|Ahead of print publication
A Giant Angiolipoma: A Case Report
Vaibhav Aggarwal1, Suneha Kumari1, Kamal Kataria1, Ankur Goyal2
1 Department of Surgical Disciplines, All India Institute of Medical Sciences (AIIMS), New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
|Date of Submission||19-Sep-2021|
|Date of Decision||02-Nov-2021|
|Date of Acceptance||04-Dec-2021|
|Date of Web Publication||16-Aug-2022|
Department of Surgical Disciplines, All India Institute of Medical Sciences (AIIMS), New Delhi-110029
Source of Support: None, Conflict of Interest: None
Angiolipomas are uncommon benign vascular adipocytic mesenchymal tumors and generally present as painful subcutaneous nodules in the extremities and trunk. Chest wall is a rare site for angiolipoma. We describe a case of a giant retromammary angiolipoma that presented clinically as an apparent large breast lump. This tumor was surgically excised after preoperative angioembolization. Latter was carried out to reduce intraoperative bleeding and facilitate the excision. We recommend keeping benign tumors such as angiolipomas in differential when dealing with apparent breast/chest wall lumps. We also advocate preoperative angioembolization in select cases while excising large angiolipomas to decrease perioperative blood loss.
Keywords: Adipocytic neoplasm, angiolipoma, angioembolization, vascular tumor
| Introduction|| |
Angiolipomas are uncommon benign mesenchymal tumors. They may be clinically indistinguishable from lipomas and are described as variants of lipoma with high vascular proliferation. They generally present as painful and tender subcutaneous nodules in young involving the extremities and trunk. These tumors rarely occur in a variety of other locations as well such as spine, breast, and mediastinum. In this study, we report a case of a large retromammary angiolipoma which was managed by preoperative angioembolization followed by excision. To the best of our knowledge, this is the first described case of a retromammary angiolipoma. This is also the first described case of a chest-wall angiolipoma which was preoperatively angioembolized.
| Case Report|| |
A 39-year-old perimenopausal lady complained of a lump in her right breast which was first noticed 3 years back. There was no complaint of pain or trauma at the site. There was no history of nipple discharge or retraction. Medical history and family history were unremarkable. On examination, fullness was present in the right breast. A firm nontender lump of size 10 × 7 cm was present in the upper inner quadrant of the right breast [Figure 1]a,b. The lump was smooth and fixed to the underlying pectoral muscle. Nipple areolar complexes appeared normal. The left breast examination was unremarkable. Mammography revealed that this clinically apparent breast lump was actually due to retromammary soft-tissue mass in the pectoralis muscle [Figure 2]a. Ultrasonography-guided biopsy from the mass showed thin- and thick-walled arteriolar caliber blood vessels admixed with fibro collagenous and mature adipose tissue suggestive of angiolipoma. Contrast-enhanced computed tomography of the chest revealed a heterogeneously enhancing soft-tissue mass measuring 9.2 cm × 6.9 cm × 12 cm diffusely involving the right pectoralis major muscle and consisting of soft tissue and fat attenuation along with tortuous vessels within [Figure 2]b–d.
|Figure 1: Clinical images of the patient. Right-sided breast fullness is evident both in (a) lateral and (b) front views.|
Click here to view
|Figure 2: Mammogram and computed tomography (CT). (a) Mammogram right breast MLO view shows that the clinically apparent breast lump was actually due to retromammary soft-tissue mass in the pectoralis muscle (asterisk). (b, c) Axial and (d) coronal contrast-enhanced CT images show that the mass diffusely involves the right pectoralis major and consists of soft tissue and fat attenuation along with tortuous vessels within.|
Click here to view
We planned the excision of the tumor. As the tumor showed moderate vascularity with tortuous intralesional and perilesional vessels, the patient was planned for preoperative embolization to reduce intraoperative blood loss. The hypertrophied feeder branches from the right internal mammary artery and the right superior thoracic artery were selectively embolized using 300 micron polyvinyl alcohol particles [Figure 3a]–g. The patient then underwent surgery. The right-sided skin incision was made along the lateral mammary crease. Breast tissue was lifted off the pectoralis major muscle from lateral to medial. Pectoralis major muscle and part of involved pectoralis minor muscle fibers were excised with tumor while securing hemostasis from lateral to medial. . The intraoperative blood loss was <100 mL. The postoperative period was uneventful. Macroscopically the tumor was yellowish in color with areas of hemorrhage. Specimen histopathology confirmed it to be an intramural angiolipoma with thrombotic blood vessels and chronic inflammatory infiltrate. All margins were free of tumor. At 8 months of follow-up, the patient is doing well with no evidence of recurrence.
|Figure 3: Static images from digital subtraction angiography embolization procedure. (a, b) Selective run of right superior thoracic artery depicts tortuous feeders and dense parenchymal blush. (c) Demonstrates super selective coaxial catheterization and (d) depicts postembolization run with cessation of tumor blush. (e, f) Selective run of right internal mammary artery shows multiple feeder branches and abnormal tumor blush which is not observed in postembolization (g).|
Click here to view
| Discussion|| |
Bowen gave the first clinical description of angiolipoma in 1912 and its detailed microscopic features were described only in 1960 by Howard and Helwig. World Health Organization classification of soft-tissue tumors 2020 classifies angiolipoma as adipocytic tumors. The majority of these cases are sporadic. A few genetic mutations on chromosome 13 and of the PKD2 gene have been described., These tumors are subclassified into two histologic subtypes: a more common noninfiltrating subtype and an uncommon infiltrating subtype (which is nonencapsulated and involves deep soft tissues).
Chest wall angiolipomas are uncommon. They are, however, useful to be aware of as they may mimic malignant breast/chest wall masses clinically, radiologically and on biopsy. Most cases present with a palpable mass in the chest wall or breast as in our case. They may be associated with dull aching pain. Imaging features are nonspecific and highly variable. The most common mammographic and sonographic feature is of an isodense circumscribed mass and circumscribed hyperechoic mass, respectively.[8 Computed tomography and magnetic resonance imaging may suggest the possibility based on fat signal intensity and tortuous vessels, but histology is usually required to make the diagnosis. The degree of vascular proliferation can range from 5% to 90% in these tumors. The tumors with high vascularity also termed as cellular angiolipomas may be confused with Kaposi sarcoma, angiosarcoma, capillary hemangioma, or myofibroblastoma on core needle biopsy. However, the lack of cellular atypia and irregular blood vessels and the presence of microthrombi favors the diagnosis of angiolipoma., Therefore, excision of the mass is preferred to confirm the diagnosis. These tumors have recently been found to express androgen receptors in adipocytes and stromal cells.
Breast angiolipomas are small (generally <2 cm). To the best of our knowledge, this is the first case describing a giant angiolipoma in the retromammary region involving the pectoralis major muscle. Due to the hypervascular nature of the tumor, we decided to preoperatively angioembolize the tumor to decrease the risk of intraoperative bleeding and facilitate excision. A few case reports have reported selective preoperative angioembolization in large angiolipomas of the mediastinum and spine., We recommend that large angiolipomas be preoperatively angioembolized to decrease perioperative blood loss and aid in the complete resection of the tumor in other locations as well. Surgical resection is the definitive management in these patients. The results of complete surgical resection of these tumors are excellent and there is no report of recurrence after excision in the current medical literature.
| Conclusion|| |
The occurrence of chest wall angiolipoma is uncommon and the literature is currently limited to a few case reports. Clinicians should keep this tumor in differential when dealing with breast/chest wall lumps as this tumor can mimic malignancy clinically, radiologically, and on biopsy. Surgical excision provides the definite treatment. Preoperative angioembolization should be used in select cases of large angiolipomas to decrease perioperative blood loss and associated morbidity.
VA, SK: concept, design, processing, and writing manuscript.
KK, AG: concept, design, supervision, processing, writing manuscript and critical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Howard WR, Helwig EB. Angiolipoma. Arch Dermatol 1960;82:924-31.
Reiser V, Haj Yahya B, Chaushu G, Kaplan I, Hamzani Y. Angiolipoma in the head and neck: imaging, diagnosis and management. Medicina (Mex) 2020;56:283.
Kryvenko ON, Chitale DA, Van Egmond EM, Gupta NS, Schultz D, Lee MW. Angiolipoma of the female breast: clinicomorphological correlation of 52 cases. Int J Surg Pathol 2011;19:35-43.
Hantous-Zannad S, Neji H, Zidi A et al.
Posterior mediastinal angiomyxolipoma with spinal canal extension. Tunis Med 2012;90:816-8.
WHO Classification of Tumours, 5th Edition, Volume 3 (IARC) International agency for research on cancer publications. 2020.
Panagopoulos I, Gorunova L, Andersen K, Lobmaier I, Bjerkehagen B, Heim S. Consistent involvement of chromosome 13 in angiolipoma. Cancer Genomics Proteomics 2017;15:61-5.
Hofvander J, Arbajian E, Stenkula KG et al.
Frequent low-level mutations of protein kinase D2 in angiolipoma. J Pathol 2017;241:578-82.
Darling MLR, Babagbemi TO, Smith DN, Brown FM, Lester SC, Meyer JE. Mammographic and sonographic features of angiolipoma of the breast. Breast J 2000;6:166-70.
Kahng HC, Chin NW, Opitz LM, Pahuja M, Goldberg SL. Cellular angiolipoma of the breast: immunohistochemical study and review of the literature. Breast J 2002;8:47-9.
Jain R, Bitterman P, Lamzabi I, Reddy VB, Gattuso P. Androgen receptor expression in vascular neoplasms of the breast. Appl Immunohistochem Mol Morphol 2014;22:132-5.
Gorospe L, García-Poza J, González-Gordaliza MC, Cabañero-Sánchez A, Muñoz-Molina GM, Saldaña-Garrido D. Preoperative embolization of a posterior mediastinal lipid-poor angiolipoma mimicking a paravertebral nerve sheath tumor. Ann Thorac Surg 2015;100:705-7.
[Figure 1], [Figure 2], [Figure 3]