Submit Your Article CMED MEACR meeting
Home Print this page Email this page Users Online: 239
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 197-199

Aggressive angiomyxoma: An uncommon entity with literature review


Department of Pathology, NC Medical College, Panipat, Haryana, India

Date of Web Publication17-Nov-2017

Correspondence Address:
Vaanika Kaira
H. No: 570/7, Urban Estate, Karnal, Haryana - 132 001
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccij.ccij_39_17

Rights and Permissions
  Abstract 

Aggressive angiomyxoma (AA) is a soft-tissue tumor of mesenchymal origin, not so common, but it occurs and exhibits marked tendency for local recurrence with extremely low risk of distant metastasis. The most common sites of origin include vulvovaginal region, perineum, and pelvis of reproductive age females. We report a case of AA in a 36-year-old female presenting with polypoidal vulval growth on the right side with a previous history of surgical resection at the same site 4 years before. Fine needle aspiration cytology of the growth revealed only blood and no cellular component. The tumor was excised and submitted for histopathological examination. A diagnosis of aggressive angiomyxoma was made based on characteristic histological features

Keywords: Aggressive angiomyxoma, mesenchymal tumors, vulva


How to cite this article:
Kaira V, Gupta AK, Kaur A. Aggressive angiomyxoma: An uncommon entity with literature review. Clin Cancer Investig J 2017;6:197-9

How to cite this URL:
Kaira V, Gupta AK, Kaur A. Aggressive angiomyxoma: An uncommon entity with literature review. Clin Cancer Investig J [serial online] 2017 [cited 2019 Oct 14];6:197-9. Available from: http://www.ccij-online.org/text.asp?2017/6/4/197/218612


  Introduction Top


Aggressive angiomyxoma (AA) is a rare slow-growing tumor of mesenchymal origin, which affects women of childbearing age. These tumors are famous for having marked propensity for local recurrence, hence the term aggressive designated to them. Destructive recurrence may occur, but it is now appreciated that more than one recurrence is very uncommon. Aggressive angiomyxoma was first described by Steeper and Rosai in 1983.[1] Clinically, these tumors are mistaken for a number of benign and malignant lesions chiefly including fibroepithelial polyp, bartholin gland cyst, leiomyoma, myxoid lipoma, and liposarcomas [1],[2] Recently, the terminology has been changed to deep angiomyxoma instead of aggressive as the recurrences occur many years after the initial excision.[3] In fact, it has become evident that these neoplasms have a favorable, less aggressive course if initially completely excised with negative margins.[4] Wide local excision with 1-cm margin is considered optimal.


  Case Report Top


A 36-year-old female presented with a slow-growing polypoidal growth on the right of the vulva in Obstetrics and gynecology Department of NC Medical College of Israna, Panipat. A clinical diagnosis of vulval carcinoma/rhabdomyosarcoma was made. Fine needle aspiration cytology of the lesion was nondiagnostic. The tumor was excised with wide margin and submitted for histopathological examination in Department of Pathology.

Grossly, the specimen comprised of a polypoidal growth measuring 8.5 cm × 8.0 cm × 6.5 cm [Figure 1]. Cut surface was glistening and homogeneous with focal areas of hemorrhage. Multiples microsections examined from tumor mass revealed monotonous and hypocellular areas composed of small spindle and stellate fibroblasts. Stroma was myxoid with collagen fibers and prominent dilated, thick-walled blood vessels [Figure 2] and [Figure 3]. Mitosis was not appreciated, and no evidence of tumor necrosis was seen. Surgical margins were free from tumor infiltration. A histopatological diagnosis of AA was made.
Figure 1: Gross image of aggressive angiomyxoma showing polypoidal growth

Click here to view
Figure 2: Photomicrograph showing stellate cells lying in abundant myxoid stroma (H and E, ×100)

Click here to view
Figure 3: Photomicrograph showing blood vessels of varying caliber (H and E, ×400)

Click here to view



  Discussion Top


The diverse mesenchymal tumors and tumor-like lesions that occur within female genital tract include a number of entities that have only been recently characterized. Among these, one entity is AA, which typically occurs in adult women with a median age in the fourth decade and is a nonmetastasizing, locally infiltrative neoplasm that commonly involves the perineum.[5],[6] This lesion is occasionally reported in man, male to female ratio 1:6.[7],[8] Histologically, AA is sparsely cellular tumor with prominent stroma studded with numerous haphazardly arranged blood vessels that range in size from thin-walled capillaries and venules to larger muscular arteries.[9],[10]

Immunohistochemically, the tumor cells show diffuse reactivity for vimentin [Figure 4] and desmin. Perhaps, the most characteristic feature is estrogen and progesterone positivity.[5]
Figure 4: Photomicrograph showing diffuse vimentin positivity in tumor cells (H and E, ×100)

Click here to view


Cytogenetic analysis and fluorescent in situ hybridization have confirmed the presence of HMGA2 gene rearrangement in majority of AAs thus depicting the same molecular genetic background as other common mesenchymal tumors.[11]

Important differentials of AA include various benign and malignant soft-tissue lesions chiefly including fibroepithelial polyp, angiomyofibroblastoma, superficial angiomyxoma, and myxoid lipomatous tumors.[12] Fibroepithelial stromal polyp is relatively common benign lesion of the vulvovaginal region, close clinical mimic of AA. Histologically, fibroepithelial stromal polyps are lined by unremarkable squamous epithelium with underlying edematous or myxoid stroma. Local excision is usually curative.

Angiomyofibroblastoma is a recently described benign and myxoid vascular soft-tissue tumor of the vulva, relatively well circumscribed with much lower rate of recurrence.[12] Histologically multinucleated giant cells with linearly arranged nuclei are key histological features along with hypocellular and hypercellular zones composed of cytologically bland cells.

Superficial angiomyxomas are commonly located in extragenital sites but may arise in vulvovaginal region.[10] Histologically, tumor lacks large caliber vessels, as seen in AA.

Another important differentials include myxoid lipoma and myxoid liposarcoma. Myxoid lipomas contain abundant mature adipose tissue in myxoid stroma with rare stellate cells. Myxoid liposarcoma contain characteristic lipoblast and arborizing network of capillaries as opposed to disorganized thin- and thick-walled blood vessels of AA.[5]

The treatment of choice for AA is wide local excision with 1-cm margin. As this tumor is locally invasive and tends to infiltrate deep into pelvic soft tissues, preoperative knowledge of the tumor extent is important in determining surgical approach MRI is investigation of choice to determine the extent of deep invasion of AA because of characterstic imaging features.[13]


  Conclusion Top


Our case report concluded that AA is a rare, benign mesenchymal tumor occurring in women of reproductive age group. Despite the morbidity associated with tumor recurrence and repeated surgeries, the prognosis is generally considered good. Close clinical follow-up is strongly recommended to detect early recurrence for appropriate patient management, either with wide local excision or more recent treatment modalities including hormonal therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Steeper TA, Rosai J. Aggressive angiomyxoma of the female pelvis and perineum. Report of nine cases of a distinctive type of gynecologic soft-tissue neoplasm. Am J Surg Pathol 1983;7:463-75.  Back to cited text no. 1
[PUBMED]    
2.
Bégin LR, Clement PB, Kirk ME, Jothy S, McCaughey WT, Ferenczy A, et al. Aggressive angiomyxoma of pelvic soft parts: A clinicopathologic study of nine cases. Hum Pathol 1985;16:621-8.  Back to cited text no. 2
    
3.
Fletcher CD. Diagnostic Histopathology of Tumors. 4th ed. Vol. 1. Philadelphia: Elsevier Saunders; 2013. p. 863.  Back to cited text no. 3
    
4.
van Roggen JF, van Unnik JA, Briaire-de Bruijn IH, Hogendoorn PC. Aggressive angiomyxoma: A clinicopathological and immunohistochemical study of 11 cases with long-term follow-up. Virchows Arch 2005;446:157-63.  Back to cited text no. 4
[PUBMED]    
5.
Fetsch JF, Laskin WB, Lefkowitz M, Kindblom LG, Meis-Kindblom JM. Aggressive angiomyxoma: A clinicopathologic study of 29 female patients. Cancer 1996;78:79-90.  Back to cited text no. 5
[PUBMED]    
6.
Granter SR, Nucci MR, Fletcher CD. Aggressive angiomyxoma: Reappraisal of its relationship to angiomyofibroblastoma in a series of 16 cases. Histopathology 1997;30:3-10.  Back to cited text no. 6
[PUBMED]    
7.
Tsang WY, Chan JK, Lee KC, Fisher C, Fletcher CD. Aggressive angiomyxoma. A report of four cases occurring in men. Am J Surg Pathol 1992;16:1059-65.  Back to cited text no. 7
[PUBMED]    
8.
Iezzoni JC, Fechner RE, Wong LS, Rosai J. Aggressive angiomyxoma in males. A report of four cases. Am J Clin Pathol 1995;104:391-6.  Back to cited text no. 8
[PUBMED]    
9.
Haldar K, Martinek IE, Kehoe S. Aggressive angiomyxoma: A case series and literature review. Eur J Surg Oncol 2010;36:335-9.  Back to cited text no. 9
[PUBMED]    
10.
McCluggage WG. A review and update of morphologically bland vulvovaginal mesenchymal lesions. Int J Gynecol Pathol 2005;24:26-38.  Back to cited text no. 10
[PUBMED]    
11.
Rabban JT, Dal Cin P, Oliva E. HMGA2 rearrangement in a case of vulvar aggressive angiomyxoma. Int J Gynecol Pathol 2006;25:403-7.  Back to cited text no. 11
[PUBMED]    
12.
Fletcher CD, Tsang WY, Fisher C, Lee KC, Chan JK. Angiomyofibroblastoma of the vulva. A benign neoplasm distinct from aggressive angiomyxoma. Am J Surg Pathol 1992;16:373-82.  Back to cited text no. 12
[PUBMED]    
13.
Jeyadevan NN, Sohaib SA, Thomas JM, Jeyarajah A, Shepherd JH, Fisher C, et al. Imaging features of aggressive angiomyxoma. Clin Radiol 2003;58:157-62.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed1268    
    Printed29    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal