Individualized managing strategies of aggressive angiomyxoma of female genital tract and pelvis

An Aggressive Angiomyxoma Presenting as a Vaginal Wall Carbuncle in a 31-Year-Old Female: A Case Report

An aggressive angiomyxoma (AA) is a rare soft tissue neoplasm of the lower female genital tract. The incidence of vaginal involvement is low, so it is commonly misdiagnosed as a Bartholin cyst, lipoma, and abscess, among others. This is a case of a 31-year-old female patient presenting with anterior vaginal wall swelling measuring 1 x 1 cm, clinically diagnosed as vaginal carbuncle. Histological and immunohistochemical examination of the lesion showed an AA. Some AAs recur locally, while distant metastasis is rare. The tumor is infiltrative with a characteristic histologic picture. The tumor is positive for high mobility group A2 (HMGA2), estrogen receptors (ERs), a cluster of differentiation 34 (CD34), and desmin immunomarkers. Due to the infiltrative nature of the tumor, surgical margins are commonly positive.

Deep (aggressive) angiomyxoma of the vulva in a pregnant woman

Aggressive angiomyxoma is a rare mesenchymal tumour, which usually appears in the pelvic region of women in their reproductive age. Although benign, it is a locally infiltrative tumour with frequent recurrence. We report a case of a pregnant woman in her 30s with a vulvar aggressive angiomyxoma which was initially misdiagnosed. Features of this case are discussed, highlighting the difficulty in its diagnosis and the challenge of the follow-up and treatment of recurrences.

Value of contrast-enhanced ultrasound in deep angiomyxoma using a biplane transrectal probe: A case report

BACKGROUND

Deep angiomyxoma (DAM) is a very rare tumor type. Magnetic resonance imaging (MRI) is considered the best imaging modality for diagnosing DAM. Computed tomography (CT) is used mainly to assess the invasion range of DAM. The value of ultrasonography in the diagnosis of DAM is still controversial. Through a literature review, we summarized the current state of ultrasonic examination for DAM and reported for the first time the contrast-enhanced ultrasound (CEUS) features of DAM seen using a biplane transrectal probe.

CASE SUMMARY

A 37-year-old woman presented with a sacrococcygeal mass that had gradually increased in size over the previous 6 mo. MRI and CT examinations failed to allow a definite diagnosis to be made. Transperineal core needle biopsy (CNB) guided by transrectal ultrasound and CEUS was suggested after a multidisciplinary discussion. Grayscale ultrasound of the lesion showed a layered appearance with alternating hyperechoic and hypoechoic patterns. Transrectal CEUS showed a laminated distribution of the contrast agent that was consistent with the layered appearance of the tumor on grayscale ultrasound. We performed transperineal CNB of the enhanced area inside the tumor under transrectal CEUS guidance and finally made a definitive diagnosis of DAM through histopathology. The patient underwent laparoscopic-assisted transabdominal surgery combined with transperineal surgery for large pelvic tumor resection and pelvic floor peritoneal reconstruction. No recurrence or metastasis was found at the nine-month follow-up.

CONCLUSION

Transrectal CEUS can show the layered perfusion characteristics of the contrast agent, guiding subsequent transperineal CNB of the enhanced area within the DAM.

Characteristics and outcomes of patients with primary abdominopelvic aggressive angiomyxoma: a retrospective review of 12 consecutive cases from a sarcoma referral center

BACKGROUND

Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor that mostly arises from the pelvic and perineal soft tissues. Few studies reported its characteristics and outcomes previously due to its rarity and challenges of treatments. This study aimed to investigate the clinical characteristics as well as surgical and short-term survival outcomes of primary abdominopelvic AAM.

METHODS

Medical records of patients who were admitted to surgery with pathological confirmation of primary abdominopelvic AAM at Peking University International Hospital from January 2016 through December 2021 were retrospectively retrieved from our retroperitoneal tumor database. Demographics, operative outcomes and pathological findings were collected. Patients received followed-up routinely after the surgery. Survival probabilities were calculated and determined through Kaplan-Meier analysis.

RESULTS

A total of 12 consecutive patients (male/female 4:8) were included in this study. The median age was 45 years old. The clinical presentation varied among individuals, consisting of 2 abdominal discomforts, 4 constipations, 1 lumbago, 1 prolonged menstruation, and 1 buttock swelling. R0/R1 resection was achieved in 100% of patients. Postoperatively, 50% of patients developed various complications including 3 fistulas and 3 wound infections. No operative mortality was observed. Histopathology of all patients was suggestive of AAM. Immunohistochemistry was done with a 91.7% positive rate for estrogen and progesterone receptors. The median recurrence-free survival time was 38 months. There were no cases of deceased or presented with distal metastasis during a median of 42 months' follow-up.

CONCLUSIONS

The clinical manifestations of abdominopelvic AAM are mostly atypical. Surgical resection with curative intents remains the mainstay treatment of this disease, which was strongly suggested in experienced sarcoma centers due to the high probability of severe postoperative complications. In addition, long-term follow-up is necessary due to the high rate of local recurrences.

Aggressive Angiomyxoma in the Scrotum: A Case Series and Literature Review

Purpose

Aggressive angiomyxoma (AAM) was identified as a distinct clinicopathological entity in 1983. Since then, a few cases of its occurrence in the scrotum have been reported. This case series was performed to increase clinicians' understanding of the clinical features and treatment of AAM in the scrotum.

Methods

We evaluated the clinical presentations, treatments, and follow-up of two patients with AAM in the scrotum in our hospital and 34 cases reported in the literature.

Results

Among the 36 patients, the average age was 48.3 ± 20.6 years old (range from 1 to 81); the average maximum diameter of the tumor was 8.36 cm (1.6–25 cm); the site of one (2.78%) patient was located in the epididymis, two (5.56%) in the testes, five (13.89%) in the spermatic cord, and 28 (77.77%) in the scrotum. The clinical symptoms were generally non-specific and 20 patients inadvertently discovered their slow-growing painless masses. The treatments for all these patients were surgical excision once the tumor had been found and one case underwent excision followed by radiotherapy. The median follow-up time for the remaining 32 cases was 24.5 months (1 to 84 months). Recurrence occurred in three cases (9.09%) at the primary sites and no cases of distant metastasis.

Conclusion

AAM of the scrotum can occur in middle-aged and elderly men. The clinical manifestation generally involves a long history of asymptomatic masses or swelling in the scrotum. Ultrasound is the most commonly used diagnostic technique but magnetic resonance imaging may be more effective. The mainly treatment is surgical excision and postoperative histopathological examination is still the gold standard for its diagnosis. Although it is locally aggressive, metastasis is extremely rare in males.

Radio-pathological and Clinical Correlation of Aggressive Angiomyxoma: Experience of a Tertiary Care Cancer Hospital

Background  Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor predominantly affecting the pelvis and perineum of females. Due to its variable clinical presentation, it is often misinterpreted and treated as other pathologies like Bartholin gland cyst, vulvar abscess, and hernia. The tumor is locally infiltrative, making its complete surgical removal difficult. Aim  The aim of the study is to highlight and illustrate the imaging and pathological features of AAM. Materials and Methods  After obtaining clearance from the Institutional Ethics Committee, a retrospective study was conducted on patients with histopathological diagnosis of AAM, presenting to the dedicated sarcoma clinic between 2016 and 2019. The demographic, clinical, radiological, pathological, and treatment details were obtained from the institute's database. The magnetic resonance imaging (MRI) and computed tomography images were reviewed to assess different imaging parameters. Follow-up imaging was assessed for residual or recurrent mass in the pelvis or perineum and distant metastasis. Results  A total of four patients were included with an age range of 28 to 50 years. The baseline MRI of these four patients shows pelvic mass extending into the perineum, infiltrating along the surrounding fascial planes with the characteristic laminated appearance on T2-weighted image and gradual intense enhancement following contrast administration. All patients had residual disease post-surgery and were put on hormonal therapy. Conclusion  AAMs are locally aggressive, rarely metastasizing mesenchymal tumor that has a specific predilection for the perineum and pelvis of females. MRI features like laminated or striated appearance, post-contrast enhancement, and finger-like infiltrating projections should raise the suspicion of the diagnosis on baseline imaging.

Aggressive angiomyxoma of the vagina: Case report and review of the literature

OBJECTIVE

To present the case of a patient diagnosed with aggressive angiomyxoma of the vagina and to conduct a review of the diagnosis, treatment and prognosis of this disease condition.

METHODS

A 46-year old female patient complaining of dysuria and vaginal mass sensation. Physical exploration and imaging studies revealed a tumor extending into the pelvic cavity. The mass was resected through a vaginal approach and pathology of the surgical specimen showed an aggressive angiomyxoma of the vagina. New retrorectar surgery was performed three months after the initial resection because of recurrence. A search was conducted in the Medline via PubMed, Lilacs, Scielo and Google Scholar databases using the terms "Angiomyxoma," "Aggressive" and "Vagina." The search included review articles, case reports and case series published in English and Spanish since 1995. The information extracted included diagnosis, symptoms, signs, immunohistochemistry and imaging studies used, type of treatment surgical or other - and prognosis. Findings are described in narrative form.

RESULTS

Overall, 23 titles were identified, of which 14 case reports, 2 clinical case series and 1 review article met the inclusion criteria. Sixty-five per cent of the patients were between 30 and 50 years of age. Diagnosis was made by immunohistochemistry in 8 cases, and diagnostic imaging was used in 12 cases. Computed tomography showed sharper contours of the lesions. Surgical treatment was applied in all reports, supplemented by hormonal therapy in 4 cases. There was follow-up in 14 of the 17 cases reported.

CONCLUSIONS

Aggressive angiomyxoma of the vagina is rare. Assessment of the role of various immunohistochemical tests is needed in cases identified as aggressive angiomyxoma on histopathology. Evaluation of hormonal treatment as an adjunct to surgery is required. Prognosis is good.

Incidental para-ureteral aggressive angiomyxoma: a rare case report and literature review

BACKGROUND

Aggressive angiomyxoma (AA) is a rare tumor that typically occurs in the pelvis and perineum, most commonly in women of reproductive age. However, no para-ureteral AA has been reported according to the literature. Case presentation We herein describe the first case of para-ureteral AA. A 62-year-old male presented to our institute in March 2017 with a para-ureteral mass that was 15 mm in diameter incidentally. No symptom was observed and laboratory analysis was unremarkable. Magnetic resonance and computed tomography imaging showed a non-enhancing mass abutting the left ureter without causing obstruction. Laparoscopic resection of the mass was performed without injury to the ureter. Pathologic and immunohistochemical results were consistent with AA. Till now, no recurrence was noticed.

CONCLUSIONS

We reported a rare case of para-ureteral AA, along with a literature review. Early diagnosis, proper surgical plan and long-term close follow-up is recommended for its high risk of recurrence and malignant potential.

Retrospective analysis of clinicopathological features and prognosis for aggressive angiomyxoma of 27 cases in a tertiary center: a 14-year survey and related literature review

PURPOSE

Aggressive angiomyxoma (AAM) is a rare and often misdiagnosed tumor that is characterized by frequent local recurrences. This study aimed to investigate the clinicopathological characteristics, surgical experiences, and prognosis for aggressive angiomyxoma to improve the accuracy of diagnosis and develop treatment strategies for decreasing recurrence rates.

METHODS

Clinicopathological data and follow-up information for 27 patients with AAM diagnosed and treated at the Shengjing Hospital of China Medical University between January 2006 and October 2019 were retrospectively analyzed.

RESULTS

The median age at disease onset among 27 patients was 39 years. The male to female ratio was 1:4.4. Painless and slow-growing mass was the most common symptom. Masses occurring in the perineum and pelvic cavity accounted for 81.5% (22/27). All of the 27 patients underwent surgical treatment. Surgical approaches included transperineal and transvaginal resection. Large pelvic masses were treated with combined abdominoperineal surgery. The postoperative recurrence rate was 37%. Kaplan-Meier survival analysis revealed that 5-year progression-free survival (PFS) rate was 64.4% and the median PFS was 132.0 ± 29.6 (95% CI 72.9-190.1). Multivariate Cox proportional analysis found that surgical margin is an independent prognostic factor for PFS (P = 0.018). None of the patients experienced distant metastasis.

CONCLUSIONS

Clinical manifestations of AAM are non-specific. Laboratory testing, imaging examinations, and immunohistochemistry are helpful for diagnosis and differential diagnosis. Surgical approach can be determined according to the relationship between the tumor and adjacent organs and infiltration degree. The development of personalized treatment strategies should aim to achieve a complete resection on the premise of preserving the structure and function of important organs to maintain patient quality of life.

Pelvic Aggressive Angiomyxoma: Major Challenges in Diagnosis and Treatment

Aggressive pelvic angiomyxoma is a very rare mesenchymal tumor that is usually diagnosed in premenopausal female patients. The current mainly reported treatment is wide surgical excision. Other treatment options, such as radiotherapy and hormonal therapy, have been suggested as potential alternatives. A 61-year-old postmenopausal female patient presented with hematuria that led to the identification of a perirectal mass on abdominopelvic imaging. A 46-year-old female patient presented with a perineal mass of unknown etiology. Despite extensive investigations, the diagnosis could not be confirmed before surgical resection in both patients. Surgical excisions were performed and revealed the presence of an aggressive angiomyxoma with positive estrogen and progesterone tumoral receptors in both cases. Radiological and clinical recurrence was noted in one patient. Tumor regression was noted in this patient after treatment with a luteinizing hormone-releasing hormone (LHRH) agonist with long-term remission. The diagnosis of a perirectal aggressive angiomyxoma is an exceedingly rare event. Preoperative biopsy and pathological diagnosis are challenging and often yields poor results. Its slow growth and expression of hormonal receptors make noninvasive therapeutic strategies, such as radiotherapy, gonadotropin-releasing hormone agonists, or even watchful waiting, valid options in selected patients. Due to the lack of reported cases, the best treatment has yet to be elucidated.

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.

A persistent mass: A case of aggressive Angiomyxoma of the vulva

We present a case of aggressive angiomyxoma of the vulva. The patient presented with a persistent, enlarging vulvar mass, initially misdiagnosed as a Bartholin gland cyst. The patient underwent wide local excision, which resulted in total resection of the mass. Final pathology was consistent with aggressive angiomyxoma, a rare soft tissue tumor with a predilection for the female pelvis. Though rare, it is important to consider in the differential diagnosis of a pelvic mass, given the locally aggressive nature of this tumor and propensity for recurrence.

An unusual vaginal lump

A 46-year-old woman presented with a 2-week history of a painless golf ball sized lump in her vagina. Despite transvaginal ultrasound scan, biopsy and MRI, it was only after surgery had been performed that it became clear what the nature of the mass actually was.Immunohistochemistry revealed the lump to be an aggressive angiomyxoma. Follow-up MRI showed residual (or recurrence of) angiomyxoma which was successfully treated with monthly injections of Prostap (leuprorelin acetate), a gonadotropin-releasing hormone agonist. Further MRI showed complete resolution of the lesion.

Selective marginal resections in the management of aggressive angiomyxomas

AIM

Aggressive angiomyxomas (AA) are rare tumors, most commonly presenting in the pelvis of women of childbearing age. This study presents the results of selective marginal resection of this disease in patients managed at a single institution.

METHODS

Patients diagnosed with AA from July 2001 to July 2015 were identified from a prospectively maintained histopathology database.

RESULTS

Seventeen patients were diagnosed with AA in the study period. The median age at diagnosis was 48 years. Females were more commonly affected with a M:F of 1:8.5. The most common differential diagnoses were an ischiorectal abscess or Bartholin's cyst. Fifteen cases occurred in the pelvis, with two cases at other sites. Median maximum tumor diameter was 10 cm. Of the pelvic cases, 12 were managed operatively via perineal, abdominal, or abdominoperineal approaches. Excision was performed in a marginal fashion with minimal morbidity. Local recurrence developed in 58.3% with a median local recurrence free survival of 25 months. No patients developed metastatic disease or died from disease.

CONCLUSION

AA are rare tumors with a propensity for local recurrence. Atypical presentations of other perineal pathologies should prompt further investigation. Surgery should be reserved for symptomatic patients and is associated with low rates of morbidity. J. Surg. Oncol. 2016;114:828-832. © 2016 2016 Wiley Periodicals, Inc.

Aggressive Angiomyxoma in Pregnancy: A Rare Condition, a Common Misdiagnosis

Introduction. Aggressive angiomyxoma is a rare mesenchymal neoplasm. Although benign in the majority of the cases, these neoplasms usually present a locally infiltrative nature and high rates of recurrence. Due to its rarity, misdiagnosis is a common problem. Case Presentation. We present one case of aggressive angiomyxoma in a 25-year-old pregnant woman. The patient presented with a large vaginal mass that was interpreted as a vaginal cyst. We performed surgical resection of the neoplasm and the correct diagnosis was only achieved after histological examination. With this case, we highlight the importance of considering this diagnosis in patients with genital and perineal masses of unknown origin and the impact of a correct preoperative diagnosis in patient's management and follow-up. Conclusion. Although aggressive angiomyxoma is rare, it should be considered in differential diagnosis of pelviperineal masses in young women. Its positivity to estrogen and progesterone receptors can justify enlargement and recurrence during pregnancy, although few cases are reported. Early recognition demands high index of suspicion for both gynaecologists and pathologists. Wide surgical excision with tumor free margins is the basis of curative treatment. Adjuvant therapy may be necessary for residual or recurrent tumors. Long-term follow-up is recommended.

Algorithm for the surgical management of mesenchymal tumors of the perineum in adults

BACKGROUND

Perineal soft tissue tumors are rare, so that little is known about their management and the outcome of treatment.

OBJECTIVE

The aim of this study is to describe the presentation, management, and outcome of the surgical treatment of soft tissue tumors and to provide a final decision algorithm.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted in a single tertiary care hospital with a dedicated unit on sarcoma.

PATIENTS

Fifty-one consecutive patients from 1998 to 2013 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured are patient demographics, treatment decisions, and outcome of surgical treatment.

RESULTS

Forty-nine patients presented with a primary soft tissue tumor, and 2 underwent simple excisions for isolated metastases. The median tumor size was 75 mm (50-110). Symptoms were nonspecific, and MRI had insufficient specificity for malignancy so that a preoperative biopsy was systematically performed according to European Society for Medical Oncology and National Comprehensive Cancer Network soft tissue tumor guidelines. Six benign soft tissue tumors (3 lipomas, 3 leiomyomas), 16 intermediate soft tissue tumors (12 aggressive angiomyxoma, 4 desmoid tumors), and 27 sarcomas were identified. Treatments and surgery were tailored from the beginning according to histology. All but 1 benign soft tissue tumor were treated by 'shelling out.' Aggressive angiomyxoma were treated with en bloc resection sparing uninvolved organs. Nonsurgical treatments were our first choice for desmoid tumors. Wide en bloc surgery was planned for all sarcomas (n = 27) after the induction treatment for 16 patients (chemotherapy, n = 12; radiotherapy, n = 4). In the sarcoma group, the 5-year estimated metastasis-free, local recurrence-free, and overall survival rates were 68.1% (95% CI, 50.7-91.5), 84.7% (95% CI, 66.7-100), and 85.7% (95% CI, 71.8-100). In the benign and intermediate tumor groups, there were no deaths, local recurrences, or progression.

LIMITATIONS

This study was limited by the small number of patients, given the rarity of this disease in the perineum.

CONCLUSION

We provide useful indications for the best strategy necessary to treat these rare tumors located in a complex site.