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CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 2  |  Page : 210-212
Aggressive angiomyxoma with lymphangitis a rare entity – Case report


1 Department of Dermatology, Venereology and, Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India
2 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India

Date of Web Publication16-Apr-2021

Correspondence Address:
Sumit Kar
Department of Dermatology, Venereology and, Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_756_19

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How to cite this article:
Patrick S, Kar S, Gangane N, Deshmukh A, Date P, Sawant A. Aggressive angiomyxoma with lymphangitis a rare entity – Case report. Indian J Dermatol 2021;66:210-2

How to cite this URL:
Patrick S, Kar S, Gangane N, Deshmukh A, Date P, Sawant A. Aggressive angiomyxoma with lymphangitis a rare entity – Case report. Indian J Dermatol [serial online] 2021 [cited 2021 Oct 16];66:210-2. Available from: https://www.e-ijd.org/text.asp?2021/66/2/210/313772




Sir,

Aggressive angiomyxoma is a rare but locally invasive mesenchymal tumor occurring usually in women of reproductive age. It is a slow-growing vulvovaginal mesenchymal neoplasm with a marked tendency for local recurrence, but with a low tendency to metastasize. It was first described by Steeper and Rosai in 1983.[1] It presents as a vulval polyp clinically and is diagnosed on histology. Estrogen and progesterone receptors are commonly found in AAM.[2] It is thus likely to grow during pregnancy and respond to hormonal manipulation. It involves mainly the pelvis, vulva, perineum, vagina and urinary bladder in adult women in the reproductive age. Incomplete excision is common because of the infiltrating nature of the neoplasm and absence of a definite capsule. Non-surgical interventions like hormonal manipulation, radiotherapy, arterial embolization have been tried with variable success rates.[3]

A 28-year-old female with asymptomatic slow growing mass over pubic area since 8 years which increased in size after her pregnancy 6 years back and with unilateral swelling over limb since childhood. Local examination showed multiple skin colored to hyperpigmented polypoidal to pedunculated growth with smooth surface [Figure 1] and spongy and soft in consistency and non-tender. Her inguinal and axillary lymphnodes were not enlarged. Unilateral swelling over left foot extending until knee non-pitting in nature was observed. Viral markers were negative. Unilateral swelling over left foot extending up to knee was pitting in nature. Later punch biopsy with excisional biopsy was performed from one of the pedunculated mass, which showed findings suggestive with fibrous growth. We referred her to surgeon who performed wide local excision of the mass, which was en mass again sent for histopathology, which confirmed the diagnosis of aggressive angiomyxoma.
Figure 1: (1) Shows multiple skin colored to hyperpigmented polypoidal to pedunculated growth over pubis and lower abdominal wall. (2) Postoperative (day 20) surgical wound in healing phase

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Aggressive angiomyxoma (AAM) is a rare mesenchymal neoplasm arising primarily in soft tissue of pelvis and perineum of adults. It occurs predominantly in women of reproductive age, with a peak incidence in the fourth decade of life and an age range of 11 to 77 years.[4] AAM is often mistaken for more-common, superficial lesions, such as vaginal or labial cysts and lipomas, and the frequently large, bulky size and extent of the deep tissue involvement is not appreciated until radiographic imaging and surgical resection are performed. These tumors often have a smooth surface, partially or completely encapsulated with finger-like projection on adjacent soft tissue and cut surface gives a glistening, gelatinous appearance, bluish grey in color, with areas of hemorrhage and congestion.[3] In our case macroscopically external surface showed presence of multiple pedunculated growth, grey brown in color [Figure 1] and was soft and spongy in consistency with unilateral left foot non-pitting edema [Figure 2] since childhood. Therapeutic surgical excision was performed and sent for histopathology. Histological examination on H and E stained section showed presence of small spindle and stellate-shaped cells in a myxoid background. The tumor cells showed pink eosinophilic cytoplasm [Figure 3]. There was no nuclear pleomorphism and mitosis. There was also presence of numerous prominent dilated thick walled vessels (H and E, x100) [Figure 4]. Immunohistochemical staining of the tumor reveals high positivity for desmin, vimentin, ER, and PR receptor and negative for S-100 protein.[5] We also performed immunohistochemistry (IHC) for confirming the diagnosis. IHC stained section showed presence of focal Smooth Muscle Antigen (SMA) positivity (H and E, x400) [Figure 5]. Since our hospital lacks facility for ER, PR receptor staining we couldn't test for the same. Surgical resection is the main treatment modality, but local recurrence rates are high. The reported recurrence rate varies from 35% to 72%, even with clear surgical margins.[4]
Figure 2: Shows unilateral non-pitting edema over left foot extending up to knee

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Figure 3: Tumor mass composed of small spindle and stellate-shaped cells in a myxoid matrix with presence of numerous dilated thick walled vessels (H and E, x40)

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Figure 4: Tumor mass composed of small spindle and stellate.shaped cells in a myxoid matrix (pointed arrows) on left side and presence of numerous dilated thick walled vessels on right side (H and E, x100)

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Figure 5: IHC showing focal positivity for SMA (IHC x400)

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Radiation therapy and chemotherapy are less-suitable options due to low mitotic activity. Hormonal manipulation with tamoxifen, raloxifene and gonadotropin-releasing hormone analogues reduce the tumor size and help to make complete excision feasible in large tumors. Angiographic embolization shrinks tumor and makes it easier for excision.[6] In our case, AAM with lymphangitis was found. Even after extensive literature search, relation between AAM and lymphangitis has been found to be rare, which is found in our case. Further study is required to find out any association between AAM and lymphangitis. Also post-treatment examination for remission of lymphangitis couldn't be done as there was lost to follow-up. Hence AAM being rarely reported entity extensive reporting of AAM with associated abnormality is required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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
    
2.
Han-Geurts IJ, Van Geel AN, van Doorn L, den Bakker MD, Eggermont AM, Verhoef C. Aggressive angiomyxoma: Multimodality treatments can avoid mutilating surgery. Eur J Surg Oncol 2006;32:1217-21.  Back to cited text no. 2
    
3.
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. 3
    
4.
Sutton BJ, Laudadio J. Aggressive angiomyxoma. Arch Pathol Lab Med 2012;136:217-21.  Back to cited text no. 4
    
5.
Mathieson A, Chandrakanth S, Yousef G, Wadden P, Sala E, Wirtzfeld D. Aggressive angiomyxoma of the pelvis: A case report. Can J Surg 2007;50:228-9.  Back to cited text no. 5
    
6.
Kura MM, Jindal SR, Khemani UN. Aggressive angiomyxoma of the vulva: An uncommon entity. Indian Dermatol Online J 2012;3:128-30.  Back to cited text no. 6
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