Comp Clin Pathol (2010) 19:413–416
DOI 10.1007/s00580-010-0960-2
BRIEF COMMUNICATION
Vaginal cavernous hemangioma with cystic ovaries
and cystic endometrial hyperplasia in a dog
Omid Azari & Baharak Akhtardanesh &
Amin Derakhshanfar & Mohammad Mehdi Oloumi &
Daruosh Vosough
Received: 18 June 2009 / Accepted: 7 January 2010 / Published online: 25 February 2010
# Springer-Verlag London Limited 2010
Abstract A 10-year-old intact female German shepherd
dog was presented with a chief compliant of vaginal
bleeding that had become progressively heavier over a 2-
week period. On clinical examination, the abdominal cavity
was distended, and no wounds or masses were observed in
vulva and caudal vaginal regions. Digital vaginal examina-
tion and vaginoscopy had no specific findings. Abdominal
ultrasonography and radiography revealed a giant soft
tissue mass in caudal part of the abdomen that extended
in to the pelvic cavity. A midline exploratory laparotomy
was performed. On gross examination, a very huge tumor
was noticed in the caudal part of the abdomen, which
extended to the pelvic cavity, right behind the cervix. On
the other hand, uterine vessels were engorged obviously,
and both ovaries had a multicystic appearance. Surgical
excision of the mass, cystic ovaries, and uterus was
performed. Histopathological studies revealed the complex
of vaginal hemangioma with luteal ovarian cysts and cystic
endometrial hyperplasia (CEH). Vaginal hemangioma is
extremely rare in dogs, and to the authors' knowledge, this
is the first reported case of a synchronous vaginal
hemangioma with ovarian cyst and CEH in dogs.
Keywords Vaginal hemangioma . Cystic endometrial
hyperplasia . Cystic ovary . Dog
O. Azari (*) : B. Akhtardanesh : M. M. Oloumi : D. Vosough
Department of Clinical Sciences, Faculty of Veterinary Medicine,
Shahid Bahonar University of Kerman,
Kerman, Iran
e-mail: omidazari@mail.uk.ac.ir
A. Derakhshanfar
Department of Pathology, Faculty of Veterinary Medicine,
Shahid Bahonar University of Kerman,
Kerman, Iran
Introduction
Vaginal and vulvar tumors account for 2.5% to 3% of all
canine tumors, whereas 70% to 80% of these tumors are
benign. Leiomyomas are the most common benign tumor in
vagina, and leiomyosarcoma is the most common malignant
tumor (Purswell 2006). Hemangioma, a benign vascular
neoplasm or a congenital malformation, is a proliferation of
endothelial cells (Lee et al. 2008). It commonly involves
skin and subcutis of dogs; however, it is rarely reported in
genitalia (Lee et al. 2008; Miller et al. 2007). The average
age of the affected dogs with vaginal and vulvar tumor is
assumed about 11 years, and 65% of these dogs are intact
females (Robbins 2003). The primary causative defect in
hemangiogenesis is still unknown (Marchuk 2001). Growth
factors and hormonal and mechanical influences have been
claimed to affect the abnormal proliferation of endothelial
cells in hemangioma. Surgical excision and ovariohyster-
ectomy are the choice treatment for vaginal tumors
(Robbins 2003; Fossum et al. 2002; Purswell 2006).
Cystic endometrial hyperplasia, which is a dioestral
syndrome in bitches, assumed to be caused by hormonal
disturbances and changes in endometrial steroid hormone
receptor levels (Kim and Kim 2005). It has been reported
that progesterone and its derivatives may increase cystic
endometrial hyperplasia (Munson et al. 2002; Kim and Kim
2005). Histologically, cystic dilated glands are observed in
the endometria (Kim and Kim 2005). It was speculated that
luteal cysts might be associated with cystic endometrial
hyperplasia or pyometra. These cysts may be formed with
no clinical sign and incidentally found during routine
ovariohysterectomy or laparotomy (Stone 2003).
Incidence of hemangioma in genital tract of female dogs
is extremely rare, and there is only one record (Miller et al.
2008). To the authors' knowledge, this is the first case of a
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synchronous vaginal hemangioma with ovarian cyst and
cystic endometrial hyperplasia in dogs.
Case history
A 10-year-old intact female German shepherd dog was
referred to the teaching veterinary hospital with a progres-
sive vaginal bleeding over a 2-week period. The animal had
prolonged proestrus bleeding (40 days) in her last heat and
was referred to a private veterinary clinic later. A follicular
cyst was presumed as the main cause of prolonged
bleeding, and ovariohysterectomy was recommended.
However, as the bleeding period was resolved spontane-
ously, the surgery was refused by the owner at first visit.
The animal was referred to Kerman veterinary hospital,
when the bleeding phase relapsed.
In clinical examination, the abdominal cavity was
distended, and no lesions or masses were observed in vulva
and the caudal vaginal regions. Vaginoscopy revealed that
the vaginal lumen had been filled with clotted blood, and
digital examination showed no evidence of foreign bodies
or palpable tumor. Abdominal ultrasonography and radiog-
raphy showed enlarged soft tissue mass in the caudal part of
abdomen and the pelvic cavity. The low hematocrit (24%)
and elevated progesterone level (6 ng/ml) were the main
laboratory alterations, whereas leukogram and platelet
counts were within the normal range.
The animal was referred to surgery ward for midline
exploratory laparotomy. During surgery, the patient was
transfused with whole blood because of considerable blood
loss and decreasing hematocrit level.
On gross examination, a very huge mass was observed in
the caudal part of the abdomen, which was extended to the
pelvic cavity, right behind the cervix (Fig. 1, A). The uterine
and cervical size was normal, but both ovaries were
massively enlarged and polycystic (Fig. 1, B). No abnor-
mality was identified in other abdominal organs. A routine
Fig. 1 Vaginal cavernous hem-
angioma. A Vaginal tumor has
grown into the abdominal
cavity. B Ovarian luteal cyst
Comp Clin Pathol (2010) 19:413–416
ovariohysterectomy operation was carried out, and the mass,
cystic ovaries, and uterus were all resected. The owner
reported no considerable postsurgical complications, and the
animal continued to recover well during 30 days follow-up.
For routine histopathological studies, the obtained
samples from the mass, uterus, cervix, and ovaries were
fixed in 10% buffered formalin. The samples were
embedded in paraffin, sectioned at 4 μm, and stained with
hematoxylin and eosin.
Histological examination of the vaginal tumor revealed
areas of the vascular channels, which were separated by
fibrous connective tissue. In some parts of the tumor,
myxomatous stroma and neutrophilic infiltration were seen.
The tumor was composed of thin-walled blood vessels,
which were filled by red blood cells and thrombus. No
mitotic figures, pleomorphism, or anaplasia was seen.
Based on the size of the vascular channels, cavernous
hemangioma was diagnosed (Figs. 2 and 3).
The surface epithelium of the uterus was hyperplastic
and papillary, with an increase in the size and number of
glands, so cystic endometrial hyperplasia was confirmed
(Fig. 4).
Discussion
The main origin of the persistent vulvar bleeding could be
either genital or extragenital and must be identified clearly
for an accurate differential diagnosis. Extragenital origin of
hemorrhage includes urinary tract inflammation, injury,
neoplasm, or coagulopathies. Genital causes of bleeding
include vaginal trauma, uterine disease, and malignant
reproductive system neoplasia (Feldman and Nelson
2004). Miller et al. (2008) reported persistent vulvar
hemorrhage due to the vaginal hemangioma in both intact
and spayed dogs.
Hemangioma is a benign tumor made up of newly
formed blood vessels clustered together (Blood and
Comp Clin Pathol (2010) 19:413–416
Fig. 2 Vaginal hemangioma. Many vascular channels filled by red
blood cells. ×100, hematoxylin and eosin
Studdert 1993). Canine hemangiomas have been reported to
occur in skin, oral mucosa, tongue, spinal cord, kidney,
bladder, liver, and spleen (Miller et al. 2008). Vascular
tumors are rare in female genital tract and occur most
commonly in ovary, followed by vulva, cervix, and vagina
(Patricia and Schultheiss 2004). Incidence of hemangioma
in genital tract is extremely rare. There is only one report
(two cases) about vaginal hemangioma in bitches, which
caused persistent vulvar hemorrhage in an intact and a
spayed dog. In both cases, the tumor was in vestibule-
vaginal area (Miller et al. 2008). In the present case, the
mass was located just behind the cervix in the cranial part
of vagina and was not visible in preoperative vaginoscopy.
Due to gradual growth, the massive tumor pushed the
cervical os foreside into the caudal part of abdominal cavity
and was vivid in routine ovariohysterectomy.
Fig. 3 Vaginal hemangioma. Large vessels are separated by myxo-
matous connective tissue. ×200, hematoxylin and eosin
415
Fig. 4 Cystic endometrial hyperplasia. Hyperplastic epithelium of the
uterus with increase number and size of the glands are seen. ×40,
hematoxylin and eosin
There are slightly more numbers of females with
hemangiomas that suggest hormonal changes may play a
role in the development of this lesion (Patricia and
Schultheiss 2004). In human medicine, focal expression of
estrogen receptors was detected in female genital tract
hemangioma. No positive reaction was obtained with
progesterone receptor antibodies. The presence of estrogen
receptor in the endothelial cells of the cervix hemangioma
suggests a direct role of this hormone in hemangioma
development (Reggiani et al. 2009). Review of orbital
cavernous hemangioma cases showed immunohistochemi-
cal reactivity with progesterone antibody, which indicated
that this vascular tumor could be added to the list of
mesenchymal lesions that express progesterone receptors
(Tommaso et al. 2000). This is in contrast with the findings
of Reggiani et al. (2009), which proposed the presence of
estrogen receptor in the endothelial cells of the cervical
hemangioma.
Coincidence of vascular hamartoma in vaginal lumen
with cystic endometrial hyperplasia has been already
reported in an intact German shepherd dog (Troxel et al.
2002), but to the authors' knowledge, this is the first report
of simultaneous occurrence of vaginal hemangioma and
cystic endometrial hyperplasia with luteal cyst in a dog.
They assumed that steroids hormonal alterations due to
ovarian luteal cyst not only caused cystic endometrial
hyperplasia but also could be a predisposing factor for
hemangioma.
Hormonal disturbance was proposed as a predisposing
factor for genital tract tumors, so ovariohysterectomy could
effectively decrease the tumor recurrence rate and allows
full evaluation of the abdomen for metastasis (Robbins
2003; Fossum et al. 2002).
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The prognosis for vaginal and vulvar tumors is good,
and metastasis has not occurred even in the malignant
tumors (Purswell 2006). In the reported case, the bitch had
a complete recovery after ovariohysterectomy; thus, con-
servative surgical excision and ovariohysterectomy could
be the best treatment for similar cases.
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