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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 139-141

Cavernous hemangioma of ureter masquerading as malignancy – A rare case report


Department of Pathology, K S Hegde Medical Academy of Nitte (Deemed to be University), Mangaluru, Karnataka, India

Date of Submission15-Feb-2020
Date of Decision19-Feb-2020
Date of Acceptance03-Mar-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
H L Kishan Prasad
Department of Pathology, K S Hegde Medical Academy of Nitte (Deemed to be University), Mangaluru - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_15_20

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  Abstract 


Hemangiomas of the genitourinary tract are rare. They may be clinically silent or present with profuse or recurrent hematuria. They result from embryological remains of unipotent angioblastic cells that show anomalous development within the blood vessels. They can be single or multiple. Multiple hemangiomas are called cutaneous angiomatosis, occurring in the setting of genetic disorders such as Klippel–Trenaunay syndrome or Sturge–Weber syndrome. Careful correlation between the clinical, radiological, and histological findings may help in avoiding unnecessary radical procedures. Here, we present a case of cavernous hemangioma occurring in the proximal ureter, causing hydronephrosis and posing a diagnostic challenge.

Keywords: Cavernous hemangioma, hydroureteronephrosis, renal cell carcinoma, ureter


How to cite this article:
Sajitha K, Kishan Prasad H L, Pradeep A, Rajeev T P, Mathias M, Shetty K J. Cavernous hemangioma of ureter masquerading as malignancy – A rare case report. Urol Sci 2020;31:139-41

How to cite this URL:
Sajitha K, Kishan Prasad H L, Pradeep A, Rajeev T P, Mathias M, Shetty K J. Cavernous hemangioma of ureter masquerading as malignancy – A rare case report. Urol Sci [serial online] 2020 [cited 2020 Jul 12];31:139-41. Available from: http://www.e-urol-sci.com/text.asp?2020/31/3/139/287974




  Introduction Top


Hemangiomas are benign vascular tumors rarely seen in the genitourinary tract. They are most commonly found in the liver and skin and are rarely reported in the prostate, bladder, ureter, and perineum. Sometimes, it is difficult to distinguish them from malignant ureteral tumors.[1] They may be clinically silent or present with profuse or recurrent hematuria.[2] Most hemangiomas of the ureter are diagnosed postoperatively by pathologic examination. Here, we present a rare case of cavernous hemangioma occurring in the proximal ureter causing hydronephrosis and posing a diagnostic challenge.


  Case Report Top


A 58-year-old male patient presented with complaints of poor urine stream for 3 months associated with intermittency and nocturia. On examination, there was Grade 1 prostatomegaly. The sphincter tone was found to be normal; external genitalia, bilateral spermatic cords, and testis were normal. His urine cytology showed atypical cells suspicious of urothelial carcinoma. Computerized tomography of the abdomen showed a circumferential and eccentric soft-tissue density lesion in the right upper ureter that is significantly narrowing the lumen, suggesting a neoplastic lesion [Figure 1]a. Cystoscopy showed narrowing of the upper ureter with irregular and edematous mucosa and Grade 2 hydronephrosis. Because of suspicious radiological and cytological findings, the patient underwent radical nephrectomy.
Figure 1: (a) Computerized tomography of the abdomen showing circumferential and eccentric soft-tissue density lesion in the right upper ureter. (b) The upper end of the ureter was thickened and on cut surface showing a 5.2 cm × 1 cm lesion which appeared to encase and compress the lumen of the ureter

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On gross examination, the pelvicalyceal system was dilated. The upper end of the ureter was thickened, and the cut surface of the ureter showed a 5.2 cm × 1 cm lesion which appeared to encase and compress the lumen of the ureter. Multiple tiny cystic and hemorrhagic areas with narrowing of the proximal ureter were observed. A cortical cyst was noted in the upper pole of the kidney [Figure 1]b.
Figure 2: (a-c) Microscopically, showing multiple thin-walled vascular spaces of varying sizes, lined by flat endothelial cells with red blood cells in the lumen. The vascular spaces involved the adventitia, muscular area, and lamina propria

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Microscopically, the sections from the hemorrhagic and cystic mass showed multiple thin-walled vascular spaces of varying sizes, lined by flat endothelial cells with red blood cells in the lumen. The vascular spaces were present in the adventitia, muscular area, and lamina propria [Figure 2]a-c]. A diagnosis of cavernous hemangioma of the right ureter with right hydroureteronephrosis and the simple renal cyst was reached. Postoperative period was uneventful. The patient was doing well in the last follow-up.


  Discussion Top


Hemangiomas are benign vascular tumors. Most benign ureteral tumors are misdiagnosed as malignant tumors. The most common benign tumor in the ureter is fibromyoma. Hemangiomas are rare benign tumors of the ureter. They result from embryological remains of unipotent angioblastic cells that develop in an anomalous way inside the blood vessels. They can occur at any age with male predominance. They are prerogative of the skin and liver, rarely in the ureter. However, they can grow at all levels of the urinary tract, including kidney, ureter, bladder, urethra, and prostate. Hemangiomas of the urinary tract are found in the age group of 19–85 years. Multiple hemangiomas are called cutaneous angiomatosis. They commonly occur in the pediatric age group in the setting of genetic syndromes such as Klippel–Trenaunay syndrome or Sturge–Weber syndrome. Clinically, patients most commonly present with symptoms of hematuria due to thrombus, infarction, and angiogenesis by the erosion of the urothelium.[3] Computed tomography (CT) scans are not helpful diagnostic tools in distinguishing ureteral hemangiomas from other ureteral tumors. Ureteroscopic examination shows a reddish-blue, polypoid, submucosal mass with intact urothelium.[3] In our case, the patient came with complaints of poor urine stream, intermittency, and nocturia. Cystoscopy showed narrowing of the upper ureter with irregular, edematous mucosa and Grade 2 hydronephrosis. CT images showed a circumferential and eccentric soft-tissue density lesion in the right upper ureter with significant narrowing.

They are generally diagnosed by pathologic examination after surgery.[4] Histologically, the lesion consists of lacunas, covered with endothelium, containing erythrocytes and organized thrombi.[5] This case was diagnosed as cavernous hemangioma of the ureter, based on the above-mentioned gross and microscopic features in a radical nephrectomy specimen. Nevertheless, owing to relatively high incidence of malignant ureteral tumors, it is difficult and challenging to choose a treatment method.


  Conclusion Top


Ureteral hemangiomas are benign tumors with the tendency for recurrence. A careful correlation between the clinical, radiological, and histological findings is required to help as an aid to diagnosis. Therefore, we suggest that unnecessary radical surgery can be prevented when clinicians keep the possibility of a benign ureteral tumor in mind during evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim S, Cho HJ. Cavernous hemangioma of the ureter. Korean J Urology 2009;50:192-4.  Back to cited text no. 1
    
2.
Regragui S, Slaoui A, Karmouni T, El Khader K, Koutani A, Attya AI. Urethral hemangioma: Case report and review of the literature. Pan Afr Med J 2016;23:96.  Back to cited text no. 2
    
3.
Sethi S, Agarwal V, Chopra P. Cavernous hemangioma of the kidney: A report of two cases and review of the literature. Urol Ann 2012;4:187-90.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Ahuja A, Sen AK, Bhardwaj M. Cavernous hemangioma of anterior urethra: An unusual cause of vaginal bleeding. Indian J Pathol Microbiol 2016;59:245-6.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kanthikar SN, Nikumbh DB. Female urethral cavernous hemangioma- An unusual cause of hematuria: A rare case report. Clin Cancer Invest J 2015;4:462-4.  Back to cited text no. 5
    


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