Hormonal Therapy for Aggressive Angiomyxoma: A Case Report and Proposed Management Algorithm

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

RATIONALE

Aggressive angiomyxoma (AAM) is an exceptionally rare mesenchymal tumor that predominantly manifests in the female genital organs during the reproductive age. Its rarity alone makes it a fascinating subject for study. The diagnosis of AAM necessitates differentiation from other benign or mesenchymal tumors and can be confirmed through immunohistochemistry (IHC) staining. Surgical resection is the primary treatment, and adjuvant treatment can be used as hormonal therapy with gonadotropin-releasing hormone agonists, selective estrogen receptor modulators, and aromatase inhibitors.

PATIENT CONCERNS

A 44-year-old premenopausal Korean woman presented with a growing perineal mass and frequent urination.

DIAGNOSES

Histopathological findings confirmed AAM, with IHC staining showing estrogen receptor, progesterone receptor, actin and desmin positivity, and CD34 and S100 negativity.

INTERVENTIONS

The mass was excised transvaginally under general anesthesia.

OUTCOMES

The patient showed no signs of recurrence 6 months postoperatively.

LESSONS

AAM in the vagina is a rare tumor that requires differential diagnosis using IHC staining. Previously, we reviewed reported cases and confirmed the feasibility and effectiveness of surgery as the main treatment. This might reassure us about the potential successful treatment of AAM. Adjuvant hormonal therapy with gonadotropin-releasing hormone agonists, selective estrogen receptor modulators, and aromatase inhibitors can further reduce the risk of recurrence.

Atypical Vaginal Aggressive Angiomyxoma in a Virgin: A Case Report from South Jordan

Aggressive angiomyxoma is a locally invasive, rarely diagnosed mesenchymal tumor that predominantly affects the perineal region of women in their reproductive years. It is typically found in areas such as the vagina, vulva, and other pelvic soft tissues, but its presentation can be highly variable. We describe a particularly unique case of aggressive angiomyxoma, presenting in an atypical manner within the vaginal region of a 31-year-old virgin woman. This case is noteworthy for the unusual growth pattern of the angiomyxoma-located strictly within the vaginal epithelium, showing no signs of invasion into surrounding tissues, which is not typical of the aggressive nature of this type of tumor. The patient presented with a mass that protruded through the hymen, an uncommon presentation that led to initial speculation about the nature of the mass. The definitive diagnosis of aggressive angiomyxoma was made by meticulous histopathological examination after surgical excision of the mass. This case emphasizes the critical importance of considering aggressive angiomyxoma in the differential diagnosis of vaginal masses, particularly those that do not exhibit invasive characteristics. The case also highlights the need for increased awareness among clinicians about the potential for atypical presentations of this rare tumor, to facilitate timely and accurate diagnosis, and to guide appropriate management strategies. This report contributes to the growing body of literature on aggressive angiomyxoma, highlighting the variability in its presentation and the need to heighten suspicion in atypical cases.

Aggressive angiomyxoma of female pelvis and perineum: Retrospective study of 17 cases

OBJECTIVE

Aggressive angiomyxoma is an uncommon mesenchymal neoplasm characterized by a high recurrence rate, usually observed in the lower genital tract of women during their reproductive age.

STUDY DESIGN

Seventeen cases of aggressive angiomyxoma confirmed by pathology from January 2007 to December 2021 in Beijing Chao-yang Hospital were included. We collected clinical data and summarized the clinical and immunohistochemical features.

RESULTS

All seventeen included patients were females, aged between 23 and 57 years (mean, 37.7 years; median, 42 years). Fourteen patients were newly diagnosed and three were recurrent. The tumors were located in vulva (58.8 %), vagina (23.5 %), buttock (11.8 %), and cervix (5.9 %). The tumors size were 2 to 15 cm in greatest dimension (mean 8 ± 4.4 cm, median 6 cm). Follow-up data was available for nine patients, which ranged from 25 to 124 months (mean, 82 months; median, 80 months). At the end of follow-up, no other recurrence or metastasis was reported. Immunohistochemical analysis showed immunoreactive for estrogen (10/11) and progesterone (8/11) receptor, desmin (6/8), smooth muscle actin (4/10), and vimentin (4/4), S-100 (1/8) and CD34 (1/7). The Ki67 level was less than 5 % in five cases.

CONCLUSIONS

AAM is a hormone-sensitive, distinct rare mesenchymal neoplasm with high incidence of local recurrence. Surgery is the preferred treatment, with complete resection being an essential prerequisite for minimizing the risk of recurrence.

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.

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.

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 of pelvis: A case report and literature review

RATIONALE

Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor primarily involving the lower genital tract of reproductive females. It often shares pathologic morphology with other mesenchymal lesions, which result in diagnostic difficulties for pathologists.

PATIENT CONCERNS AND DIAGNOSES

We described the case of a 32-year-old female presenting with a pelvic mass. Imaging examination showed a "swirling sign" within the mass. The mass was 10.2 × 10 × 7.7 cm, located in the right front of the uterus, with unclear demarcation from the surrounding organs and tissues. The gross appearance was grayish brown with a solid section and a myxedematous cut surface. Microscopically, it was a mesenchymal tumor with a presence of perivascular smooth muscle fibers radiating from the blood vessel and an infiltrative growth pattern. The pelvic AAM was diagnosed based on clinicopathologic and imaging features.

INTERVENTIONS AND OUTCOMES

A surgery with local excision of the mass was performed. The patient experienced 1 relapse during 2-year follow-up and underwent the radiation therapy.

LESSONS

When the pathological morphology of AAM overlaps with other mesenchymal lesions, the comprehensive understanding of tumor clinicopathological characteristics combined with imaging features is important for the accurate diagnosis of AAM.

Aggressive angiomyxoma of the female urethra

Aggressive angiomyxoma is a rare locally invasive mesenchymal neoplasm of unknown pathogenesis arising predominantly in pelvic and perineal tissues of adult women. Surgical excision is the classical management but is associated with the risk of recurrence, especially with incomplete excision. There is a proposed role for adjuvant hormonal therapy. We report a very rare case of urethral aggressive angiomyxoma, managed by surgical excision, in a 40-year-old woman who presented with severe hematuria with clot retention.

A case series of aggressive angiomyxoma: Using morphologic type and hormonal modification to tailor treatment

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Aggressive angiomyxoma tends toward two forms: deeply invasive and pedunculated.

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Anti-hormonal therapy can be an adjunct to aggressive angiomyxoma treatment.

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Pedunculated aggressive angiomyxoma can be considered for shorter follow-up.

Aggressive angiomyxoma is a rare tumour type with a predilection for the female pelvis, high rates of estrogen and progesterone receptor positivity and local recurrence. A retrospective chart review of patients with aggressive angiomyxoma treated at 2 cancer centres is presented.

Nine patients were identified with a mean age of 41. Five patients had deeply invasive tumours that were difficult to surgically resect. Four patients had pedunculated tumours with less complex resections. In only two cases was aggressive angiomyxoma considered before resection: one due to classic magnetic resonance imaging findings and one with a preoperative biopsy. Four patients had positive margins after resection, with only one having persistent disease. Two patients were treated with gonadotropin-releasing hormone (GnRH) agonists resulting in tumour regression in one and no recurrence in the other. In this case series, aggressive angiomyxoma presented in deeply invasive and pedunculated forms. Previously reported high rates of recurrence were not observed in this group, perhaps secondary to easier resection in the pedunculated forms. GnRH agonists were successfully used as adjuncts to surgery. Evidence in this case series could be used to provide tailored treatment to patients with aggressive angiomyxoma.

Recurrent perineal aggressive angiomyxoma: dilemma in diagnosis and outcome of this rare disease

Aggressive angiomyxoma (AAM) is a very rare, benign, locally infiltrative mesenchymal tumour with a high chance of recurrence following surgical excision. In the male population, it is so rare that less than only 50 cases have been reported so far. We present a case of a large recurrent perineal AAM in a man who presented with swelling in the perineal region following surgical excision 3 years ago. After evaluation, the diagnostic dilemma of a possible perineal hernia or recurrence remained. Surgical exploration ruled out hernia and the tumour was excised with difficulty. Immunohistochemical examination showed tumour cells with diffuse nuclear positivity for oestrogen receptor and patchy cytoplasmic positivity for desmin (A2). Histological and immunohistochemical features confirmed the diagnosis. Being very rare, AAMs need to be considered as a differential diagnosis of pelvic/perineal tumours among males. With no standardised therapy for AAM, complete resection would be the goal of therapy.

Aggressive angiomyxoma to 57-year old man

Aggressive angiomyxoma is a rare mesenchymal tumor occurring usually in women of reproductive age in pelvic-perineum region. These myofibroblastic tumors rarely affect men and non-pelvic-perineum anatomical sites. There are few literature references for aggressive angiomyxoma in men. We describe a case of a 57-year old male with aggressive angiomyxoma of the scrotum and its management.

A solitary fibrous tumour mimicking an aggressive angiomyxoma/liposarcoma

We present a case of a solitary fibrous tumour (SFT) resembling an aggressive angiomyxoma/liposarcoma on radiological imaging, causing significant diagnostic challenges preoperatively. A 76-year-old male was incidentally found to have a large pelvic mass on a CT scan. Further evaluation with an MRI scan confirmed a presacral mass containing fat and soft tissue components. It was inseparable from the sacrococcygeal spine, rectal serosa and the posterior wall of the urinary bladder, but no evidence of invasion was seen. A prominent vascular pedicle arising from the epidural vasculature was also noted. Differentials discussed at the multidisciplinary tumour board were an aggressive angiomyxoma versus a liposarcoma. The patient underwent wide resection of the pelvic tumour, anterior resection and end colostomy. Intraoperatively, a large 20 cm pelvic mass involving the sigmoid mesocolon and presacral fascia was found. Final histology reported an SFT with extensive adipocytic metaplasia.

High Grade Leiomyosarcoma Mimicking a Recurrent Angiomyxoma in the Perineum

Perineal leiomyosarcoma is an extremely rare and aggressive cancer with a high metastatic potential and no defined standard treatment. There are only a few (six) reported cases in the literature. We report the case of a 67-year-old woman with a perineal leiomyosarcoma arising at the same site of a previously resected superficial angiomyxoma. Initially, she was treated for a presumptive recurrence of angiomyxoma. As she did not respond to medical therapy, she underwent repeat surgical excision. Pathology revealed a high grade leiomyosarcoma, histologically strikingly distinct from the initial diagnosis. She received adjuvant local radiation therapy, and remains without evidence of recurrent disease 36 months after completion of all therapy. This is the first reported case of a high grade perineal leiomyosarcoma originating at the same site as a resected benign superficial angiomyxoma. Our case emphasizes the necessity of a prompt histological diagnosis in cases of presumed recurrent perineal angiomyxoma.

Paravaginal aggressive angiomyxoma

A 34-year-old nulliparous woman with a long-standing history of uterine fibroids and infertility had undergone prior open myomectomy, then uterine artery embolisation in treatment of an apparent large fibroid. Imaging on referral revealed an atypical 12×11×10 cm pelvic mass with the appearance of a fibroid. At laparotomy, the lesion was encapsulated but softer than a fibroid and located deep in the paravaginal space. The histopathological outcome was an aggressive angiomyxoma.