Primary Cavernous Hemangioma with Concomitant Papillary Thyroid Carcinoma: A Case Report
Athbah Alblooshi * , Fotoon Aldhanhani 1, Hussein Saadi 1, Yasin Ahmed 1, Mahdi Shkoukani 1
*Correspondence to: Athbah Alblooshi, Department of Otolaryngology - Head and Neck Surgery Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
Copyright.
© 2026 Athbah Alblooshi, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 25 September 2026
Published: 01 October 2026
DOI: https://doi.org/10.5281/zenodo.23077942
Abstract
Introduction: Primary thyroid hemangioma is an exceedingly rare benign vascular neoplasm, with fewer than 35 cases reported worldwide since its first description in 1975. Its coexistence with papillary thyroid carcinoma (PTC) has been documented only once previously. We report the second known case of concurrent primary thyroid cavernous hemangioma and PTC.
Case Presentation: A 65-year-old man with a history of coronary artery disease was incidentally found to have a left thyroid nodule on chest computed tomography performed for an unrelated indication. He was asymptomatic, euthyroid, and had no palpable neck mass. Ultrasonography demonstrated a 3.3x2.1x2.4 cm solid, hypoechoic nodule classified as ACR TI-RADS TR5. Two separate fine-needle aspiration biopsies yielded nondiagnostic cytology. Given the high risk sonographic features and repeated inconclusive sampling, the patient underwent left hemithyroidectomy after shared decision making. Histopathology unexpectedly revealed a 2.5 cm cavernous hemangioma along with an incidental 1.7 mm BRAF V600E-positive oncocytic variant papillary thyroid microcarcinoma, without angioinvasion, lymphovascular invasion, or extrathyroidal extension (pT1a). The postoperative course was uneventful, and the patient remained asymptomatic at follow up.
Conclusion: Primary thyroid hemangioma remains a diagnostic challenge owing to its nonspecific clinical, radiologic, and cytologic features, with definitive diagnosis typically established only after surgical excision. Its rare coexistence with PTC, as illustrated in this case, underscores the importance of considering benign vascular lesions in the differential diagnosis of indeterminate thyroid nodules and highlights the diagnostic and therapeutic value of surgical excision in equivocal cases.
Keywords: thyroid hemangioma, cavernous hemangioma, papillary thyroid carcinoma, thyroid nodule, hemithyroidectomy.
Introduction
Hemangioma is a benign vascular neoplasm resulting from prolifration of endothlial lined blood vessles or vascular malformatiosns, and commonly occurs in the subcutaneous soft tissues, oral cavity, liver, gastrointestinal tract, skeletal muscle, and head and neck regions [2-3]. Although hemangiomas are common benign vascular neoplasms, primary thyroid involvement is rare [1-4]. The first case of thyroid hemangioma was reported in 1975 in a 56-year-old man who presented with a neck mass, tracheal deviation, and unilateral vocal cord paralysis. The lesion measured 7.5 x 3.0 x 2.0 cm and was located in the left lobe of the thyroid gland. A preoperative diagnosis was established using 99mTc angiography, which demonstrated the vascular nature of the lesion. The mass was subsequently surgically excised [5]. Since then, only a limited number of cases have been reported in the literature. According to the most recent literature review published in 2020, only 31 cases have been documented worldwide [4].
Thyroid hemangiomas are generally classified as primary or secondary. Secondary hemangiomas usually occur after neck trauma, thyroid surgery, or fine-needle aspiration and are believed to develop through vascular proliferation within an organized hematoma [3]. Primary hemangiomas, however, are considered congenital lesions resulting from abnormalities in vascular development, including defective canalization of angioblastic mesenchyme or failure of immature vascular channels to establish normal communication with the surrounding circulation [1-3].
Clinically, thyroid hemangiomas most often manifest as a painless, gradually enlarging cervical swelling, with few or no associated symptoms. Preoperative identification is challenging because radiological findings are generally nonspecific, and fine-needle aspiration (FNA) usually yields only blood with insufficient cellular material for cytologic evaluation, often resulting in nondiagnostic specimens [2,3]. Consequently, definitive diagnosis is usually established only after surgical excision and histopathological assessment. Recognizing this uncommon entity is important due to its potential to resemble other thyroid lesions and its risk of significant bleeding during surgery [4].
To date, only one case of concomitant thyroid hemangioma and papillary thyroid carcinoma (PTC) has been reported. In that case, the hemangioma mimicked extrathyroidal extension on preoperative imaging, raising concern for locally invasive disease. However, histopathological examination confirmed the coexistence of PTC and a venous hemangioma without true tumor invasion, highlighting the potential for thyroid hemangiomas to imitate aggressive thyroid malignancy and complicate preoperative assessment [17].
In this report, we present the second case in literature of a primary thyroid cavernous hemangioma with concomittant papillary thyroid carcinoma and highlights its clinical presentation, radiological and pathological features, surgical management, follow ups and relevant literature.
Case Presentation
A 65-year-old male with past medical history of coronary artery disease status post CABG. He was referred for further evaluation of a left thyroid nodule that was incidentally identified during investigation for an unrelated condition. The nodule was first noted on a computed tomography scan of the chest performed in September 2025. Prior to that, the patient had no known history of thyroid disease and he was not aware of any thyroid abnormality.
The patient was initially evaluated in the endocrinology clinic in November 2025. At that time, he denied any neck swelling or palpable mass. He also denied any compressive symptoms, such as dysphagia, odynophagia, choking episodes, or positional respiratory difficulty. There was no history of voice change, hoarseness, or neck discomfort. In addition, he denied symptoms suggestive of thyroid dysfunction, including palpitations, tremors, heat or cold intolerance, unexplained weight change, or alteration in bowel habits.
Further investigation with thyroid ultrasonography was done in December 2025. Ultrasound demonstrated a solitary left thyroid nodule measuring 3.3 × 2.1 × 2.4 cm. The lesion was characterized as solid or nearly completely solid, hypoechoic, taller-than-wide in configuration, and demonstrated lobulated or irregular margins. No punctate echogenic foci were identified ((Figure 1 & 2). Based on these sonographic characteristics, the lesion accumulated nine points according to the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) and was therefore classified as a TR5 nodule, representing a highly suspicious lesion. No further suspicious cervical lymphadenopathy was noted on sonographic examination.
The patient thereafter underwent ultrasound-guided fine needle aspiration biopsy on two separate occasions. Despite of additional sampling, both aspirations revealed nondiagnostic cytological results. Thyroid function testing revealed a normal thyroid-stimulating hormone level, and the patient remained clinically euthyroid.
In January 2026, the patient was referred to the otolaryngology service for further evaluation and discussion of management options. During this evaluation, he continued to deny any symptoms related to the thyroid nodule. Especially, there were no compressive symptoms, no noticeable neck mass, and no symptoms suggestive of hyperthyroidism or hypothyroidism. There was no history of previous head and neck radiation. Family history of thyroid malignancy was not reported.
Comprehensive head and neck examination was unremarkable. Flexible fiberoptic laryngoscopy confirmed normal laryngeal anatomy with bilaterally mobile vocal folds. Given the highly suspicious ultrasonographic appearance of the lesion in addition to two consecutive nondiagnostic fine needle aspiration biopsies, management options were discussed extensively with the patient. These included continued surveillance with interval imaging and repeat biopsy versus diagnostic surgical excision. Following counselling regarding the potential risks and benefits of each approach, the patient decided to proceed with surgical management which is left hemithyroidectomy.
The postoperative course was uncomplicated, patient was admitted for one night in the hospital for observation. On postoperative day one, the patient was ambulating independently and tolerating oral intake without difficulty. He denied nausea, vomiting, dysphagia, respiratory symptoms, or significant postoperative pain. Examination demonstrated a clean and dry cervical incision with minimal expected postoperative swelling and no evidence of hematoma or fluctuance. Given his acceptable recovery, he was discharged home. Given the patient's history of coronary artery disease requiring clopidogrel therapy, perioperative antiplatelet management was undertaken in coordination with the cardiology team. With their agreement, clopidogrel was withheld preoperatively and during the immediate postoperative period before being resumed as clinically appropriate.
Histopathological examination of the surgical specimen revealed unexpected findings. The dominant lesion corresponded to a benign vascular proliferation consistent with cavernous hemangioma measuring 2.5 cm in greatest dimension. In addition, an incidental papillary thyroid carcinoma of oncocytic subtype measuring 1.7 mm was identified elsewhere within the thyroid specimen. Histological evaluation demonstrated no angioinvasion, lymphatic invasion, perineural invasion, tumor necrosis, or extrathyroidal extension. Surgical margins were free of carcinoma, with the closest margin measuring 1 mm posteriorly. No lymph nodes were submitted for pathological evaluation. Immunohistochemical staining demonstrated positivity for BRAF V600E. Based on the AJCC 8th edition staging system, the carcinoma was classified as pT1a (Figure 3).
The patient presented to the otolaryngology clinic later in April 2026 for post operative evaluation. At follow-up, he remained asymptomatic and reported no postoperative concerns. Examination demonstrated a well-healed cervical incision without evidence of hematoma, seroma, infection, or wound-related complications. Plans were made for thyroid function monitoring and endocrinology follow-up.
The case was subsequently presented at the institutional multidisciplinary endocrine tumor board. Following review of the clinical, radiological, operative, and pathological findings, the lesion was concluded to represent a thyroid cavernous hemangioma associated with an incidental low-risk oncocytic papillary thyroid microcarcinoma. Pathology review was recommended, and the papillary thyroid carcinoma was considered low risk.
Upon pathology review, the pathologist reported that the diagnosis of cavernous hemangioma is confirmed. The specimen was entirely submitted for histologic evaluation. The lesion is a fibrotic, vascular nodule attached to the thyroid, as demonstrated in the image (Figure 4). In addition, two independent pathologists have reviewed the findings and concur with this diagnosis.
Discussion
Most thyroid neoplasms originate from epithelial follicular or parafollicular cells, with primary non-epithelial tumors being an extremely rare entity of all thyroid lesions. Non-epithelial thyroid neoplasms represent a heterogeneous group of tumors that are lymphoid and mesenchymal in origin, which includes vascular, neural, adipocytic, fibroblastic, and smooth muscle tumors. These tumors rare and many studies reporting on them consist of case reports or small case series, making them hard to study and their true burden on epidemiology unknown. Mesenchymal neoplasms of the thyroid are uncommon. Among these rare lesions, vascular neoplasms such as hemangiomas are among the few mesenchymal entities that have been documented in the literature [6-7]. The rarity of these lesions, together with their nonspecific clinical and radiologic presentationscan, makes preoperative diagnosis particularly difficult. Consequently, definitive diagnosis typically relies on thorough histopathological examination and immunohistochemical analysis.
Patients with primary thyroid hemangiomas typically present as a slowly enlarging, painless cervical mass and are often clinically indistinguishable from more common thyroid nodules or goiters. Most patients are euthyroid and lack systemic symptoms, with the lesion discovered during evaluation of a palpable neck swelling. Given their benign nature and typically slow progression, these lesions often remain asymptomatic until local mass effect develops. Reported compressive symptoms include dysphagia, dyspnea, neck discomfort, hoarseness, voice changes, tracheal deviation, and recurrent laryngeal nerve palsy with vocal cord paralysis [8].
The duration of symptoms is highly variable, ranging from a few weeks to several years. Although most lesions demonstrate slow growth, occasional cases of rapid enlargement have been described, often attributed to intralesional hemorrhage or thrombosis. Reported cases have demonstrated markedly different clinical courses, ranging from lesions that remained present for up to 16 years before diagnosis to masses that developed within 20 days of symptom onset. In another reported case, compressive symptoms, including orthopnea and dyspnea on exertion, developed two months after the onset of neck swelling [3].
Thyroid nodules are a common clinical finding, with ultrasonography detecting nodules in up to 68% of the general population. Although the majority are benign, approximately 7-15% are malignant [9]. The diagnostic evaluation of a thyroid nodule typically includes clinical assessment, measurement of thyroid-stimulating hormone (TSH) levels, ultrasonographic risk stratification, and selective fine-needle aspiration (FNA). The diagnosis of primary thyroid hemangioma remains challenging due to the absence of distinctive clinical manifestations and radiologic characteristics. As a result, establishing a definitive diagnosis prior to surgical intervention is uncommon. A review of the literature revealed only two cases of thyroid hemangioma were accurately diagnosed preoperatively based primarily on imaging findings. Nevertheless, several sonographic features have been proposed as potentially suggestive of this rare entity. These include a markedly hypoechoic solid lesion with well-circumscribed margins, prominent intralesional vascularity demonstrated on color Doppler imaging, and a heterogeneous internal echotexture. Additionally, the absence of calcifications and cystic degeneration may further support the diagnosis [10]. Although these imaging characteristics can raise suspicion for thyroid hemangioma, they are not sufficiently specific to establish a definitive diagnosis.
Several authors have explored the use of advanced imaging modalities in the preoperative evaluation of thyroid hemangiomas. Shpitzer et al. [11] recommended the use of digital subtraction angiography (DSA), magnetic resonance imaging (MRI), red blood cell (RBC) scintigraphy, and single-photon emission computed tomography (SPECT) for the identification of these vascular lesions. Similarly, Kumar et al. [1] suggested technetium-99m-labeled erythrocyte scintigraphy as a useful adjunct for confirming the diagnosis of hemangioma. Additionally, Yang et al. [4] reported further evaluation with contrast-enhanced ultrasonography (CEUS) which revealed a characteristic “slow-in and slow-out” enhancement pattern, reflecting markedly slow intralesional blood flow. Delayed washout within the lesion compared with the surrounding thyroid parenchyma was observed, a finding consistent with the vascular behavior of venous hemangiomas described in other anatomical locations. However, despite their potential diagnostic value, these investigations are not routinely performed because of their limited availability, high cost, and lack of accessibility. These investigations were not performed in the present case. As has been reported in most published cases, definitive diagnosis was established only after surgical excision and subsequent histopathological evaluation.
Although fine-needle aspiration (FNA) is a standard diagnostic tool for thyroid nodules based on their size and sonographic risk stratification, it is generally not reliable for establishing a diagnosis of primary thyroid hemangioma. Cytological assessment is frequently nondiagnostic because these lesions often yield acellular or sparsely cellular aspirates composed predominantly of blood, with only occasional endothelial cells that may be difficult to distinguish from those encountered in a traumatic puncture [12]. In this case, the patient underwent ultrasound-guided FNA on two separate occasions. The initial aspiration was deemed nondiagnostic because of insufficient follicular cell groups for reliable cytological evaluation according to the Bethesda criteria, while the repeat aspiration performed one month later demonstrated only blood, inflammatory cells, and debris. These findings are consistent with previous reports describing the limited diagnostic yield of FNA in thyroid hemangiomas.
The preoperative identification of thyroid hemangioma is clinically important, as these highly vascular lesions may be associated with substantial intraoperative hemorrhage. Pickleman et al. [5] reported blood loss exceeding 2 L during hemithyroidectomy for a thyroid hemangioma, necessitating transfusion of four units of whole blood. Although some authors have suggested that the diagnostic yield of FNA may be improved by preparing a cell block from the residual aspirated material, this technique does not involve a core needle biopsy [12]. Instead, the aspirated material is processed into a paraffin block for histopathological and immunohistochemical analysis, provided that sufficient cellular material is obtained. However, because thyroid hemangiomas typically yield predominantly blood with scant cellularity, preoperative diagnosis remains rare.
The relationship between FNA and thyroid vascular proliferations has also been discussed in the literature. FNA is recognized as a potential cause of intrathyroidal hematoma formation, and rare cases of subsequent fibrovascular proliferation resembling cavernous hemangioma have been reported. These lesions are generally considered organized hematomas rather than true primary hemangiomas [1,13]. The incidence of post-FNAB thyroid vascular proliferations ranges between 2.7% to 8.1% [12]. Although vascular proliferations may develop following FNA and have been reported with variable incidence rates, the development of primary thyroid hemangioma is believed to follow a different pathophysiologic process and is generally considered a congenital vascular anomaly resulting from abnormal angioblastic mesenchymal differentiation and vascular development.
An additional consideration in the present case is the patient's use of clopidogrel at the time of ultrasound-guided FNA. Although antiplatelet and anticoagulant therapies may increase the risk of post-procedural bleeding and hematoma formation, there is currently no evidence to suggest that blood thinners or FNA itself contribute to the development of a true primary thyroid hemangioma. Furthermore, several studies have demonstrated that thyroid FNA can be safely performed in patients receiving antithrombotic therapy, with most procedure-related hematomas resolving spontaneously with conservative management [14]. Consequently, the thyroid hemangioma identified in the present patient is more likely to represent a pre-existing vascular lesion that remained undetected preoperatively rather than a lesion induced by clopidogrel therapy or repeated FNA procedures.
Histopathological examination generally classifies primary thyroid hemangiomas into cavernous, synovial, arteriovenous, venous, capillary, and racemose [16], with the cavernous variant being the most commonly encountered form reported in the literature [2,4,15]. Cavernous hemangiomas are benign vascular malformations characterized by large, dilated blood-filled vascular spaces separated by thin fibrous septa. In contrast, venous hemangiomas are characterized by predominantly dilated venous channels and exhibit considerable histopathological overlap with cavernous hemangiomas. Microscopically, both subtypes are characterized by irregularly dilated vascular spaces filled with erythrocytes, accompanied by areas of hemorrhage and well-circumscribed borders. Immunohistochemically, the endothelial cells typically express vascular markers such as CD31, while smooth muscle actin highlights the vascular wall components [2,4]. Because thyroid hemangiomas are exceedingly uncommon, a standardized histopathological classification has not yet been established.
Surgical excision remains the preferred treatment for primary thyroid hemangioma, with either hemithyroidectomy or total thyroidectomy performed according to the size and extent of the lesion. In this patient, repeat imaging and FNA with ongoing surveillance were offered as alternative management options. However, given the persistent diagnostic uncertainty and the concern for an underlying neoplasm, he ultimately elected to undergo left hemithyroidectomy.
In conclusion, as illustrated by the present case and the majority of cases reported in the literature, a definitive diagnosis of primary thyroid hemangioma is most often established only after histopathological examination of the resected specimen. Despite being a benign vascular lesion, primary thyroid hemangioma remains a diagnostic challenge because of its nonspecific clinical presentation and lack of characteristic radiologic and cytological findings. Consequently, preoperative diagnosis is rarely achieved. Surgical excision therefore serves both a diagnostic and therapeutic role, with excellent postoperative outcomes and an overall favorable prognosis.
Acknowledgements
The authors acknowledge the healthcare professionals involved in the clinical care of the patient and thank all contributors who supported the preparation of this case report.
Conflict of Interest Statemnt
The authors declare that they have no conflicts of interest regarding the publication of this case report. No author has received financial support, honoraria, consultancy fees, or any other form of compensation from organizations or commercial entities that could be perceived as influencing the content of this work. The management of the patient described herein was conducted as part of routine clinical care, and the preparation of this manuscript was undertaken independently, without external funding or sponsorship.
Reference