Importance of accurate preoperative diagnosis in the management of aggressive angiomyxoma: report of three cases and review of the literature

Aggressive Angiomyxoma of the Pelvis: 35-Year Experience

BACKGROUND

Aggressive angiomyxoma is a very rare mesenchymal tumor most commonly found in the pelvic and perineal regions. Although many are estrogen and progesterone hormone receptor positive, the pathogenesis is unknown. Due to its rarity, there is a paucity of literature relating to this pathology. This article presents a case series on the management of aggressive angiomyxoma of the pelvis.

OBJECTIVE

To present a 35-year experience managing aggressive angiomyxoma of the pelvis.

DESIGN

This was a retrospective single-system analysis.

SETTINGS

This study was conducted at a quaternary referral academic health care system.

PATIENTS

All patients treated for aggressive angiomyxoma of the pelvis.

INTERVENTIONS

All patients underwent surgical or medical management of their disease.

MAIN OUTCOME MEASURES

The primary outcomes were disease recurrence and mortality. Secondary outcomes included risk factors for recurrence.

RESULTS

A total of 32 patients (94% women) were identified with a median follow-up of 65 months. Thirty patients (94%) underwent operative resection and 2 patients were treated solely with medical management. Fifteen achieved an R0 resection (negative microscopic margins) at the index operation, of which 4 (27%) experienced tumor recurrence. There were no mortalities. No risk factors for disease recurrence were identified.

LIMITATIONS

Limitations to our study include its nonrandomized retrospective nature, single health care system experience, and small patient sample size.

CONCLUSIONS

Aggressive angiomyxoma is a rare, slow-growing tumor with locally invasive features and a high potential for recurrence even after resection with negative margins. Imaging modalities such as CT or MRI should be obtained to aid in diagnosis and surgical planning. Workup should be paired with preoperative biopsy and testing for hormone receptor status, which can increase diagnostic accuracy and guide medical treatment. Close posttreatment surveillance is imperative to detect recurrence. See Video Abstract .

ANGIOMIXOMA AGRESIVO DE PELVIS EXPERIENCIA DE AOS

ANTECEDENTES:El angiomixoma agresivo es un tumor mesenquimal muy raro que se encuentra más comúnmente en las regiones pélvica y perineal. Aunque muchos son positivos para los receptores hormonales como el estrógeno y la progesterona, la patogénesis es aún desconocida. Debido a su rareza, existe escasa literatura relacionada con esta patología. Este artículo presenta una serie de casos sobre el tratamiento del angiomixoma agresivo de pelvis.OBJETIVO:Presentar una experiencia de 35 años en el manejo del angiomixoma agresivo de pelvis.DISEÑO:Este fue un análisis retrospectivo de sistema único.AJUSTES:Este estudio se llevó a cabo en un sistema de salud académico de referencia de nivel cuaternario.PACIENTES:Todos los pacientes tratados por angiomixoma agresivo de pelvis.INTERVENCIONES:Todos los pacientes se sometieron a tratamiento quirúrgico y/o médico de su enfermedad.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la recurrencia de la enfermedad y la mortalidad. Los resultados secundarios incluyeron factores de riesgo de recurrencia.RESULTADOS:Se identificaron un total de 32 pacientes (94% mujeres) con una mediana de seguimiento de 65 meses. Treinta (94%) fueron sometidos a resección quirúrgica y dos fueron tratados únicamente con tratamiento médico. Quince lograron una resección R0 (márgenes microscópicos negativos) en la operación inicial, de los cuales cuatro (27%) experimentaron recurrencia tumoral. No hubo mortalidades. No se identificaron factores de riesgo para la recurrencia de la enfermedad.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva no aleatoria, la experiencia de un solo sistema de atención médica y el tamaño pequeño de la muestra de pacientes.CONCLUSIONES:El angiomixoma agresivo es un tumor raro, de crecimiento lento, con características localmente invasivas y un alto potencial de recurrencia incluso después de una resección con márgenes negativos. Se deben obtener modalidades de imágenes como CT y/o MRI para la ayuda diagnóstica y la planificación quirúrgica. El estudio debe combinarse con una biopsia preoperatoria y pruebas del estado de los receptores hormonales, que pueden aumentar la precisión del diagnóstico y guiar el tratamiento médico. Es imperativa una estrecha vigilancia posterior al tratamiento para detectar recurrencia. (Traducción-Dr Osvaldo Gauto ).

Aggressive Angiomyxoma of the Lower Female Genital Tract: A Review of the MITO Rare Tumors Group

Aggressive angiomyxoma (AAM) is a rare, locally aggressive, myxoid mesenchymal neoplasm primarily found in the pelvic and perineal regions of young adult females. It is a slow growing and locally infiltrating tumor. Preoperative diagnosis is difficult due to the rarity of these tumors and absence of characteristic signs and symptoms. The primary management is tumor excision. Incomplete excision is common because of the infiltrating nature of the neoplasm and absence of a definite capsule. Other non- surgical modalities have been employed, such as radiotherapy, embolization, GnRH analogues or other anti-estrogenic agents. Local relapses occur in 30-40% of the cases, and often appear many years (sometimes decades) after the first excision. Occasional distant metastasis has also been reported. A limited number of cases have been reported in the literature, mostly in the form of small case series or isolated case reports. Therefore, the aim of this paper by a team of experts from the MITO rare tumors group is to review clinical findings, pathologic characteristics and outcome of patients affected by this rare condition in order to be able to offer up-to-date guidance on the management of these cases.

Misleading clinical and imaging features in atypical aggressive angiomyxoma of the female vulvovaginal or perianal region: report of three cases and review of the literature

Objectives

Aggressive (deep) angiomyxoma (AAM) is a rare mesenchymal tumor that typically originates from the vulvovaginal region, perineum, and pelvis in adult women. The objective of this case report and literature review is to comprehensively analyze the clinical, imaging, and pathological characteristics of atypical AAM in the female lower genital tract and pelvic floor in order to minimize preoperative misdiagnosis or missed diagnosis and ultimately optimize the clinical management strategy.

Methods

The data of three cases with atypical AAM, which demonstrate similarities with other lesions observed in the female lower genital tract over the past 1.5 years, were retrospectively described. This description included clinical management, images and reports of ultrasonography (US) and magnetic resonance imaging (MRI), clinicopathological features, follow-up, and outcomes. In the Discussion section, a review of the literature on MEDLINE (PubMed) and Web of Science from the past 50 years was conducted.

Results

The three cases all underwent preoperative ultrasonography, and two of them also underwent preoperative MRI examination. Complete resection of the lesions was performed in all three cases, followed by postoperative pathological examination. The histopathology of these three cases revealed invasive angiomyxoma, as confirmed by immunohistochemical staining, which demonstrated positive expression of desmin, vimentin, estrogen, and progesterone receptors. The patients experienced a smooth postoperative recovery. Ultrasound had a diagnostic accuracy rate of 100% (3/3) for locating and determining the extent of the lesions; however, its specific diagnostic accuracy rate for identifying the pathological type was only 33% (1/3). In contrast, MRI had a diagnostic accuracy rate of 100% (2/2) for locating and determining the extent of lesions but did not show any specific diagnostic accuracy for identifying the pathological types.

Conclusions

Our findings indicate that even if a vulvovaginal lesion presents with a superficial location, small size, limited scope, and regular shape, suspicion of atypical AAM should arise when palpation reveals toughness, tensility, and deformability under pressure. US reveals a well-defined hypoechoic to anechoic mass with uniformly distributed coarse dot echoes, with or without detectable intratumoral blood flow signal. MRI shows prolonged T1 and T2 signals with inhomogeneous enhancement and evident diffusion restriction on diffusion-weighted imaging (DWI).

Aggressive Angiomyxoma of the Vulva: Which Is the Best Management Strategy? Description of a Case Report and Review of Literature of the Last Ten Years

BACKGROUND

Aggressive angiomyxoma is a rare mesenchymal tumour of the genital tract with a high incidence in women of reproductive age. The aim of our work is to understand which is the best management strategy for this condition, starting from the description of a rare case report up to the performance of a narrative review of the literature.

METHODS

We report a case of a 46-year-old woman who came to our attention because of the growth of a 10-centimetre pedunculated, non-soft, non-tender mass of the left labium majus. She underwent surgical excision, and the histologic diagnosis was aggressive angiomyxoma. Due to a lack of tumour-free margins, radicalization surgery was carried out after three months. A review of the literature of the last ten years was performed following the PRISMA statement on MEDLINE (PubMed). We obtained data from twenty-five studies describing thirty-three cases.

RESULTS

Aggressive angiomyxoma is characterized by a high recurrence rate of between 36 and 72% after surgery. There is no universal consensus about hormonal therapy, and most studies (85%) describe surgical excision followed by only clinical and radiological follow-up.

CONCLUSION

Wide surgical excision is the gold-standard treatment for aggressive angiomyxoma, succeeded by either clinical or radiological (ultrasound or MRI) follow-up.

Aggressive angiomyxoma: The first case report in skull

Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor primarily growing in the soft tissue of the pelvis and perineum in women of reproductive age. It is a benign tumor that still has a probability of being accompanied by localized invasion. Although negative margins of resection are difficult to achieve due to the invasive nature of the tumor and the lack of a well-defined capsule, the first line of treatment for AAM is surgery. The diagnosis of AAM is difficult to make due to a lack of specific manifestations and specific tumor markers. In this study, we reported a case of aggressive angiomyxoma in a 2-year-old girl that rarely develops in the skull with craniocerebral compression. The patient initially had a mass on her head that attracted the attention of her family, and then she began to have episodic headaches. Surgery was performed after hospitalization, and the tumor recurred 1 year after the operation, around the originally affected skull.

Rare Mesenchymal Tumors of the Pelvis: Imaging and Pathologic Correlation

Most pelvic tumors originate from the organs. Less commonly, tumors can arise from the various anatomic pelvic compartments and are comprised of mesenchymal tissue: muscles, connective tissue, vessels, lymphatics, and fat. Among some of the rarer entities are benign tumors (eg, angiomyxoma, cellular angiofibroma, and desmoid fibromatosis), malignant tumors (eg, sarcoma), and tumors that can manifest as benign or malignant (eg, solitary fibrous tumor or nerve sheath tumor). Because these tumors are uncommon and often manifest with nonspecific clinical features, imaging (usually MRI) is an initial step in the evaluation. Radiologists interpreting these images are asked to help narrow the differential diagnosis and assess the likelihood of malignancy for treatment planning. Thus, the MRI report should include the imaging features that would indicate the underlying tissue histology for pathologic diagnosis as well as a description of the anatomic extent and pattern of growth. The authors describe multiple locally aggressive benign and malignant mesenchymal tumors and highlight characteristic clinical and imaging features that enable the radiologist to narrow the differential diagnosis. The anatomic spaces of the pelvis are reviewed with illustrations to aid the radiologist in describing these tumors, which often span multiple pelvic compartments. Tumor appearance at T2-weighted, diffusion-weighted, and postcontrast MRI is summarized and illustrated with correlation at CT or fluorodeoxyglucose PET/CT, when available. MRI features that correspond to specific types of tissue (eg, myxoid, fibrous, or vascular) are highlighted and correlated with images from pathologic evaluation. Online supplemental material is available for this article. ^©RSNA, 2021.

Aggressive angiomyxoma of the ischioanal fossa in a post-menopausal woman

Aggressive angiomyxoma is a rare mesenchymal tumour, primarily arising in the soft tissue of the pelvis and perineum in women of reproductive age. There is a paucity of evidence on optimal management because of the rarity of these tumours, but the consensus has been for surgical excision. We present the case of a 65-year-old woman who was admitted with left-sided buttock pain and initially diagnosed with a perianal abscess. She underwent examination under anaesthesia rectum with surgical excision of the lesion, subsequent histopathological and immunochemical analysis was suggestive of aggressive angiomyxoma. To complement our case report, we also present a literature review focusing on aggressive angiomyxoma in the ischioanal fossa (also known as the ischiorectal fossa) with only eight cases of primary aggressive angiomyxoma involving the ischioanal fossa documented to date. The primary aims of this case report and literature review are to familiarise clinicians with the clinical, histopathological and immunochemical features of these tumours, and to increase appreciation that despite the rarity of aggressive angiomyxoma, it might be considered in the differential diagnosis of ischioanal lesions.

Application of ultrasound in aggressive angiomyxoma: Eight case reports and review of literature

Aggressive angiomyxoma (AAM) is a rare tumour that often occurs in soft tissues of the female genital tract. Eight cases of AAM are reported in this article, and the clinical features and ultrasound and magnetic resonance imaging (MRI) results of the eight cases are reviewed and summarized. The main complaints of all the patients were palpable and painless masses in the vulva or scrotum. The lesions were mainly located in the vulva, pelvis, and perineal region, with a large scope of involvement. The sonographic features of AAM were characteristic. On sonography, all of the masses were of irregular shape and showed hypoechogenicity, with a heterogeneous inner echotexture. Intratumoural and peritumoural blood flows were detected by colour Doppler imaging. On real-time ultrasonic imaging, prominent deformation of the lesions was observed by compressing the masses with the probe. Some special imaging features were also revealed, including a laminated or swirled appearance of inner echogenicity, and a finger-like or tongue-like growth pattern. On MRI imaging, the lesions showed intermediate-intensity signals and intermediate to high-intensity signals on TI-weighted and T2-weighted sequences. A rapid and uneven enhancement pattern was demonstrated. After the comparison of sonographic features with MRI and pathological findings, we found the relevance of the ultrasonographic characteristics with MRI and histological features of AAM. Ultrasound can be a valuable imaging method for the preoperative diagnosis, evaluation of scope, and follow-up of AAM.

Aggressive angiomyxoma of the liver: a case report and literature review

Background

Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor that occurs almost exclusively in the soft tissue of the pelvis and perineum. AAM has both locally infiltrative and recurrent characteristics. Very few cases of AAM occurring outside of the pelvis and perineum have been reported. Here, we report a case of AAM originating in the liver of a 33-year-old female patient.

Case presentation

A 33-year-old woman underwent S8 subsegmentectomy after clinical diagnosis of a mucinous cystic neoplasm of the liver. Histological analysis revealed a tumor composed of spindle-shaped cells with vascular proliferation in a myxoid stroma. Immunohistochemically, the tumor cells stained positively for CD34, estrogen receptor (ER), and progesterone receptor (PgR) and negatively for S-100, EMA, CK19, CD99, HMB45, and α-smooth muscle actin. The tumor was diagnosed as AAM originating from the liver. The patient received no adjuvant chemotherapy. No sign of recurrence or distant metastasis has been noted for 10 months after the surgery.

Conclusions

We here report a second case of AAM originating from the liver, which is an uncommon location for this particular tumor.

Surgical Resection of Retroperitoneal Aggressive Angiomyxoma: Case Report and Review of the Literature

Aggressive angiomyxoma is a benign stromal tumor with a higher prevalence in middle-aged women. The objective of this case report is to illustrate the aggressive clinical behavior of this benign tumor. We present the case of a 45-year-old female patient, with tumor recurrence after multiple surgical resections of a pelvis-subperitoneal angiomyxoma. Surgical excision of the tumor, with extensive pelvic dissection and organ resection, was performed. The 12-month follow-up showed no tumor recurrence. Based on this case, and the published literature we may conclude that surgical resection represents the main treatment of aggressive angiomyxoma, even though it is associated with significant morbidity and a poor local control of the tumor.

Aggressive angiomyxoma presenting with back and perineal bulge; a complex surgical approach: A case report

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90% of patients are women.

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Different incisions allows full mobilization of the tumor.

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Wide excision should keep capsule intact.

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R0 resection should be achieved.

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Follow-up should be at 1–2 yearly intervals.

Introduction

Aggressive angiomyxoma is a rare mesenchymal tumor occurring predominantly in the pelvi-perineal region. It is more common in females during their reproductive age. Our focus is on the surgical approach for a recurrent angiomyxoma.

Case presentation

We present a case of a 36-year-old female patient with a recurrent lower back and perineal bulges. One year ago, she had the same presentation and underwent resection of that mass in a peripheral hospital without available information. Five months later, she started to have the same bulge. Computed tomography scan and true cut biopsy were suggestive of angiomyxoma with single lung metastasis. The decision was to proceed with resection through a transabdominal and perineal incision, even in the presence of metastasis since it’s a very slow growing tumor with long life expectancy. The pathology was consistent with aggressive angiomyxoma.

Discussion

90% of patients with angiomyxoma are women. Although it is benign, the tumor is still aggressive because of the high rate of local recurrence after resection. Angiomyxoma is a mesenchymal tumor, composed of fibroblasts within a myxoid background. Treatment is usually through wide local excision to achieve an R0 resection. Our approach was through a transabdominal and perineal incision, which allowed full control and mobilization of the tumor without disrupting the capsule. This surgical approach was not described previously in the literature.

Conclusion

The principle to achieve cure in aggressive angiomyxoma is by optimizing exposure through two different incisions, wide excision while keeping the capsule intact and removing enbloc any invaded organ.

Practical approach to MRI of female pelvic masses

OBJECTIVE

Female pelvic masses have a broad differential diagnosis, including benign and malignant neoplasms and nonneoplastic entities.

CONCLUSION

By using a systematic approach to the evaluation of a complex pelvic mass, including incorporating the clinical and surgical history, and by using multiparametric MRI to identify the anatomic origin, morphologic features, and tissue composition of a mass, a short meaningful differential diagnosis or definitive diagnosis can often be established.

Robotic assisted excision of retrovesical angiomyxoma in a male patient

Angiomyxoma is a rare tumour found predominantly in pelvis of young females. Less than 150 cases have been reported, more than 90% in females and only few cases in males. Its surgical excision is a big challenge and usually leads to recurrence due to incomplete excision. We report a case of retrovesical Angiomyxoma in an elderly male. The aim of this report is to highlight the rarity of this disease, especially in males, and robotic assisted excision as an evolving option of treatment.

Aggressive angiomyxoma with diffusion-weighted magnetic resonance imaging and dynamic contrast enhancement: a case report and review of the literature

Introduction

Aggressive angiomyxoma (AA) is a rare benign soft tissue tumour usually affecting the pelvis and perineum of young women. Magnetic resonance imaging (MRI) is crucial in the management of AA patients for its diagnostic contribution and for the preoperative assessment of the actual tumour extension. Given the current development of less aggressive therapeutics associated with a higher risk of recurrence, close follow-up with MRI is fundamental after treatment. In this context, diffusion-weighted (DW) imaging has already shown high efficacy in the detection of early small relapses in prostate or rectal cancer.

Case Report

We report here a case of pelvic AA in a 51-year-old woman examined with dynamic contrast enhancement and DW-MRI, including apparent diffusion coefficient mapping and calculation.

Conclusion

To our knowledge, this is the first description of DW-MRI in AA reported in the literature. Here, knowledge about imaging features of AA will be reviewed and expanded.

Imaging findings of angiomyxolipoma of the spermatic cord mimicking inguinal hernia

We report the case in a 72-year-old man who presented with a right inguinal mass and with a one month history that was initially interpreted as an inguinal hernia. Ultrasonography (US) and computed tomography (CT) demonstrated a right inguinal mass, including myxoid and fat component, extending from the right spermatic cord to the right inguinal subcutaneous layer. Mass excision was performed, and the diagnosis turned out to be angiomyxolipoma. Angiomyxolipoma is a rare tumor and the preoperative diagnosis of this disease is very difficult. However, angiomyxolipoma of the spermatic cord should be considered in the differential diagnosis in patients with an irreducible inguinal mass. Imaging diagnosis, such as US and CT may help to make a preoperative diagnosis.

Conservative En Bloc Surgery for Aggressive Angiomyxoma Achieves Good Local Control: Analysis of 14 Patients From a Single Institution

Background

The purpose of this study was to assess the value of conservative surgery in aggressive angiomyxoma (AA) in our institutional series.

Method

This was a retrospective review of patients with AA treated at our institution between 1999 and 2010.

Results

Fourteen consecutive patients were analyzed: 8 primary tumors and 6 recurrences. Female/male ratio was 13:1; median female age was 36 years. Median size of primary lesions was 12 cm (range, 7–17 cm). Median size of recurrences was 20.5 cm (range, 3–44 cm). Twelve patients were operated on. Two asymptomatic patients whose surgery would have been mutilating were placed under wait and see. Four patients had concomitant visceral resections because of massive infiltration. No tumor rupture was recorded on pathological examination. Margins were R0 (n = 2), R1 (n = 10), and R2 (n = 0). Seven patients (50%) received radiotherapy. Median postoperative follow-up was 69 months, and no patient was lost at follow-up. All patients operated on (primaries and recurrences) had no evidence of recurrence.

Conclusion

Conservative and planned en bloc surgery achieves good local control with low morbidity. Radiotherapy could enhance local control in advanced disease. Wait and see is an exploratory option for asymptomatic, stable, and nonprogressing AA in which surgery would be mutilating.

Aggressive angiomyxoma of the thigh: A case report and review of the literature

In this study, we report a case of aggressive angiomyxoma (AAM) of the thigh in a 43-year-old female patient. Ultrasonography revealed a 6.1×3.7×5.3 cm solid mass in the right thigh with well-demarcated borders and a heterogeneous echotexture. Color Doppler ultrasonography (CDUS) revealed weak blood flow in the mass with peripheral and central avascularity. Computed tomography (CT) of the thigh revealed a homogeneous low-density mass under the spatium intermusculare of the quadriceps femoris. The mass was diagnosed as AAM by histopathological examination following complete excision around the adventitia of the tumor. At 18 months follow-up, there was no recurrence. In conclusion, this case is noteworthy as it involves AAM of the thigh, which is a rare tumor.

Imaging of unusual perineal masses

OBJECTIVE

The purpose of this article is to describe the radiologic features of unusual tumors that occur in the perineum.

CONCLUSION

The perineal space is often overlooked because of the infrequency of abnormalities. Accurate image interpretation and visualization of extent of pathology is important for proper management. Trauma and infectious diseases occur in the acute setting, whereas tumors are common in the chronic setting. Cross-sectional imaging plays a crucial role in depicting perineal anatomy and evaluating the extent of disease.

Aggressive angiomyxoma of vulva and vagina: a series of three cases and review of literature

BACKGROUND

Aggressive angiomyxoma is a rare locally aggressive mesenchymal tumor of unknown etiology usually affecting the vulva, perianal region, buttocks or pelvis of reproductive age women.

MATERIAL

A series of three cases, one each of vaginal, vulval and labial angiomyxoma is being presented. The etiology, presentation, diagnosis and management of this rare genital tumor are outlined.

CONCLUSION

Angiomyxoma of vulva and vagina refers to a rare disease; diagnosis is not at all clinical, thus, cases presenting as bartholin cyst, benign vulval lesions and vaginal wall cysts should have complete radiological work up before excision, as pre-diagnosis can change the treatment modality and prognosis of patient.

Aggressive angiomyxoma presenting with huge abdominal lump: A case report

Agressive angiomyxoma is a rare mesenchymal neoplasm. It mainly presents in females. We here present a case of angiomyxoma presenting as huge abdominal lump along with gluteal swelling. Case note is described along with brief review of literature.

Aggressive angiomyxoma of the thigh

Aggressive angiomyxoma is a rare tumour that typically occurs in the perineum in women of reproductive age. A small number of cases occurring in men have been reported, all of which were located in the low pelvis, perineum or scrotum. While benign, the tumour is locally infiltrative and consequently has a high rate of local recurrence following surgery; therefore, accurate pre-operative diagnosis is important. The characteristic location of these tumours in the low pelvis or perineum has led to speculation that aggressive angiomyxomas arise from a mesenchymal cell that is unique to the perineum. We describe a case of aggressive angiomyxoma arising in the thigh of a 54-year-old man, which we believe is the first reported instance of this rare neoplasm occurring remote from the pelvis or perineum in a male patient. Cross-sectional imaging demonstrated a well-defined mass that had low density on CT and high intensity on fluid-sensitive MR sequences. Biopsy was non-diagnostic and excision was performed. At histological analysis, the tumour exhibited the characteristic features of aggressive angiomyxoma, with bland spindle cells and large, hyalinised blood vessels in a hypocellular myxoid matrix. Extensive immunohistochemical staining further supported the diagnosis. While the imaging features of these tumours are non-specific and suggestive of myxoid neoplasms, the diagnosis should be considered whenever biopsy of a myxoid-appearing mass yields hypocellular, non-diagnostic material, despite adequate sampling.