Review and Case Series: Angioleiomyoma in the Hand
Key findings
- Angioleiomyoma are vascular tumors that are rarely found in the hand
- The differential diagnosis includes giant cell tumors, ganglion cysts, nerve sheath tumors, lipoma, neuroma and glomus tumors
- Angioleiomyoma are frequently painful; other typical features are superficial location, indolent growth, well-circumscribed nature and small size
- These tumors are typically benign and can often be treated with marginal excision without the need for preoperative advanced imaging
- Biopsy should be considered in patients in whom the diagnosis is ambiguous
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Angioleiomyomas are a benign subgroup of vascular tumors that account for less than 1% of soft tissue tumors in the upper extremity. Given their rarity, the diagnosis is often initially overlooked.
Caleb M. Yeung, MD, clinical orthopaedic surgery resident, and Santiago Lozano Calderon, MD, PhD, surgeon in the Orthopaedic Oncology Service at Massachusetts General Hospital and the Mass General Cancer Center, and colleagues recently reported on five patients treated for angioleiomyomas of the hand. In The Archives of Bone & Joint Surgery, they also review the limited published literature about these tumors.
Case Series
The surgeons identified five men who were treated for angioleiomyoma in the hand at Mass General between 1992 and 2015. These cases recapitulated several findings from prior series:
- Patients were middle-aged (the median age in this series was 49)
- All presented with a painful, slow-growing mass
- Four tumors were particularly small at presentation (0.24–0.36 cm2); one was 6 cm2 in the first webspace
- Marginal surgical excision led to a return to full function without postoperative complications or recurrences
Two patients described the fluctuating size of the mass and a periodically firm consistency. Three patients reported a prior contusion at the eventual site of the angioleiomyoma associated with a sports or hyperextension injury.
Managing Suspected Malignancy
These patients had routine radiographs of the hand, but only one underwent advanced imaging preoperatively. None underwent frozen section because a diagnosis of malignancy was considered highly unlikely given the superficial location of the masses, the history of indolent growth and the small, well-circumscribed lesions.
Features such as a larger size of the mass, deep location or poorly defined borders should raise concern for malignancy. The surgeon should consider having frozen pathology available at the time of resection and include a plan for a longitudinal incision that would accommodate a more extensile resection if needed.
As used in these five patients, such patients might benefit from advanced imaging or a core needle biopsy preoperatively rather than excisional biopsy.
Differential Diagnosis
Angioleiomyoma may be mistaken for giant cell tumors or ganglion cysts, even after advanced imaging. The differential diagnosis also includes nerve sheath tumor, lipoma, neuroma and glomus tumors, although the latter typically occurs in the very distal extremity such as under the fingernail.
Monitoring
Prior studies have noted that surveillance should last one year after excision, with additional follow-up only if the patient develops new symptoms.
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