Successful treatment of pain in two patients with cutaneous leiomyomata with the oral alpha-1 adrenoceptor antagonist, doxazosin

Hereditary leiomyomatosis and renal cell cancer syndrome: An update and review

Hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome is a rare genetic disorder that predisposes individuals to multiple cutaneous leiomyomas, renal cell carcinomas, and in women, uterine leiomyomas. Also known as Reed syndrome, it is caused by a germline heterozygous mutation of the fumarate hydratase tumor suppressor gene. HLRCC is associated with significant morbidity because of pain from cutaneous and uterine leiomyomas, the cutaneous pain often of unique character. Although genetic testing is currently considered the criterion standard to diagnose HLRCC, newer immunohistochemistry markers may provide rapid and cost effective alternatives to genetic testing. Because of the potentially aggressive nature of renal cell carcinomas that develop as early as in childhood, close annual cancer surveillance is desirable in individuals with HLRCC. In this review, we offer an update and an approach to the diagnosis, management, and renal cancer surveillance in HLRCC.

A Case of Hereditary Leiomyomatosis and Renal Cell Carcinoma

A 49-year-old lady presented with multiple recurring painful lesions over her thighs, arms, and back. Past medical history included a left sided nephrectomy for renal cell carcinoma and a hysterectomy for multiple uterine fibroids (leiomyomas). Histopathological examination revealed changes consistent with pilar leiomyomas. Gene mutation analysis confirmed a diagnosis of hereditary leiomyomatosis and renal cell carcinoma. Hereditary leiomyomatosis and renal cell carcinoma is an uncommon autosomal dominant condition characterised by the concurrent presentation of cutaneous and uterine leiomyomas. Renal cell carcinoma associated with this condition is more aggressive and a significant cause of mortality. Due to this association with potentially fatal renal cell carcinoma we felt that it was important to highlight this case with an update on pathophysiology and management.

Efficacy of Intralesional Botulinum Toxin A for Treatment of Painful Cutaneous Leiomyomas: A Randomized Clinical Trial

IMPORTANCE

Cutaneous leiomyomas can be associated with severe paroxysmal pain in which nerve conduction may have a key role. Medical management of painful cutaneous leiomyomas is generally unsatisfactory.

OBJECTIVE

To assess the efficacy of intralesional botulinum toxin A in the management of pain associated with cutaneous leiomyomas.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled pilot study conducted from January 5, 2009, to March 27, 2014. The setting was a single-center study at the National Institutes of Health among participants 18 years or older with cutaneous leiomyomas characterized by pain at least once weekly and pain of at least 4 on a pain scale ranging from 0 to 10.

INTERVENTIONS

Eighteen participants were randomized to receive intralesional botulinum toxin A (5 U per 1 cm2) or equivalent volumes of intralesional saline placebo.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the differences in average lesional pain assessed by the Brief Pain Inventory and visual analog scale before and after ice provocation over a 4-week period.

RESULTS

No significant difference in average lesional pain was observed between the study arms. Decreased pain was reported in the botulinum toxin vs placebo arms by visual analog scale scores before ice provocation (median, 0.00; range, -3.30 to 0.70 for botulinum toxin and median, 0.40; range, -1.30 to 1.50 for placebo; P = .06); however, this finding was nonsignificant. No significant difference was observed in change in pain after ice provocation. A significant difference was seen between the arms in skin-related quality of life by total Dermatology Life Quality Index (median, -4.00; range, -8.00 to 2.00 for botulinum toxin and median, 0.00; range, -1.00 to 4.00 for placebo; P = .007) and with the specific skin pain-related question on the Dermatology Life Quality Index (median, -1.00; range, -2.00 to 1.00 for botulinum toxin and median, 0.00; range, -1.00 to 0.00 for placebo; P = .048). No significant difference was found in pain as ascertained by Patient Global Impression of Change at week 4. No serious adverse events related to botulinum toxin use were observed.

CONCLUSIONS AND RELEVANCE

The use of botulinum toxin to treat painful cutaneous leiomyomas was associated with improved quality of life and with a trend toward improved pain at rest.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00971620.

Leiomyoma cutis: a focused review on presentation, management, and association with malignancy

Cutaneous leiomyomas (CLs) are rare, sporadic, or inherited tumors of smooth muscle origin associated with various disorders. Hereditary leiomyomatosis and renal cell cancer (HLRCC) is the primary tumor predisposition syndrome associated with inherited CLs, affecting 180 families worldwide, with significant mortality. CLs are subdivided into piloleiomyomas, genital leiomyomas, and angioleiomyomas based on their smooth muscle of origin, as well as their clinicopathologic features. Piloleiomyomas, derived from arrector pili muscle, are solitary or multiple firm papulonodules located typically on the extremities and trunk; genital leiomyomas, derived from dartoic, vulvar, or mammary smooth muscle, are solitary papulonodules or pedunculated papules located on the scrotum, vulva, or nipple; and angioleiomyomas, which include solid, cavernous, or venous subtypes, are derived from the tunica media of small arteries and veins and typically present on the extremities. Partial/excisional biopsy is required for diagnosing all CLs. Histology shows interlacing fascicles of spindle cells with moderate amounts of eosinophilic cytoplasm and a blunt-ended, elongated nucleus with perinuclear halos. Surgical excision is curative for CLs, with other management options including medical or destructive therapy; active surveillance is advised to monitor HLRCC-associated neoplasms, with pharmacological therapies under active research.

Skin leiomyoma — clinical observation

The authors describe a clinical observation of quite a rare neoplasm such as back skin leiomyoma in a female patient aged 56. They describe the clinical picture, differential diagnostics and pathohistological picture of the disease. The pain syndrome was arrested due to the treatment with calcium channel blockers in a combination with alpha-blockers.

Multiple cutaneous leiomyomas: pain relief with pulsed hysocine butyl bromide

A 35-year-old male patient presented to our outpatient department, complaining of multiple, raised skin lesions on the forehead and back, associated with intermittent pain, especially on exposure to cold. A diagnosis of cutaneous leiomyoma (type 2 segmental) was made, which was confirmed by skin biopsy. The patient was started on a trial of pulsed Hyoscine Butyl bromide tablets, following which the patient had significant relief from pain associated with the lesions.

Dermal skin template for the management of multiple cutaneous leiomyomas

BACKGROUND

Multiple leiomyomas are rare benign tumors of the skin, originating from the arrector pili muscle, and usually appear as painful nodules. Several pharmacologic agents have been used with some success to reduce pain and discomfort since surgery may be an impractical approach owing to the extent of the disease.

OBJECTIVE

This article reports on a patient with multiple cutaneous leiomyomas of the upper limb who was managed by a method not previously reported for leiomyomas.

METHOD

The management involved total surgical resection of the defect and immediate reconstruction with the Integra artificial dermal template (Integra LifeSciences Corp., Plainsboro, NJ).

RESULTS

With this treatment, the patient was totally relieved from the pain, and optimal functional and esthetic results were achieved.

CONCLUSION

Complete surgical resection of multiple cutaneous leiomyomas prevented the disease's recurrence. The immediate reconstruction of the resultant full-thickness defect with artificial dermis ensured uneventful wound healing, resulting in optimal functional and esthetic outcome and total relief from leiomyoma-associated discomfort.

A new indication of botulinum toxin: leiomyoma-related pain

Cutaneous leiomyomas are benign neoplasms with smooth muscle differentiation. They are painful tumors of the skin. Nearly 90% of patients report lesion-associated pain, characteristically precipitated by cold or trauma. In the published literature, surgical excision and pharmacologic agents such as analgesics, nifedipine, phenoxybenzamine hydrochloride, gabapentin, and doxazosin have been used in the treatment of leiomyomas with varying degrees of success. Herein we report the use of botulinum toxin for the relief of pain in leiomyomas. The use of botulinum toxin provided a decrease in the amount of analgesic use in our patient. Our experience showed that botulinum toxin might offer a new therapeutic approach for leiomyoma by reducing the intensity and the frequency of the pain. Botulinum toxin has no known systemic adverse effects, and can be combined with other treatments without concern for drug interactions. Like any other medication, aside from its actual pharmacologic effect, botulinum toxin may have had a placebo effect in our patient.