Aggressive angiomyxoma: irradiation for recurrent disease

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 pelvis and abdominal wall: Dramatic response to chemical ablation therapy

Objective

Aggressive angiomyxoma (AAM) is a rare, locally aggressive soft tissue neoplasm with a marked tendency for local recurrence after surgery. Although hormone therapy, radiation therapy, and vascular embolization can be performed, we investigated the safety and efficacy of a new chemical ablation protocol for AAM.

Methods

This study included two female AAM patients from 2012 to 2016. The patients’ clinical and imaging data were collected. The amount of anhydrous ethanol and glacial acetic acid used for chemical ablation was documented, and the management of any complications was detailed.

Results

The maximum dimensions of the residual tumor were 12.6 cm and 14.0 cm. In one case, the lesion was in the pelvis and protruded into the vulva. Eighty milliliters of liquid with a mixture of glacial acetic acid, anhydrous ethanol, and iohexol (10:9:1) was used for chemical ablation therapy via multipoint injections with a single needle. However, a pelvic fistula developed 1 month later. In another case, the lesion was located in the abdominal wall. The ablation procedure was improved by performing chemical ablation therapy with multiple needles for multi-point injections of smaller than 30 ml injections for each procedure. To date, no recurrence or metastasis has been observed in the two cases.

Conclusion

The preferred treatment for AAM is complete resection. Chemical ablation therapy is a novel adjuvant therapy for AMM. Nonetheless, more research is needed to confirm these findings.

Incidental finding of paratesticular aggressive angiomyxoma in a 72-year-old monorchid male

Aggressive angiomyxoma is an uncommon mesenchymal neoplasm. It arises from soft tissue of pelvis and perineum in fertile females, occurring very rarely in males. Its name emphasizes the common local recurrence and infiltrative tendency, but usually it does not metastasize. Currently, the first line of therapy is surgical excision, achieving R0 surgical margins, and radiological follow-up. This case report describes an uncommon, incidental finding of paratesticular aggressive angiomyxoma in an asymptomatic, cryptorchid 72-year-old male patient.

Aggressive angiomyxoma of the perineal region

Aggressive angiomyxoma is a rare tumour that frequently involves the perineal region with a high risk of local recurrence. This is a case report of a 24-year-old female patient with a genital prolapse. We performed a surgical treatment. Histological examination found an aggressive angiomyxoma. The tumour recurred 1 year after surgery. Long-term follow-up is necessary.

Perineal aggressive angiomyxoma in a menopausal woman

Aggressive angiomyxoma (AA) is an uncommon mesenchymal tumour that is principally located in the soft tissues of the pelvis and perineum of young women. The primary features of this benign tumour are a local invasion, a high local recurrence rate and non-specific local clinical signs. We describe the case of a 58-year-old woman, initially treated for a Bartholin's cyst. Histological examination indicated the presence of an AA. The MRI showed a 7 cm soft tissue mass extending from the lateral wall of the vagina, into the left buttock and down into the subcutaneous tissue. We performed a radical excision with wide resection, which is considered the standard gold treatment.

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.

Paratesticular aggressive angiomyxoma: A rare case

Aggressive angiomyxoma (AAM) particularly testicular origin is a rare benign mesenchymal myxoid tumor which is locally aggressive, blatant for local recurrence, and may metastasize. It occurs mostly in females of childbearing age and extremely rare in males. AMM particular testicular origin is not reported in literature yet. This is a 65-year-old man who had a right scrotal swelling. Ultrasound scrotum showed a soft tissue tumor of the right testis. The patient underwent radical right orchidectomy of which histopathologically confirmed to be a paratesticular AAM with clear resection margins. There were no signs of local recurrence or metastasis 2 years postsurgical resection.

Clinicopathological Features and Treatment Analysis of Rare Aggressive Angiomyxoma of the Female Pelvis and Perineum - a Retrospective Study

The study was to evaluate the clinicopathological features of aggressive angiomyxoma (AAM) of the female pelvis and perineum and its treatments. This was a retrospective study of female patients with AAM admitted to our hospital. Clinical and pathological data were analyzed, as well as the postsurgical follow-up. Median age at initial presentation was 41 years. Thirteen patients had lesions involving adjacent organs. Eighteen patients underwent complete tumor resection, while one patient underwent partial tumor resection. The tumors were soft in texture, pink in color, and had mucus on the surface. A microscopic examination revealed that the tumors were non-encapsulated, with spindle cells and stellate cells of almost identical size loosely distributed in the myxoid stroma, and vessels of different sizes and wall thicknesses. Immunohistochemistry indicated that AAMs were strongly positive for CD34 and smooth muscle actin, moderately positive for desmin, estrogen receptors and progesterone receptor, and mostly negative for S-100. After a median follow-up of 24 months, the recurrence rate was 33.3 %. Four recurrences were in patients with positive initial margins. AAM is a slow growing, locally invasive, benign tumor. Complete resection could lead to lower recurrence rate compared with incomplete resection. Follow-up is necessary for recurrent cases with repeated surgeries. The overall prognosis could be favorable.

A Giant Aggressive Angiomyxoma of the Pelvis Misdiagnosed as Incarcerated Femoral Hernia: A Case Report and Review of the Literature

Aggressive angiomyxoma (AA) is an uncommon mesenchymal tumor that is mostly derived from the female pelvic and perineal regions. AA is a locally infiltrative slow growing tumor with a marked tendency to local recurrence. Painless swelling located around the genitofemoral region is the common symptom; thus, it is often misdiagnosed as a gynecological malignancy or a groin hernia. A 35-year-old female patient who previously underwent surgery for left femoral hernia operation resulting in surgical failure was reoperated for a giant AA located in the pelvis. The tumor was completely excised with free margins. Histopathologic examination revealed an AA. The tumor size was measured as 24 × 12 × 6 cm with a weight of 4.2 kg. Immunohistochemically, the cells show positive staining with vimentin, desmin, estrogen, and progesterone receptor. S100, MUC4, CD34, and SMA were negative in the tumor cells. AA should be considered in the differential diagnosis of any painless swelling located in the genitofemoral region, particularly in women of reproductive age. The principle treatment should be complete surgical excision with tumor-free margins. Long-term follow-up and careful monitoring are essential due to its high tendency of local recurrence in spite of wide excision of the tumor. Adjuvant antihormonal therapy yields promising results for preventing recurrence.

Aggressive angiomyxoma

Aggressive angiomyxoma is a rare mesenchymal tumor that most commonly arises in the vulvovaginal region, perineum, and pelvis of women. The term aggressive emphasizes the often infiltrative nature of the tumor and its frequent association with local recurrence. Patients often present with nonspecific symptoms which are frequently misdiagnosed with more common entities, such as a Bartholin cyst, lipoma, or hernia. Histologic examination reveals a hypocellular and highly vascular tumor with a myxoid stroma containing cytologically bland stellate or spindled cells. The tumor cells are characteristically positive for estrogen and progesterone receptors, suggesting a hormonal role in the development of the tumor. Chromosomal translocation of the 12q13-15 band involving the HMGA2 gene has been described. Surgical excision is the treatment of choice, although treatment with gonadotropin-releasing hormone agonists is an emerging therapy. Metastases are exceedingly rare, and overall, the prognosis is good.

Massive recurring angiomyxoma of the scrotum in a obese man

Aggressive angiomyxoma (AAM) is a rare mesenchymal benign myxoid tumor, characterized by locally infiltrative nature and high recurrence rate. AAM occurs almost exclusively in adult females, arising from the soft tissue of the pelvic region: to our knowledge, only 43 cases occurring in men have been reported. We report a case of massive recurrence of scrotal AAM in a 46-year-old obese man, who already underwent surgery for the same disease in 2004 and 2005. The mass had a circumference of 106 cm and weighted 30 kg. It was impossible to appreciate the testes and to find the penis. The patient underwent scrotal resection, bilateral orchidopexia and transposition of the penis, by means of a preputial flap. Residual scrotal skin was modeled in order to create a neoscrotum, where the testes were placed and secured with interrupted sutures. Histologic examination showed diffuse angiomyxoma-like lipomatosis. After three months, the patient presented with local relapse which also involved the external urethral orifice.

Unusual scrotal pathology: an overview

The diverse embryological origins of the contents of the scrotum create an environment that fosters a wide variety of unusual pathologies. Most scrotal pathologies are discovered by the patient and are initially evaluated by a thorough physical examination and scrotal ultrasonography. Scrotal lesions can be broadly grouped by the anatomical location in which they develop; the clinician must consider a wide differential diagnosis based on this location. Solid testicular masses are considered germ cell tumors until proven otherwise, but numerous other possible pathologies exist, including ectopic tissue, metastasis, and other neoplastic growths. Rete testis lesions are classified as developmental, benign or malignant. Cystic lesions of the epididymis are most commonly benign, but malignant neoplasms can also be present. The paratesticular region has the broadest differential diagnosis, as it contains numerous distinct structures and is a common location for ectopic tissue and metastatic disease; a narrower range of lesions develop in the scrotal wall because of its simpler anatomy. Treatment options range from conservative observation to wide surgical excision and should be considered carefully; the aim of therapy is to remove malignant or potentially malignant tissue while minimizing effects on fertility and function.

[Penoscrotal aggressive angiomyxoma]

Aggressive angiomyxoma denotes an extremely infrequent mesenchymal tumour. In virtually every case it involves genital, pelvic or perineal female structures. Cases involving male patients are extremely rare. It is a distinctive tumour with a characteristic clinical course and specific and well characterized microscopic features. The authors report an additional clinical case in a young male patient with massive scrotal and penile involvement, necessitating exeresis followed by complex reconstructive procedure implying flap and graft use. A review of the available literature concerning etiopathogenic, clinical, imagiologic, histological and differential diagnosis, therapeutic and prognostic aspects is also presented.

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

BACKGROUND

Aggressive angiomyxoma (AA) is a rare vulvovaginal mesenchymal neoplasm with a marked tendency to local recurrence but which usually does not metastasize.

CASE REPORT

We describe a case of AA in the left labium majus pudendi in a 47-year-old woman who underwent incomplete surgical excision. Follow-up 2years later revealed no recurrence.

CONCLUSION

In the past, most authors advocated wide excision even if genitourinary and digestive tract resection were necessary. These days, a less radical surgery is recommended, but the significance of hormonal treatment and/or radiation therapy is not clear yet. Further investigation is necessary.

Aggressive angiomyxoma: multimodality treatments can avoid mutilating surgery

AIMS

Aggressive angiomyxoma is a soft-tissue tumour of the pelvi-perineum. The recurrence rate is high, and often extensive resections are performed with considerable morbidity. In search of alternative treatment methods we present our experience in seven patients.

METHODS

The medical charts of seven patients treated in the last 20years were reviewed. Follow-up data were obtained. In addition, a literature review from 1994 to 2004 regarding treatment and clinical outcome was performed.

RESULTS

All patients were female, and three were pregnant at the time of diagnosis. All patients underwent primary surgical treatment. In five patients the surgical margins were involved; one patient received adjuvant radiotherapy treatment. Three patients experienced a total of four recurrences after 2-10years. These patients were treated with selective embolisation or surgery. At present all patients are disease-free, with follow-up ranging from 2 to 20years after last treatment.

CONCLUSION

Radical surgery does not seem to lead to a significant lower recurrence rate of aggressive angiomyxoma when compared to incomplete resection (R1), with or without radiotherapy or arterial embolisation. This casts doubt on the necessity of extensive surgery, especially in cases where an extensive surgical procedure will lead to great morbidity.

Pelvic excision of large aggressive angiomyxoma in a woman: irradiation for recurrent disease

Aggressive angiomyxoma (AAM) is a rare tumor that preferentially involves the pelvis and perineal regions and arises from the connective tissue. Its cause and pathogenesis are unknown at present. Treatment typically involves surgery, and despite apparently complete resection, local recurrences are common. We describe a case of a large angiomyxoma of the left pelvis in a 59-year-old woman who underwent two surgical excisions. The first had been done in May 1998. She developed a local recurrence in December 1998. A palliative resection with macroscopic residuals was performed in February 2001, followed by radiation therapy with a total dose of 60 Gy. The diagnosis was revised at the time of the second operation. Initially, the tumor was diagnosed as angiomyofibroblastoma. Follow-up 3 years after the radiation treatment revealed no recurrence. The time of the local control achieved as yet is already longer than the former time to progression between the first two surgical procedures. This is, to our knowledge, the second description of a therapeutic irradiation of a recurrent AAM. Radiation therapy is able to control a recurrent AAM for at least 3 years.

Aggressive angiomyxoma in the scrotum expressing androgen and progesterone receptors

Aggressive angiomyxoma is a rare benign mesenchymal myxoid tumor that arises from the pelvic soft tissues and perineum in relatively young females. This tumor has the ability to infiltrate locally and has a high risk of local recurrence after extirpation, but no potential to metastasize. We report here a rare case of aggressive angiomyxoma that developed in the scrotum of a 47-year-old male. Immunostaining of the resected specimen revealed that the tumor cell nuclei stained strongly and diffusely for androgen receptors (80% of the tumor cells), and moderately and partly for progesterone receptors (20% of the tumor cells). However, staining was negative for estrogen receptors. It is highly suggested that the growth of aggressive angiomyxoma in males may depend on androgen manipulation, contrary to its frequent and close association with estrogen receptor expression, which has been reported in females.