomy 2 (45, 56) 8.33 Angiomyolipoma 1 (22) 4.16 Right Lymphangioma 1 (35) 4.16 Bilateral Hemangioma 1 (55) 4.16 Lymphangioma 1 (46) 4.16 Cervix (n=1) Hemangioma Polypectomy 1 (40) 4.16 Vagina (n=2, 8.33%) Hemangioma Excision of mass 1 (95) 4.16 Deep aggressive angiomyxoma 1 (35) 4.16 Vulva (n=8, 33.33%) Hemangioma 2 (46, 71) 8.33 Lymphangioma circumscriptum 2 (50, 56) 8.33 Superficial angiomyxoma 2 (40, 70) 8.33 Deep aggressive angiomyxoma 1 (50) 4.16 Angiomyofibroblastoma 1 (35) 4.16 Placenta (n=5, 20.83%) Chorangioma Placenta with the mass removed 5 (20-28) 20.83 Total number of cases 24 100.00 34 Journal of Basic and Clinical Reproductive Sciences · January - June 2016 · Vol 5 · Issue 1 Andola, et al.: Benign vascular tumors of female genital tract The deep AAM of vulva was clinically diagnosed as Bartholin’s In five cases, placenta was submitted after the delivery cyst and excised. Grossly, soft gelatinous reddish-brown of baby. Placentas contained tumors ranging in size from areas and microscopically, the lesions were moderately 0.5 to 23 cm and placenta weighing from 400 to 800 g. cellular with predominant stellate cells and few spindle cells Cut section showed large nodular lesions and dark brown in an abundant myxomatous stroma. The stromal cells were appearance. Microscopically the lesion composed of bland, oval, and showed no atypia. Plenty of pigmented numerous thin-walled fetal vessels of capillary or sinusoidal macrophages were present. IHC with CD 34 was positive, confirming the diagnosis [Figure 5c and d]. Table 3: Clinical presentation of vulval tumors Complaint Local examination Histopathological diagnosis One patient had mass in labia for last 10 years and Labia majora Clinical impression-Bartholin’s Angiomyofibroblastoma was clinically diagnosed as Bartholin’s cyst. Grossly, growth since cyst 10 years well-circumscribed and soft to rubbery in consistency Vulval swelling Vulval mass-Bartholin’s cyst Deep aggressive angiomyxoma with cut section showing grayish-white homogenous Vulval growth Many small warty lesions Lymphangioma circumscriptum Vulval growth Warty lesion of 1.5 cm×1 cm Lymphangioma circumscriptum appearance. Microscopy revealed tumor consisting of Vulval growth Dark brown pedunculated Cavernous hemangioma hypo- and hyper- cellular areas with numerous delicate mass of 4.5 cm×3 cm, clinical impression-melanoma capillary sized blood vessels lined by endothelial cells. Vulval growth Reddish brown fleshy mass of Hemangioma The stromal cells were plump to spindle with moderate 2.5 cm×2.2 cm cytoplasm and round to