Primary intracranial pleomorphic angioleiomyoma--a new morphologic variant. An immunohistochemical and electron microscopic study

Intracranial angioleiomyoma: a case series of seven patients and review of the literature

PURPOSE

Angioleiomyoma, predominantly arising from the extremities, is a benign soft tissue tumor. Reports on its intracranial location are rare. We assessed clinical, radiological, and pathological features of intracranial angioleiomyoma (iALM) treated at our neurosurgical institution.

METHODS

We consecutively enrolled all patients with neuropathologically confirmed iALM treated at a single neurosurgical institution between 2013 and 2021. Clinical and imaging data were collected, and histological tissue sections were analyzed. A review of the literature on iALM was conducted.

RESULTS

Seven patients with iALM (four female) with a median age of 45 years (range: 32-76 years) were identified. In three cases, the lesion was found incidentally. In magnetic resonance imaging (MRI), all tumors were hypo- to isointense on T1-weighted, hyperintense on T2-weighted sequences, and gadolinium-enhancing. A strong FLAIR signal was seen in six patients. Surgery consisted of gross total resection in all cases without perioperative complications. Neuropathological staining was positive for smooth muscle actin (SMA) in all lesions. Mature smooth muscle cells arranged around blood vessels were typically observed. The Ki-67 index was ≤ 3%. The patients were discharged after a median of 6 days (range: 4-9 days). During a median follow-up time of 14 months (range: 4-41 months), no tumor recurrence occurred. In the current literature, 42 additional cases of iALM were identified.

CONCLUSION

Intracranial angioleiomyoma is a benign soft tissue tumor treated by gross total resection. Tumor morphology and positive staining for SMA lead to the neuropathological diagnosis.

Primary angioleiomyoma of right frontal cranial base with intracranial and extracranial communication

INTRODUCTION

Primary intracranial angioleiomyoma (ALM) is quite rare and ALM of the adolescent is even rarer. To date, only three cases of adolescents have been reported.

MATERIAL AND METHODS

We carefully introduced a new location of intracranial ALM in an adolescent. The clinical, pathological and imaging features of intracranial ALM were described in detail and published literature was reviewed.

RESULTS

To our best knowledge, we presented the fourth primary intracranial ALM of adolescent and the first ALM of the right frontal cranial base with intracranial and extracranial communication. We not only summarize the generalities of ALM but also illustrate the difference between adult and adolescent ALM in the aspects of gender and age predominance, etiology, common location and pathologic subtype.

CONCLUSIONS

We reported the first ALM of the right frontal cranial base with intracranial and extracranial communication of an adolescent with a good prognosis. We also summarize the generalities of ALM and illustrate the difference between adult and adolescent ALM. Future investigation of control study with large patient cohorts is needed for both adult and adolescent ALM to compare the difference between them.

Diagnostic and surgical management of primary central nervous system angioleiomyoma: A case report and literature review

Angioleiomyoma (ALM) is a benign smooth muscle neoplasm that mainly occurs in lower extremities subcutaneous tissue and generally affects middle-aged adults. This tumor histotype may rarely localize intracranially, although only a few cases have been described in the literature. We report a case of intracranial ALM, whose differential diagnosis has been particularly challenging, and firstly provide a comprehensive radiological and intra-operative evaluation of a such rare entity. This represents also the first report of the use of intraoperative confocal microscopy in ALM and the first documented short-term recurrence. At this regard, a scoping literature review has been conducted with the aim of presenting the major clinical and diagnostic features along with the proposed therapeutic strategies.

Primary Intracranial Angioleiomyoma: A Case Report and Literature Review

BACKGROUND

Angioleiomyoma is a benign soft tissue tumor that manifests as pain and is more common in the extremities. However, primary intracranial angioleiomyoma is an extremely rare entity that is poorly characterized clinically, radiologically, and histopathologically. We compiled and examined reported cases of intracranial angioleiomyoma to provide an up-to-date summary of the condition. A literature search was performed using PubMed with specific key terms. Selected case studies and case series were then compared, and statistical analyses were performed where appropriate.

CASE DESCRIPTION

A 59-year-old woman presented with epileptic seizures and a 2-month history of progressive headache. Magnetic resonance imaging of the brain revealed a right temporal pole tumor near the right cavernous sinus. Gross total resection was performed. Histopathologic and immunohistochemical examination demonstrated an angioleiomyoma. No adjuvant radiation or chemotherapy was administered. Magnetic resonance imaging of the brain performed at 6-month follow-up showed no signs of recurrence.

CONCLUSIONS

Primary intracranial angioleiomyoma is an exceedingly rare central nervous system tumor. The clinical and radiologic manifestations are nonspecific. The diagnosis depends on the histopathologic and immunohistochemical examination. For patients with clinical symptoms, surgical resection should be the first-choice treatment.

Rare giant primary intracranial angioleiomyoma in lateral ventricle: a case report and the literature review

Background: Angioleiomyomas are benign tumors and can occur in subcutaneous tissues all over the body, and lower extremities are more common. Primary intracranial angioleiomyomas are rare. We present a case of intracranial angioleiomyoma and review the literature.Case description: A 35-year-old Chinese women presented with one-year history of the left leg claudication. MRI revealed a 6.3 × 7.4 × 5.4 cm lesion located in the lateral ventricle, which, to our knowledge is the first lateral ventricle ALM reported. The tumor was resected. The pathological results were consistent with angioleiomyoma. Hemiplegia of left limb was found during post-operative period and no recurrence was found during five month of follow-up.Conclusion: ALM is a rare intracranial tumor but can occur.

Tentorial Angioleiomyoma: A Rare Neurosurgical Entity. Case Report and Review of the Literature

BACKGROUND

Angioleiomyoma (ALM) is a soft tissue neoplasm rarely described in the intracranial site. Because of their uncommon presentation, atypical neuroradiologic and pathologic features, ALMs are often misdiagnosed.

CASE DESCRIPTION

We describe the neuroradiologic, clinical, and pathologic data of a 37-year-old male patient suffering from a tentorial ALM. He was admitted at our hospital because of a posterior cranial fossa mass. Magnetic resonance imaging (MRI) showed a left tentorial tumor, hypointense on T1-weighted sequences, with heterogeneous contrast enhancement after gadolinium injection ("salt-and-pepper" fashion) and slightly hyperintense signal on T2-weighted sequence. After surgery, pathological examination showed a tumor composed of several thick-walled blood vessels mixed with a population of deeply eosinophilic spindle-shaped smooth muscle cells arranged in bundles. Necrosis was absent. Neither cellular pleomorphism nor mitoses were detected. Immuno-histochemical analysis confirmed the smooth muscle phenotype of the spindle cell component: diffuse and strong positivity for alpha-smooth muscle actin, desmin, and h-caldesmon. Based on both morphologic and immunohistochemical findings, a diagnosis of primary intracranial ALM was rendered.

CONCLUSIONS

We add to the literature the tenth case of this exceedingly rare tumor and submit that ALM should be suspected when a tentorial mass with a "flame-like" time-dependent pattern of contrast enhancement on MRI, a "salt-and-pepper" post-contrast appearance on MRI T1-weighted sequences, and a relation with large intracranial feeding vessels are present.

Skull base angiomatous leiomyoma: a case report and review of literature

Leiomyomas, benign neoplasms of mesenchymal origin, are common in gastrointestinal and genitourinary tracts. They are comprised of well-differentiated smooth muscle cells with few mitotic figures. Leiomyomas should not exhibit metastatic potential, though metastasis has been reported. Primary intracranial lesions remain rare. Only 4 cases have been reported in immunocompetent patients. Here we report an intracranial leiomyoma in an immunocompetent patient. A 60 year-old woman with unremarkable past medical history presented with a right sixth nerve palsy. On examination, there was a right sixth nerve palsy with numbness over the right V2 and V3 areas. CT scan showed a well-defined lesion within the right middle cranial fossa adjacent to the cavernous sinus with bony remodelling of the lateral wall of the sphenoid sinus and greater wing of the right sphenoid. MRI showed extra axial mass lesion arising from the right Meckel´s cave/cavernous sinus. The lesion was T2 hyperintense and T1 isointense. Homogenously enhancing centrally with little enhancement peripherally. CT CAP showed no primary lesions. Differential diagnosis at that stage was between meningioma, schwannoma or metastasis. The patient underwent craniotomy and debulking of tumour. Histological analysis confirmed leiomyoma. Post-operative MRI showed residual enhancement in the region of Meckel's cave. As residual tumour was significant, the patient underwent STRS. Further MRI at 1 year showed regression of the tumour. Majority of intracranial leiomyomas are discovered in immunocompromised patients incidentally. Histology reveals spindle shaped cells with blunt ends and few mitotic figures. The best treatment option to date for primary intracranial leiomyomas remains surgical gross total resection without adjuvant radiation therapy. Intracranial leiomyoma transitioning to leiomyosarcoma post radiotherapy has been reported before and therefore follow up with serial imaging is warranted.

Cavernous sinus angioleiomyoma: case report and review of the literature

Cavernous sinus angioleiomyoma (ALM) is extremely rare. Only three cases have been reported to be cavernous sinus ALM, and very few reports described characteristic findings for intracranial ALMs in detail. We report a new case of cavernous sinus ALM, with detailed information on the clinical presentation, radiology, pathology, and surgical approach. A 52-year-old woman had a 6-month history of right eye discomfort. Magnetic resonance imaging showed a right cavernous sinus tumor with heterogenous blush enhancement. Enhanced computed tomography scans and angiography showed small nodular enhancement in the tumor. Complete tumor resection was achieved via an extradural temporopolar approach. ALM was identified based on histologic examination. Intracranial ALMs are different from the ALMs that occur in the extremities based on our review of the literature. Intracranial ALMs appear more frequently in men than women. The cavernous type was the most common pathologically, and they occur often in the epiperidural location. Because cavernous sinus ALM occurs in the interdural space, an epidural approach should be selected. Therefore, it is important to include cavernous sinus ALM into a differential diagnosis of a cavernous sinus tumor. The blush enhancement and nodular enhancement within this lesion may be useful to distinguish cavernous sinus ALM from other differential diagnoses.

Angioleiomyoma, a rare intracranial tumor: 3 case report and a literature review

Three cases of intracranial angioleiomyoma (ALM) in our neurosurgery center are reported in detail. ALM is a benign soft tissue tumor comprised of mature smooth muscle cells and a prominent vascular component, which is extremely rare as a primary intracranial lesion. Altogether, only 12 cases were recorded in the literature to date, to the best of our knowledge. Case 1 is the second report of intra-sella ALM, a 51-year-old woman presented with visual deterioration for 2 months. An MRI showed an intra-sella 3-cm tumor, partially flame-like, enhanced with gadolinium. Using microscopic endonasal transsphenoidal approach, the tumor was completely resected with great difficulty. At 11 days post-surgery, she died of a sudden catastrophic nasal hemorrhage. An angiography revealed a pseudo-aneurysm of ICA (internal carotid artery). Case 2 is a 49-year-old man who presented with weakness of the lower limbs for 1 year. A large subtentorial mass was found affixed to the torcular and straight sinus, which was partially flame-like, dramatically enhanced as in case 1. Case 3 is that of a 77-year-old man. An ALM mass was revealed in the diploe of left temporal bone, and had eroded the inner table. Immunohistochemical workup confirmed the diagnosis of angioleiomyoma in all 3 cases. The radiology, operation, and complication of surgery in each case were discussed. In conclusion, intracranial ALMs are extremely rare, usually located ex-neuro axis (such as in our cases), in the sella, in posterior fossa, or in the skull. Magnetic resonance imaging (MRI) revealed a special feature of flame-like partial enhancement that may be helpful to distinguish ALM from pituitary tumors or meningiomas, and should result in the consideration of this rare tumor entity early on in the diagnostic process. A definitive diagnosis depends on histological analyses. The resection of ALM in certain locations is difficult and risky because of the rich blood supply.

Splenic angioleiomyoma in an owl monkey (Aotus nancymae)

BACKGROUND

An adult male owl monkey (Aotus nancymae) underwent a splenectomy. When the spleen was removed, a small, nodular mass slightly bulging over the splenic surface was noted.

METHODS

The mass was examined by light and transmission electron microscopy and by immunohistochemistry.

RESULTS

On light microscopy, the mass was well-circumscribed, non-encapsulated, and composed of haphazardly arranged smooth muscle bundles admixed with numerous small capillary-like structures containing blood. Immunohistochemical (IHC) staining revealed the tumor was strongly positive for smooth muscle actin yielding vascular smooth muscle bundles, and for Factor VIII, staining endothelial cells within the smooth muscle bundles. Transmission electron microscopy (TEM) showed a large portion of the cells to be atypical appearing smooth muscle and a few cells had structures resembling Weibel-Palade bodies indicating endothelial cells.

CONCLUSIONS

Based on cell morphology, by light and TEM, and IHC a final diagnosis of splenic angioleiomyoma was made. This is, to our knowledge, the first report of an angioleiomyoma in a non-human primate.

Primary intracranial leiomyomas: Report of two cases and review of the literature

A leiomyoma is a benign neoplasm composed of smooth muscle cells that commonly occurs in the genitourinary and gastrointestinal tracts. Primary intracranial leiomyoma, however, is extremely rare and only a few cases have been reported to date. In this study, we present two cases of primary intracranial leiomyomas in middle-aged men. Magnetic resonance images (MRI) showed lesions with homogeneous low signals on T1-, T2-, diffusion-weighted, and FLAIR sequences. Tumors were totally removed and there was no evidence of recurrence in the follow-up study. Pathological analysis with immunohistochemistry revealed that tumors had characteristics of benign smooth muscles. A review of relevant literature has been conducted.

Infratentorial angioleiomyoma: a new location for a rare neoplastic entity

Angioleiomyomas are benign neoplasms most often located in the subcutaneous tissue of middle-aged individuals and usually confined to the subcuticular and deep dermal layers of the lower extremities. An intracranial site for this tumor is exceedingly rare, with very few reports documenting locations in the neuraxis. To the authors' knowledge the present case represents the first reported instance of an infratentorial angioleiomyoma. The authors conducted a review of selected English-language papers published since 1960 describing well-documented cases of intracranial vascular leiomyomas, with detailed information on the clinical presentation, radiology, pathology, and particulars of surgical management in each case.

Frontal intradiploic angioleiomyoma

A left frontal intradiploic angioleiomyoma in a 10-year-old girl is presented with a review of the literature. The pathological and differential diagnosis and management of this rare lesion is discussed.

Symplastic hemangioma: report of two cases

Symplastic hemangioma is characterized by degenerative atypia of vascular smooth muscle and interstitial cells within a pre-existing vascular lesion with minimal endothelial cell atypia. We describe an additional two cases of this distinctive but poorly recognized entity. On histology, both lesions revealed a cirsoid aneurysm-type appearance with thick-walled and variably dilated blood vessels. The vascular endothelial cells showed mild nuclear hyperchromasia with no multilayering or mitoses. The atypical cells, either located within the vascular smooth muscle wall or within the interstitium, were spindle or epithelioid with varying degrees of hyperchromasia, nuclear enlargement, pleomorphism, and multinucleation. Perivascular hemorrhage, vascular thrombosis, and focal papillary endothelial hyperplasia were uniformly present. The variably fibrous to edematous stroma showed hemosiderin deposits and a mononuclear inflammatory infiltrate. Clusters of adipocytes were present within the superficial dermis. Rare atypical mitoses and occasional bizarre lipoblast-like stromal cells were identified in one tumor. Immunohistochemistry showed focal smooth muscle actin positivity in the pleomorphic cells of the vascular walls. CD68 and CD34 stained occasional stromal cells in the interstitial location. Both the cases showed no recurrence. The bizarre cytologic changes are interpreted as degenerative in nature and probably akin to that observed in ancient schwannoma and uterine symplastic leiomyoma.

Primary Extradural Epithelioid Leiomyosarcoma of the Cervical Spine: Case Report and Literature Review

OBJECTIVE AND IMPORTANCE:

No case of primary epithelioid leiomyosarcoma involving the spine has been reported previously.

CLINICAL PRESENTATION:

A 61-year-old Nigerian woman presented with progressive spastic quadriparesis and acute urinary retention. Her only medical history included a total abdominal hysterectomy for fibroids 10 years earlier in Nigeria. Results of the general examination were normal. Pyramidal spastic quadriparesis (3/5) with a sensory level at C5–C6 was found neurologically. Magnetic resonance imaging scans of the brain and spine revealed extradural cord compression at C3–C5 as the sole abnormality. This was caused by a large, soft tissue mass arising from the erector spinae muscles, which was predominantly isointense on T1-weighted images, of mixed intensity on T2-weighted images, and homogenously enhanced after gadolinium contrast agent administration. There was an associated signal change in the cord at C3–C4. Computed tomography confirmed the predominantly soft tissue involvement, but with bone erosion and infiltration within the posterior elements of C4. Systemic screening for cancer was negative.

INTERVENTION:

At decompressive laminectomy, urgently undertaken under corticosteroid cover, an excessively vascularized, soft tissue tumor was subtotally excised, after which independent walking and normal sphincter function were regained within 1 week. Four weeks later, a complete macroscopic tumor excision was undertaken, incorporating lateral mass (C3–C6) and C2 pedicle screw stabilization, along with iliac crest bone grafting. The patient's neurological status continued to improve. However, while awaiting radical radiotherapy, the patient declined further treatment and returned to her native Nigeria. Histopathological findings were consistent with an epithelioid leiomyosarcoma.

CONCLUSION:

This is the first reported case of a primary craniospinal epithelioid leiomyosarcoma.

Angioleiomyoma of the Internal Auditory Meatus: A Rare Occurrence in the Internal Auditory Canal

We describe a case of angioleiomyoma of the internal auditory meatus. A finding of this tumor at this site is very unusual. In fact, our review of the literature revealed that only 1 case has been previously reported. In our patient, the tumor was clinically and radiologically difficult to distinguish from an acoustic neuroma. It would be important to recognize this rare small tumor preoperatively because it may be appropriate to manage it conservatively.

Angioleiomyoma of the Cavernous Sinus: Case Report

OBJECTIVE AND IMPORTANCE:

Angioleiomyomas (ALMs) are relatively rare, benign, vascular soft tissue tumors that occur most frequently in the extremities of middle-aged individuals. To date, only two cases of intracranial ALMs have been described, both with little emphasis on the clinical, surgical, and radiological aspects. Neither of these reported cases of ALM involved the cavernous sinus. Furthermore, there is no previous intracranial ALM magnetic resonance imaging scan described in the literature. This report presents the first case of cavernous sinus ALM, emphasizing the clinical, radiological, and surgical aspects.

CLINICAL PRESENTATION:

A 52-year-old man had a 2-year history of horizontal diplopia and frontal headache. Facial numbness and impaired visual acuity in the previous 6 months were also reported. Physical examination revealed paralysis of right Cranial Nerves III, IV, and VI. A decrease in optical acuity was also noted. Computed tomographic and magnetic resonance imaging scans demonstrated a mass lesion located in the right cavernous sinus, which enhanced homogeneously with administration of intravenous contrast medium.

INTERVENTION:

A total resection was performed via a right frontotemporal craniotomy and a pretemporal approach with peeling of the middle fossa. The postoperative course was uneventful. Histological examination identified the ALM, with no recurrence noted during follow-up.

CONCLUSION:

It is unknown why intracranial ALMs have not been reported more frequently in the literature. Although ALMs are a rare occurrence, misinterpretation of this lesion may also have contributed to the lack of reported cases. Before surgery, ALMs can be distinguished from meningiomas and schwannomas but not from hemangiomas. The prognosis of intracranial ALM is good, as suggested in this case as well as the two previously reported cases.

Benign metastasizing leiomyoma to skull base and spine: a report of two cases

OBJECTIVE AND IMPORTANCE

We report two patients with benign uterine leiomyoma metastasizing to the nervous system, respectively, to the skull base and to the spine. Although primary cranial and metastatic spinal leiomyomas have been rarely described, to our knowledge no case of benign leiomyoma metastasizing to the skull base has been reported before.

CLINICAL PRESENTATION

Two female patients with history of hysterectomy for benign leiomyoma, subsequently metastasizing to the lungs and smooth muscles of the skin, presented with a focal neurologic deficit. Magnetic resonance imaging revealed a sacral mass in one case and a skull base tumor in the other.

INTERVENTION

Both patients underwent surgery for resection of the lesions. Good postoperative results were obtained. Histologic examination of the surgical specimen revealed a benign metastasizing leiomyoma.

CONCLUSION

Benign metastasizing leiomyoma should be considered in the differential diagnosis of mass lesions in the sacral spine and skull base in patients who have a history of uterine leiomyoma or benign metastases of the same disease in organs outside the nervous system.

Basal ganglionic angioleiomyoma

A rare case of basal ganglionic angioleiomyoma in a 12-year-old girl is reported. She presented with features of raised intracranial tension, multifocal seizures, left hemidystonia and apraxia of eyelid closure. Cranial CT scan showed a large hypodense lesion with an enhancing mural nodule in the region of head of the caudate nucleus on the right side. The lesion was extending to the posterior limb of internal capsule postero-medially and to globus pallidus laterally. Another small, hyperdense, enhancing lesion was seen in the region of globus pallidus on the left side. The right basal ganglionic mass was excised through frontal craniotomy. Histopathological, Immunocytochemical and Ultrastructural examination of the right basal ganglionic mass showed features characteristic of angioleiomyoma. Following surgery the patient improved initially with respect to dystonia but worsened later on. Repeat cranial CT, 20 months after surgery, showed bilateral frontotemporal atrophy without any tumor recurrence while the lesion on the left side remained quiescent.