CASE REPORT
Fetal abdominal cavernous hemangioma diagnosed by duplex Doppler velocimetry C. BATTAGLIA, P. G. ARTINI, G. D'AMBROGIO, F. DROGHINI AND A. R. GENAZZANI
From the Department of Obstetrics and Gynecology, University of Modena, Italy
Acru Obstet Gynecol Scund 1992; 71: 476478 A fetal abdominal wall mass was detected by ultrasound and analyzed by duplex Doppler showing a low resistence to blood flow through its vessels. The antenatal diagnosis of cavernous hemangioma was confirmed after birth.
Key words: cavernous hemangioma; duplex Doppler; abdominal wall Submitted 30 September, 1991 Accepted 16 March, 1992
A variety of congenital abnormalities can be detected in the fetal abdomen region. Often the diagnosis is made only on the basis of the echographic features and without considering the functional aspects of these pathologies. We report the prenatal diagnosis of a cavernous hemangioma of the fetal abdominal wall, made by ultrasound and confirmed by Doppler velocimetry.
were intact and no linkage with intraabdominal organs was noted. The remainder of the anatomy, the amniotic fluid and the placenta were normal. We excluded gastroschisis, omphalocele and umbilical cord hernia on the basis of the sonographic anatomy. The differential diagnoses remaining were teratoma, mesenchimal sarcoma, lymphangioma and cavernous hemangioma.
Case report P.B.R., a 36-year-old white woman, gravida 11, para I , at 32 weeks of gestation, was referred, for ultrasound examination, to our department. The patient was examined in a semirecumbent position using a 3.5 MHz convex-array transducer and a 3.5 MHz pulsed Doppler (duplex) convex device (Ansaldo A U 940, Genova, Italy) with high-pass filter set to 100 Hz. No registration was obtained during fetal breathing and/or fetal motor activity. The Resistance Index (RI=(a-b)/a) was calculated from artery waveforms as the mean value of three consecutive waveforms (1). Fetal biometry was commensurate with amenorrhea. A right fetal ( 5 x 5 cm), contained small cystic and solid areas (Fig. I ) . Tiny pulsations were observed within the mass, which was fed by a main central vessel. Underlying structures Actu Uhstet Gynecol Scarid 71 (1992)
Fig, 1, The hemangioma (>) showed cystic and solid and protruded from the right abdominal wall (...), The mass is fed by a main central vessel (*) originating from the abdomen.
Diagnosis of hemangioma by duplex Doppler
Fig. 2. Flow pattern of the main mass vessel.
Doppler sonograms were obtained from the main mass vessel within the fetal abdomen (Fig. 2) and from a small vessel inside the mass. Flow patterns with RI of 0.37 and 0.24, respectively, were registered. On this basis a diagnosis of abdominal wall hemangioma was established. A weekly examination of mass and of fetal wellbeing was performed until term by ultrasound. Although large hemangiomas can result in congestive heart failure, due to either shunting of blood into the tumor or anemia secondary to red blood cells destruction within capillary networks, no fetal functional alterations were evidenced. A 3 100 gr. healthy female baby was delivered vaginally. Physical postnatal examination showed, at right abdomen, a purplish, protruding, pulsatile, compressible cavernous hemangioma. It appeared unattached to deeper structures. The remainder of the physical examination was normal. N o hypovolemic shock due to changes in cardiovascular dynamics and shunting post-delivery was observed. O n e month later, the mass appeared smaller and had changed into a gray-blue coloration. Because of this change and the superficial localization, a selective angiography was not performed. Actually, three months after birth, the mass measures 3x3 cm.
Discussion Hemangioma is one o f the most common benign neoplasms. I t is a vascular hamartoma, distributed equally between males and females. It occurs most frequently at skin level. Histologically, multiple large vascular spaces divided by interstitial connective tissue are shown. The cavernous type is located
477
deeper in the dermis and contains large vessels. The lesion may be located widespread (2). The sonographic finding is not typical in the diagnosis (3). In the present case, on the basis of location and ultrasound characteristics, it was relatively easy to exclude the diagnosis of a defect of the abdominal wall (4, 5). However, the complexity of the mass did not allow a differential diagnosis between teratoma, sarcoma, lymphangioma and hemangioma (6). The latter was suspected because the mass appeared with well-defined pulsatile vascular spaces. Our suspicions were later confirmed by pulsed Doppler which revealed a pattern consistent with low-resistance blood flow (7, 8). This report is the third case in which the diagnosis of cavernous hemangioma has been made by a duplex Doppler system (7-Y), based upon Doppler sonograms obtained by positioning the Doppler gate within it. Doppler analysis was important because the two dimensional sonographic image did not differentiate it from other disorders. A misdiagnosis might have led to wrong obstetric management. In conclusion, we suggest that Doppler velocimetry may be helpful in the diagnosis of soft tissue masses of the fetus.
Acknowledgments The present study was in part supported by the Italian National Research Council (CNR) targeted project 'Prevention and Control Disease Factor' subproject 'Maternal Infant Disease' contract 92.00155.PF.41. We thank Dr. Felice Petraglia for his kind collaboration in preparing the manuscript.
References I . Pourcelot L. Applications cliniques de I'examen Doppler transcutani?. In: INSEKM ed. Velocinietrie ultrasonorc Doppler Paris, 1974: 213. 2. Edgerton MT. Vascular hamartomas and hemangiomas classification and treatment. South Mcd J 1982; 75: 1.541. 3. Mcizner I , Bar-Ziv J, Holcberg G , Katz M. In utero prenatal diagnosis of fetal facial tumor-hemangioma. J Clin Ultrasound 1985; 13: 435. 4. Redford D H A , Mc Nay MB, Whittle MJ. Gastroschisis and cxomphalos: Precise diagnosis by midpregnancy ultrasound. Br. J Obstet Gynecol 1985; 92: 54. 5 . Seashore J H . Congenital abdomen wall defects. Clin Perinatol 1978; 5: 62. 6. Pennell KG. Baltarowich OH. Prenatal sonographic diagnosis of a fetal facial hemagioma. J Ultrasound Med 1986; 5: 525. Actu Ohstet Gynecol S c u d 71 (1992)
478
C. Battagliu et al.
7. Degani S. Antenatal diagnosis of giant cystic cavernous hemangioma by Doppler velocimetry. Obstct Gynecol 1989; 73: 6. 8. Lasser D, Oded Preis, DoI N , Tancer ML. Antenatal diagnosis of giant cystic cavernous hcmangioma by Doppler velocimetry. Ohstet & Gynecol 1988; 72: 476. 9. Smith LG, Carpentcr RJ, Couronlin W, Mari G , Keiter Greeherg F, Powell C. Prenatal diagnosis of a chest well mass with ultrasonography and doppler velocimctry. Am J Obstct Gynecol 1990; 163: 567.
Actu Obstet Gynecol Scund 71 (1992)
Address for correspondence; Dr Ccsare B ~M.D. ~ Clinica Obstctricia e Ginegologica Universita di Modena v , del, pozzo 71 41 100 Modena Italy
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Fetal abdominal cavernous hemangioma diagnosed by duplex Doppler velocimetry C. BATTAGLIA, P. G. ARTINI, G. D'AMBROGIO, F. DROGHINI AND A. R. GENAZZANI
From the Department of Obstetrics and Gynecology, University of Modena, Italy
Acru Obstet Gynecol Scund 1992; 71: 476478 A fetal abdominal wall mass was detected by ultrasound and analyzed by duplex Doppler showing a low resistence to blood flow through its vessels. The antenatal diagnosis of cavernous hemangioma was confirmed after birth.
Key words: cavernous hemangioma; duplex Doppler; abdominal wall Submitted 30 September, 1991 Accepted 16 March, 1992
A variety of congenital abnormalities can be detected in the fetal abdomen region. Often the diagnosis is made only on the basis of the echographic features and without considering the functional aspects of these pathologies. We report the prenatal diagnosis of a cavernous hemangioma of the fetal abdominal wall, made by ultrasound and confirmed by Doppler velocimetry.
were intact and no linkage with intraabdominal organs was noted. The remainder of the anatomy, the amniotic fluid and the placenta were normal. We excluded gastroschisis, omphalocele and umbilical cord hernia on the basis of the sonographic anatomy. The differential diagnoses remaining were teratoma, mesenchimal sarcoma, lymphangioma and cavernous hemangioma.
Case report P.B.R., a 36-year-old white woman, gravida 11, para I , at 32 weeks of gestation, was referred, for ultrasound examination, to our department. The patient was examined in a semirecumbent position using a 3.5 MHz convex-array transducer and a 3.5 MHz pulsed Doppler (duplex) convex device (Ansaldo A U 940, Genova, Italy) with high-pass filter set to 100 Hz. No registration was obtained during fetal breathing and/or fetal motor activity. The Resistance Index (RI=(a-b)/a) was calculated from artery waveforms as the mean value of three consecutive waveforms (1). Fetal biometry was commensurate with amenorrhea. A right fetal ( 5 x 5 cm), contained small cystic and solid areas (Fig. I ) . Tiny pulsations were observed within the mass, which was fed by a main central vessel. Underlying structures Actu Uhstet Gynecol Scarid 71 (1992)
Fig, 1, The hemangioma (>) showed cystic and solid and protruded from the right abdominal wall (...), The mass is fed by a main central vessel (*) originating from the abdomen.
Diagnosis of hemangioma by duplex Doppler
Fig. 2. Flow pattern of the main mass vessel.
Doppler sonograms were obtained from the main mass vessel within the fetal abdomen (Fig. 2) and from a small vessel inside the mass. Flow patterns with RI of 0.37 and 0.24, respectively, were registered. On this basis a diagnosis of abdominal wall hemangioma was established. A weekly examination of mass and of fetal wellbeing was performed until term by ultrasound. Although large hemangiomas can result in congestive heart failure, due to either shunting of blood into the tumor or anemia secondary to red blood cells destruction within capillary networks, no fetal functional alterations were evidenced. A 3 100 gr. healthy female baby was delivered vaginally. Physical postnatal examination showed, at right abdomen, a purplish, protruding, pulsatile, compressible cavernous hemangioma. It appeared unattached to deeper structures. The remainder of the physical examination was normal. N o hypovolemic shock due to changes in cardiovascular dynamics and shunting post-delivery was observed. O n e month later, the mass appeared smaller and had changed into a gray-blue coloration. Because of this change and the superficial localization, a selective angiography was not performed. Actually, three months after birth, the mass measures 3x3 cm.
Discussion Hemangioma is one o f the most common benign neoplasms. I t is a vascular hamartoma, distributed equally between males and females. It occurs most frequently at skin level. Histologically, multiple large vascular spaces divided by interstitial connective tissue are shown. The cavernous type is located
477
deeper in the dermis and contains large vessels. The lesion may be located widespread (2). The sonographic finding is not typical in the diagnosis (3). In the present case, on the basis of location and ultrasound characteristics, it was relatively easy to exclude the diagnosis of a defect of the abdominal wall (4, 5). However, the complexity of the mass did not allow a differential diagnosis between teratoma, sarcoma, lymphangioma and hemangioma (6). The latter was suspected because the mass appeared with well-defined pulsatile vascular spaces. Our suspicions were later confirmed by pulsed Doppler which revealed a pattern consistent with low-resistance blood flow (7, 8). This report is the third case in which the diagnosis of cavernous hemangioma has been made by a duplex Doppler system (7-Y), based upon Doppler sonograms obtained by positioning the Doppler gate within it. Doppler analysis was important because the two dimensional sonographic image did not differentiate it from other disorders. A misdiagnosis might have led to wrong obstetric management. In conclusion, we suggest that Doppler velocimetry may be helpful in the diagnosis of soft tissue masses of the fetus.
Acknowledgments The present study was in part supported by the Italian National Research Council (CNR) targeted project 'Prevention and Control Disease Factor' subproject 'Maternal Infant Disease' contract 92.00155.PF.41. We thank Dr. Felice Petraglia for his kind collaboration in preparing the manuscript.
References I . Pourcelot L. Applications cliniques de I'examen Doppler transcutani?. In: INSEKM ed. Velocinietrie ultrasonorc Doppler Paris, 1974: 213. 2. Edgerton MT. Vascular hamartomas and hemangiomas classification and treatment. South Mcd J 1982; 75: 1.541. 3. Mcizner I , Bar-Ziv J, Holcberg G , Katz M. In utero prenatal diagnosis of fetal facial tumor-hemangioma. J Clin Ultrasound 1985; 13: 435. 4. Redford D H A , Mc Nay MB, Whittle MJ. Gastroschisis and cxomphalos: Precise diagnosis by midpregnancy ultrasound. Br. J Obstet Gynecol 1985; 92: 54. 5 . Seashore J H . Congenital abdomen wall defects. Clin Perinatol 1978; 5: 62. 6. Pennell KG. Baltarowich OH. Prenatal sonographic diagnosis of a fetal facial hemagioma. J Ultrasound Med 1986; 5: 525. Actu Ohstet Gynecol S c u d 71 (1992)
478
C. Battagliu et al.
7. Degani S. Antenatal diagnosis of giant cystic cavernous hemangioma by Doppler velocimetry. Obstct Gynecol 1989; 73: 6. 8. Lasser D, Oded Preis, DoI N , Tancer ML. Antenatal diagnosis of giant cystic cavernous hcmangioma by Doppler velocimetry. Ohstet & Gynecol 1988; 72: 476. 9. Smith LG, Carpentcr RJ, Couronlin W, Mari G , Keiter Greeherg F, Powell C. Prenatal diagnosis of a chest well mass with ultrasonography and doppler velocimctry. Am J Obstct Gynecol 1990; 163: 567.
Actu Obstet Gynecol Scund 71 (1992)
Address for correspondence; Dr Ccsare B ~M.D. ~ Clinica Obstctricia e Ginegologica Universita di Modena v , del, pozzo 71 41 100 Modena Italy
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