JBR–BTR, 2014, 97: 245-247.

ANGIOLEIOMYOMA IN THE SOLEUS MUSCLE

A. Van Holsbeeck1, L. Van den Daelen2, E. Steenkiste3, B. Van Holsbeeck1

We present a case of angioleiomyoma, a benign angiomatous soft tissue tumor in a 52-year-old patient. We empha- size that small nodular tumors showing hypervascularity on MRI or ultrasound may be malignant and should be treated with tumor excision.

Key-word: Soft tissues, neoplasms.

Case report The patient was referred for sity of the lesion was mostly inter- sonography for the presumed diag- mediate (similar to adjacent muscle) A 52-year-old female patient pre- nosis of Achilles tendinosis or tear. (Fig. 2A). On T2-weighted sequence, sented to the orthopaedic depart- The examination, however, showed signal intensity was high (Fig. 2B). ment with intermittent right pain normal and a small Strong enhancement was seen after of 12 months duration. There was hypervascular lesion in the distal intravenous contrast administration no clinical history of trauma. Exam- soleus muscle (Fig. 1). For charac- (Fig. 2C). ination showed a tender nodular terization, therapy planning and lo- Amongst other soft tissue lesions swelling at the musculotendinous cal staging MR was performed. On (see discussion), an angioleiomyoma junction of the Achilles. T1-weighted sequence, signal inten- in the soleus muscle was suggest-

A B Fig. 1. — Sonography of the Achilles tendon and calf muscles (A) showed a heterogeneous hypoechoic lesion with sharp delin- eation measuring 1 cm × 0.7 cm. The lesion is located in the distal soleus muscle. Color Doppler sonography (B) demonstrated hypervascularity of the lesion.

A B C Fig. 2. — Sagittal T1-weighted MR- sequence (A) revealed a oval lesion located in the distal soleus muscle, anterior to the Achilles tendon (arrow). The lesion is homogeneous isointense to . On sagittal fat-suppressed T2-weighted image (B), the lesion is heterogeneous, predominantly From: Department of 1. Radiology, 2. Orthopaedic surgery and 3. Pathology, Stedelijk hyperintense to skeletal muscle, how- Ziekenhuis Roeselare, Belgium. ever with some internal isointense foci. Address for correspondence: Dr A. Van Holsbeeck, Department of Radiology, Stedelijk Gadolinium enhanced sagittal fat- sup- Ziekenhuis Roeselare, Rode Kruisstraat 20, 8800 Roesealre, Belgium. pressed T1-weighted image (C) showed E-mail: [email protected] strong enhancement.

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A Fig. 3. — Histopathology. Low- power view (A) showed a relatively sharp delineated nodular proliferation of smooth muscle cells (arrows) surrounding multiple vascular B channels (asterisk). The nodule is embedded in bundles of skeletal muscle cells (short arrow) (× 50). Immunohistochemical staining (B) was positive with desmine (muscle marker) (× 200).

ed, based on the sonographic and to blood vessels. The isointense coma, mostly occurs in the distal up- MR characteristics. Histopatholog- areas are likely related to fibrous per extremity, followed by the lower ical findings and immunohistolog- tissue and intravascular thrombi. extremity. The tumor often shows an ical analysis with smooth muscle Frequently, a hypointense periph- indolent course with high risk for re- cell markers confirmed the diagno- eral rim is present on both T1- and currence and metastasis (7, 8). sis (Fig. 3). T2-weighted images, corresponding MR is not able to differentiate to a fibrous capsule (5). between the different histological Discussion There are several other lesions subtypes of angioleiomyoma, and with a rich vascular supply that what’s more worrisome, a radiolo- Angioleiomyoma is a smooth should be included in the differential gist can mistakenly diagnose a ma- muscle tumor accounting for 5% of diagnosis. Soft tissue hemangioma lignant lesion as benign based only all benign soft tissue neoplasms. The is the most common soft tissue tu- on MR features. The importance of lesion originates in the tunica media mor. However, sonography usually MRI relates to its ability to distin- of the blood vessels. It can occur shows a heterogeneous, irregular guish soft tissue planes that allow for anywhere in the body, however most lesion and acoustic shadowing may complete and safe surgical excision. commonly it will be discovered in an be present due to phleboliths. On In this patient, we were able to locate extremity, more specifically in the T1-weighted MR images a hemangi- a fat plane and a muscle interface lower leg. The tumor can be located oma is typically heterogenous with between the tumor and the Achilles either superficial, as in most cases, hyperintense areas corresponding to and the flexor hallucis muscle re- or deep in relation to the . The fat. Other angiomatous lesions that spectively. Both MRI and ultrasound peak incidence is between the fourth can present like this case include also enabled us to located sural and and sixth decades of life; there is a hemangioendothelioma and heman- saphenous at a safe distance female preponderance (1, 2). Pain giopericytoma. The benign form of from the mass. is a common presenting symptom, both these tumors can strongly re- In conclusion, we reported a case possibly due to contraction of the semble angioleiomyoma. The more of angioleiomyoma, a benign angi- smooth muscle fibers resulting in malignant forms of these vascular omatous soft tissue tumor. We em- local ischemia (2). Hasegawa et al. lesions show more aggressive fea- phasized that small nodular tumors suggested that the pain may be me- tures of infiltration of the surround- that show hypervascularity on MRI diated by irritation of nerves within ing tissue and by imaging these or ultrasound can be malignant. Tu- the lesion (3). lesions are indistinguishable from mor excision is therefore strongly MR most often demonstrates a angiosarcoma (6). In the lower ex- advised. sharply delineated oval mass which tremity, one should also be aware of is homogeneous and isointense to small tumors that can be hypervas- References muscle on T1-weighted images. On cular and despite their small size be T2-weighted and STIR images the malignant in nature including epithe- 1. Gupte C., Butt S.H., Tirabosco R., lesion is mixed hyperintense and lioid sarcoma and synovial sarcoma. Saifuddin A.: Angioleiomyoma: mag- isointense to muscle. Further, the Both these tumors most often affect netic resonance imaging features in hyperintense areas on T2-weight- the extremities in young patients. ten cases. Skeletal Radiol, 2008, 37: 1003-1009. ed images typically show enhance- Synovial sarcoma is located near a 2. Ramesh P., Annapureddy S.R., Kahn F., ment after intravenous contrast joint (especially the popliteal fossa). Sutaria P.D.: Angioleiomyoma: a injection (4, 5). A radiologic-patho- Despite its name, the tumor does not ­clinical, pathological and radiological logic study suggested that the arise from synovium. Epithelioid sar- review. Int J Clin Pract, 2004, 58: 587- hyperintense areas may correspond coma, an aggressive soft tissue sar- 591.

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