A case of cavernous hemangioma of the bladder

A CASE OF

CAVERNOUS

HEMANGIOMA

EDGAR G. BALLENGER, M.D.,

OF THE BLADDER*

P.A.c.s., OMAR F. ELDER, M.D., AND

HAROLD P. MCDONALD, M.D. ATLANTA, GA.

H

EMANGIOMA of the bIadder is probably the rarest of a11 neoDIasms of the bladder. Assisted by the ILibrarian of the American CoIIege of Surgeons, 16 cases of hemangioma have been found in the Iiterature. The first mention of such growths is that of Gross in his treatise on the urinary organs, 185 I. A soft, cauIifIower-Iike tumor was found, at autopsy, in the bladder of a woman aged seventy-two. No histoIogica1 description is given. The first authentic case appears to be that of Langhams, who is credited by CIado as having found a hemangioma, in 1879, at necropsy of a boy, aged nineteen, who had died of hematuria. The Iargest part of it was on the posterior vesical waI1, where the mucosa1 and submucosa1 Iayers were composed of cavernous tissue. AIbarran, in 1892, observed a hemangioma at necropsy of a man aged sixtyfour, who had died foIIowing operation by Guyon. The patient had suffered from hematuria. The tumor was submucosa1 and the bIadder epitheIium was we11 examination Histologica preserved. showed capiIIary dilatation surrounded by connective tissue. At the CIinicaI Society in London, 1895, Lane reported a case of extensive degenerating nevus of the bIadder in a chiId, aged three and one-haIf years. Two years before admission to the hospital the chiId commenced to pass bIoody urine, at times Iarge ffat Jots; occasionaIIy there was profuse hemorrhage. Scattered about the anus and buttocks were a few smaI1 patches of degenerated nevoid tissue and their presence led to the diagnosis that the bIadder * Submitted

condition was aIso nevoid. The mass in the bIadder couId be feIt distinctIy both above the pubes and by the rectum.

FIG. I. Hemangioma

Suprapubic cystotomy was done and large angiomatous masses protruded through the incision. AImost al1 of the mucous membrane was invoIved. Excision seemed inadvisable. For some unexplained reason the child’s condition improved greatIy after the operation. The fina outcome is not recorded. Jungano, in IgoT, described a massive cauIifIower angioma, in the region of the trigone, undergoing sarcomatous degeneration in a man aged fifty-four years.

for publication 409

of bladder. RuIe above is in inches.

October

21, 1931.

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Bryan reported, in agog, a typica cavernous angioma which was removed by suprapubic cystotomy.

FIG. 2.

Hemangioma

SEPTEMBE x, 1932

with bIood; the other part was soft : and the connective tissue was infiltrated with smaIl bIood clots.

Photomicrographof hemangiomaof bIadder.

Judd and Harrington reported, in 1918, a case of angioma in a woman, nineteen of years of age, who had compIained incontinence for two years. The tumor was the size of a Iarge grapefruit. The bladder was greatIy hypertrophied and there was an area ‘in the right anterior waI1 of the bIadder through which the growth extended into the right extravesica1 The pathoIogica1 diagnosis was space. papiIIary angioma. Launay, Achard and Carriere saw, in 1920, an angioma of the right bladder waI1. The tumor was composed of two parts; one part, gIobuIar and very hard, was composed of connective tissue in which blood vessels were diIated and filled

ScholI, in rgzo, reported, from the Mayo CIinic, three patients with tumors of the bIadder which were cIassed angiomata: CASE I. A gir1, aged nineteen, had had pus and bIood in the urine and miId incontinence for two years. At operation a Iarge poIypoid

tumor was found fiIIing an enormous bIadder. The tumor extended into the prevesical space through an area about 3 cm. in diameter. A slight recurrence three months later was successfully fulgurated and five years Iater the bIadder was normaI. The tumor was firm and contained many bIood cysts and saccuIations, but the Iargest part of the growth was composed of interIacing bIood vessels supported by connective tissue.

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CASE II. A man, aged seventy-six, had had occasiona moderate hematuria for eight months. An inoperabIe sessiIe growth, covered with papiIIomatous excrescences, was found on the Ieft base of the bIadder. The growth was extensiveIy fuIgurated but seventeen months later the symptoms returned. There was a widespread mass covering the entire Ieft haIf of the hIadder and invoIving the prostate and posterior urethra.

CASE III. GirI, aged seven, with sIight hematuria which had persisted for six years. Some bIood had passed by rectum. A mass, 6 cm. in diameter, was paIpated in the region of the bIadder. Death foIIowed severe recta1 hemorrhage. Necropsy reveaIed an extensive cavernous angioma growing from the base of the bIadder and invading the recta1 mucosa. Kahn, in 1920, saw a diffuse angioma in the bladder of a girl, aged seventeen, who had recurrent hematuria from the age of four years. Cystoscopy showed the trigone, interureteral zone and ureteral orifices were normal. The remainder of the bIadder presented two aspects; one was characterized by small red grains separated from each other by exceedingIy distinct smal1, white spaces. A few islands of normal tissue were interspersed. In other regions there were large bluish blood vesseIs and islands circumscribed by the same bluish color, with a moderate degree of projection. Some of these were about to ulcerate. The general aspect was that of a diffuse nevus, not involving the entire surface. SurgicaI intervention was avoided because of the diffuse character of the angioma. Faeber, in 1922, observed in a girl, aged eleven, who began to have hematuria when l&-e years of age, a case of hemangioma of the bladder. The bleeding recurred at intervals but there was no pain at this nor during the succeeding live years. Cystoscopy showed a Iarge hemangioma of the bIadder. The growth was removed partly by excision and partly by PaqueIin cauterization. Kidd, in 1923, reported an angioma of the bIadder removed at operation. The patient, a man aged twenty-nine, had deveIoped acute retention two years previ-

Hemangioma

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ously. The tumor was smooth, pedunculated, and Iooked Iike a red raspberry, ahhough about the size of a date. Caulk, in 1925, reported a smaI1 hemangioma of the bIadder waI1 which had the appearance of an ordinary nevus. The smaI1, bluish, bleeding elevation was destroyed by fmguration. CauIk also reported in the same article a pulsating cavernous hemangioma of the ureter, simulating inoperable carcinoma of the bladder. He was unable to lind in the literature a singIe case of hemangioma of the ureter. Marion, Huber, Okazaki, and Katz each have reported a case of cavernous angioma. While somewhat irrelevant in the present discussion, it seems of interest to note that hemangioma of the kidney is about as rare as it is of the bIadder, and very difficult to diagnose. The presence of hemangioma of the kidney shouId be suspected when al1 other possibIe Iesions are ruled out and when the onset of renaI bIeeding is sudden and severe. Mackey, in 1930, reviewed the literature. He was abIe to find only 17 cases of hemangioma of the kidney in addition to one which he reported. Since this time Bailey has reported one other case. CASE REPORT

White maIe, aged twenty-seven. The famiIy history and the past history are irrerevant, except the urinary symptoms. The physica examination was practicaIIy negative except that a Iarge mass couId be feIt in the bIadder. Present Illness. Father states that the patient had the first attack of frequent, painfu1 and bloody urination at the age of six months. These attacks recurred from time to time and Iasted usuaIIy five or six days, but occasionaIIy for two or three weeks, the Iongest was five weeks. Until the patient was eIeven years of age these attacks came on once a month or oftener ; after that the time between the attacks was from one to five years. The patient had a very severe hemorrhage in 1929 and was confined to bed for tweIve days. His parents had been toId that he had an incurabIe cancer.

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Hemangioma

SEPTEMBER. 1932

specimen when removed. The Ieft ureteral orifice was elevated by the tumor but showed norma squirts of indigo carmine; the right ureteral opening was normaI. Operation. Through a transverse suprapubic incision, the peritoneum was separated from the bIadder and the vesica1 waI1 was incised. In shape and size the growth and its short pedicIe greatIy resembIed a door knob. After excision, the bladder was cIosed and drained in the usua1 manner. The patient made an uneventfu1 recovery and has had no return of bIeeding or painfu1 symptoms. The pain and fuIness in the Ieft kidney region did not reappear after the operation. He has agreed to return from time to time for cystoscopic observation and fulguration, if required for recurrences. The pathojogist reported the tumor to be cavernous hemangioma.

In spite of repeated hemorrhages, the blood count and hemogIobin were essentially negative. Upon admission to the hospitaI the patient compIained of a feeIing of fuIness and pain in the region of the Ieft kidney and ureter. A uroseIectan picture showed the ureter and peIvis to be sIightIy diIated. Cystoscopy showed a tumor about the size of an orange, no pedicIe couId be seen. Part of the surface of the growth was covered with cIoseIy set cysts about the size of spIit peas. These cysts were of many colors; most of them were greenish yeIIow. There were occasiona1 bIeeding points. The cystoscopy picture was not that of papiIIoma or carcinoma. Different parts of the tumor, however, Iooked quite different. The diagnosis of angioma was not suspected, either from the cystoscopic appearance or from inspection of the gross

REFERENCES BAILEY, H. Brit. J. Ural., 2: 375, 1930. BRYAN. Cavernous haemangioma. Tr. South Surg. CY Gynec. Assn., 12: 578, 1gog. CAULK, J. R. Haemangiomata of the bIadder and ureter. Surg. Gynec. Obst., 49-52, 1925. CLADO. Traite des tumerus de Ia vessie, p. 174. Cited by Rafin, Assoc. .franc. urol., Procesverb. et mem., Par. 20: 562, 1920. HUBNER, A. Das Hamangiom der Blase. Ztscbr.f. Ural., 17: 29-32, 1923. JUDD and HARRINGTON.Tumors of the urinary bladder. Soutbern M. J., IO: 129, 1918. JUNGANO. Sur un cas d’angio sarcome de Ia vessie. Ann. d. mal. d. org. genito-urin., 25: 1451, 1907. KATZ, H. Cavernous haemangioma of the bIadder. J. Ural., 15: 201-207, 1926. KIDD, F. Angioma of the bladder removed at operation.

REFERENCES 5. POWERS, J. H. Acute intestina1 obstruction due to impacted gaI1 stones. Surg. Gynec. Obst., 47: 416, 1928. 6. MOORE, G. A. GaII stone iIeus. Boston M. EY S. J., 192: 1051, 1925. 7. MARTIN, F. IntestinaI obstruction due to gaI1 stones. Ann. Surg., 4: 725, 1912. 8. JACKSON, J. A., and EWELL. Wisconsin M, J., 29: 637, 1930. g. SIEWERTH, W. S. Illinois M. J., 58: 360. 1930. * Continued

OF

Proc. Roy. Sot. Med., Lond., 1921-22, Sect. UroI., P. 31. LANE, A. Extensive degenerating naevus of the bIadder. Laticet, I: 1252, 1895. LAUNAY, ACHARD and CARRIERE. Une observation d’angiome de Ia paroi vesicale. J. d’urol., g: 385, 1920. MAC~EY. Haemangioma of the kidney. Brit. J. Surg., 13: 308, 1930. MARION. Case of Iarge angioma of the bIadder. J. d’~rol.. 25: 235, 1928. OKAZAKI, M. Ueber das LymphangoiendotheIium der HarnbIase, Ztscbr. f. tiroi, 17-422-424, 1923. RAFIN. Diffuse angioma of the bIadder. Assoc. franc.. Processverb. et.-mem., Par., 20: 562, 1920. ” . SCHOLL. HistoIogy and mortality in cases of tumor of the bIadder. Surg., Cynec. Obst., 24: 189, 1922.

DR.

ANGLE*

IO. REIMANN and BLOOM. Gall

stone “Icerating into and Iodging in the stomach. Proc. Patb. Sot. Pbiladelpbia, 21: 4, 1918. I I. MURPHY J. GaII stone disease and its reIation to intestinal obstruction. Illinois M. J., 18: 272, 1910. 12. BROWN, J. S. GaII stone iIeus. Surg. Gynec. Obst., 16: 709, 1913. 13. DAVIS, N. P. Acute intestina1 obstruction by a gaI1 stone. Atlantic M. J., 29: 778, 1925. from page 368.