An Official publication of The Asian Congress of Neurological Surgeons (AsianCNS)

Search Article
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Advertise Subscribe Contacts Login  Facebook Tweeter
  Users Online: 72 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 886-889

Exploring a tumor spectrum in a patient with familial angiolipomatosis


1 Department of Neurosurgery Surgery, Dr. RN Cooper Hospital and HBT Medical College, Mumbai, Maharashtra, India
2 Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India

Date of Web Publication2-Aug-2019

Correspondence Address:
Eham Lalit Arora
Department of General Surgery, 6th Floor, JJ Hospital Campus, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai - 400 008, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_295_17

Rights and Permissions
  Abstract 


Angiolipomas are uncommon spinal tumors which differ from their cutaneous counterparts in having larger caliber vascular stroma. Although slow growing, they can cause rapid spinal cord compression and sudden-onset sensorimotor symptoms due to vascular engorgement, hemorrhage, or thrombosis. The goal of surgery is spinal decompression, and favorable outcome is the rule. We report a patient with spinal angiolipoma, vertebral hemangioma along with subcutaneous lipomas and angiolipomas, exhibiting the entire histopathological spectrum of these related soft-tissue tumors. Analysis of his family tree revealed a hereditary predilection. Familial angiolipomatosis is an uncommon genetic condition which has not been reported to occur with spinal angiolipomas thus far.

Keywords: Angiolipoma, familial angiolipomatosis, spinal angiolipoma


How to cite this article:
Maheshwari S, Arora EL. Exploring a tumor spectrum in a patient with familial angiolipomatosis. Asian J Neurosurg 2019;14:886-9

How to cite this URL:
Maheshwari S, Arora EL. Exploring a tumor spectrum in a patient with familial angiolipomatosis. Asian J Neurosurg [serial online] 2019 [cited 2019 Sep 19];14:886-9. Available from: http://www.asianjns.org/text.asp?2019/14/3/886/231052




  Introduction Top


Lipomas, angiolipomas, and hemangiomas represent a continuous histopathological spectrum of related tumors.[1] These tumors are benign and slow growing in nature. The main differentiating factor between them is the ratio between vascular and adipose components. The vascular fraction comprises <10% of tumor mass in lipomas, 15%–40% in angiolipomas,[2] whereas hemangiomas consist almost entirely of malformed vasculature with scanty intervening stroma.

Lipomas and angiolipomas occur sporadically, but have been found to have a familial incidence as well. Familial angiolipomatosis is usually included within the broader spectrum of familial lipomatosis, mirroring the classification of the tumors they encompass.[3]

While an overwhelming majority of hemangiomas are sporadic, an autosomal dominant pattern has been described.[4] In spite of similarities between lipomas, angiolipomas, and hemangiomas, individual cases where these three histological types occur together are uncommon and as per our literature review have never been reported.

We describe a patient of familial angiolipomatosis who presented with a dorsal extradural angiolipoma, with asymptomatic multiple subcutaneous lipomas, angiolipomas, and a large lumbar vertebral hemangioma, representing the spectrum of histopathologically related soft-tissue tumors within the same patient.


  Case Report Top


A 32-year-old man presented with a 20-day history of progressively severe imbalance on walking with bilateral lower limb weakness, gradually increasing numbness extending from the upper abdomen to both lower limbs, and dysesthesia on walking. He also complained of straining at micturition with a weak urinary stream over the last 20 days. On inquiry, he had multiple painless soft-tissue swellings over his left forearm and abdomen, with a family history of similar swellings in his father and two brothers.

On general examination, his swellings were well defined, nonfluctuant, and not associated with tenderness, pruritis, or overlying skin changes. On neurological examination, there was increased tone with Grade 4 power in both lower limbs. Hyperreflexia was elicited in bilateral lower limbs with ill-sustained ankle clonus, bilateral Babinski's sign, and absent abdominal reflex. There was partial sensory loss for touch and pinprick below D6 levels and impaired proprioception in both lower limbs.

Spinal magnetic resonance imaging (MRI) demonstrated a large extradural lesion extending from D5 to D8 levels causing severe compression of the cord. The lesion was hyperintense on both T1-weighted imaging (T1WI) and T2WI, with multiple flow voids within the lesion. On fat suppression images, the lesion showed suppression suggesting fatty component in the lesion; however, there was intense contrast enhancement suggestive of spinal epidural angiolipoma or spinal arteriovenous malformations (AVM). A hemangioma in L1 vertebral body was also discovered incidentally in the imaging [Figure 1] and [Figure 2].
Figure 1: Spectrum of lesions seen in this patient. From left to right: Subcutaneous angiolipoma, dorsal epidural angiolipoma, and vertebral hemangioma

Click here to view
Figure 2: Sagittal and axial cuts of magnetic resonance imaging showing large, extradural, contrast-enhancing lesion extending from D5 to D8 with hemangioma in L1 vertebral body. (a) T1-weighted images. (b) Fat-suppressed postcontrast image. (c) T2-weighted images

Click here to view


A spinal digital subtraction angiography (DSA) confirmed the diagnosis of an angiolipoma with multiple vessels feeding the lesion from right D5 and bilateral D6 and D7 intercostal arteries. There was no early venous drainage, hence ruling out the possibility of an AVM, while supporting the diagnosis of an angiolipoma.

Ultrasonography of the forearm swellings revealed three ovoid, well-defined, hyperechoic lesions within the ventral forearm space suggestive of lipomas. A Doppler scan revealed venous flow within peripherally arranged vessels without evidence of intralesional flow in some lesions, most likely representing angiolipoma. A histopathological diagnosis could not be obtained to confirm this, as the swelling was not excised.

Embolization of the spinal lesion was deferred in view of the diffuse nature of the feeders. Standard D5–D8 laminectomy was performed. A reddish yellow tumor was identified in the epidural region merging with the normal epidural fat at both the edges. It was friable, soft, and extremely vascular with interspersed spongy and hemorrhagic areas. Vascular supply of the lesion consisted of multiple large epidural feeders which made hemostasis challenging. The tumor was slowly devascularized by coagulating the intercostal feeders and was radically excised to achieve decompression of the cord. Complete excision of the tumor was achieved, which was confirmed on postoperative MRI. Histopathological examination of the excised mass revealed fibrofatty tissue embedded within numerous dilated vessels, lined by single flattened epithelium along with few areas of hyalinization, consistent with an angiolipoma.

The patient had immediate postoperative improvement of his weakness, dysesthesia, and urinary complaints and was mobilized on the 2nd postoperative day.

At 6 months' follow-up examination, the patient had Grade 5 power in both lower limbs and complete recovery of sensory deficits. There were no urinary or bowel complaints. At 1-year follow-up, there were no major complaints; however, the multiple subcutaneous swellings had increased in size and number.


  Discussion Top


Angiolipomas are considered a histological subtype of lipomas, accounting for 5%–17% of all lipomatous lesions.[5] These are benign, slow-growing lesions composed of mature adipocytes admixed with abnormal blood vessels, which are usually of capillary size.[6] Multiple lipomatous lesions in individuals are more likely to be angiolipomas, whereas isolated lesions are most commonly simple lipomas.[4]

Spinal angiolipoma is an extremely scarce entity constituting 0.04%–1.2% of all spinal tumors,[7] with just over 100 cases reported in literature.[8] However, its clinical and pathological features lean toward hemangiomatous tumors, meriting its distinction from cutaneous angiolipomas.[6]

They are most commonly located at the dorsal and lower cervical region along the midline, conforming to the last site of closure of embryonic neural arch at its rostral end.[9] These lesions commonly present as sudden-onset weakness and sensory loss in the lower limbs.[10] The rapid symptom progression may be attributed to vascular engorgement, intralesional hemorrhage, sudden thrombosis, change in capillary caliber, or vascular steal phenomenon.[7],[8],[10],[11],[12],[13] Vascular engorgement may have been the most likely culprit in our case which was characterized by significant intraoperative blood loss during tumor removal.

Like simple lipomas, spinal angiolipomas are hyperintense on both T1WIs and T2WIs.[14] Provezale and McLendon reported that large hypointense foci within spinal angiolipomas on noncontrast T1WIs are correlated with increased vascularity and most lesions enhance with gadolinium administration, whereas T2WI can be variable, but are commonly hyperintense.[15],[16] Thus, a conspicuous differentiating feature of angiolipomas on MRI is an intense contrast enhancement which is not seen with lipomas.

DSA helps in delineating the vascular supply and in differentiating spinal angiolipomas from AVMs. Embolization is not indicated as the feeders are diffuse and may jeopardize the normal supply of the cord. Total surgical excision is considered the best line of management in these cases.[17]

Spinal angiolipomas have a significantly higher caliber of vascular component in comparison with their cutaneous counterparts and therefore, may even be considered a distinct entity.[6],[18]

Familial multiple angiolipomatosis is a rare and benign condition which is transmitted in an autosomal recessive fashion, although certain cases of autosomal dominant inheritance have been noted.[19] It has been traditionally included within the broader definition of familial multiple lipomatosis.[3] The patient at hand is among the second generation within the family to be affected. No third-generation family members are symptomatic thus far, the oldest member being 14 years of age. However, one must note that most cutaneous angiolipomas arise after the second decade of life, and one cannot rule out the possibility of third-generation family members also suffering from the condition [Figure 3].
Figure 3: Pedigree chart of the family

Click here to view


Hemangiomas and lipomas are two ends of a continuous histopathological spectrum, where angiolipomas form the intermediate variety. Lipomas are tumors of mature adipocytes without cellular atypia and are the most common soft-tissue tumors of adulthood.[20] Angiolipomas are considered a rarer subtype of lipomas where mature adipocytes are dispersed within a prominent vascular stroma. Hemangiomas are endothelial tumors consisting of malformed blood vessels. The more vascular, invasive, and aggressive spinal angiolipomas would represent a shift toward the hemangioma end of the spectrum. Despite their histopathological correlation and their common mesenchymal origin, these tumors have markedly varied pathogenesis not only between themselves, but also between subtypes of the same tumor. Notably, genetic aberrations seen in cutaneous lipomas are not present in angiolipomas.[21] Given their mottled pathologic origin, the simultaneous occurrence of multiple tumor types within the same patient seems striking, more so when considering the familial nature of his affliction. There is only one case reported in literature which describes the occurrence of spinal angiolipoma in a case of familial lipomatosis.[22] Our patient is unique in that he probably represents a case of familial angiolipomatosis with multiple subcutaneous lesions, presenting with an associated dorsal angiolipoma as well as a lumbar vertebral hemangioma.


  Conclusion Top


While lipomas, angiolipomas, and hemangiomas represent a continuous histological spectrum of mesenchymal tumors, they differ greatly in their pathogenesis. Spinal angiolipomas are uncommon neoplasms, the origin of which is uncertain. Although they are considered conspicuously dissimilar to their cutaneous counterparts, we report the coincidence of both spinal and cutaneous lesions in this case of familial angiolipomatosis with lumbar vertebral hemangioma. Their coexistence in a singular patient with close histopathological features makes us hypothesize that the three lesions are nothing but natural progression of a single tumor type - either a hemangioma's vascular component gradually regresses to form an angiolipoma and eventually lipoma or a lipoma acquires progressive vascularity to reverse the aforementioned trend.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pagni CA, Canavero S. Spinal epidural angiolipoma: Rare or unreported? Neurosurgery 1992;31:758-64.  Back to cited text no. 1
    
2.
Hemavathy S, Roy S, Kiresur A. Intraosseous angiolipoma of the mandible. J Oral Maxillofac Pathol 2012;16:283-7.  Back to cited text no. 2
  [Full text]  
3.
Abbasi NR, Brownell I, Fangman W. Familial multiple angiolipomatosis. Dermatol Online J 2007;13:3.  Back to cited text no. 3
    
4.
Blei F, Walter J, Orlow SJ, Marchuk DA. Familial segregation of hemangiomas and vascular malformations as an autosomal dominant trait. Arch Dermatol 1998;134:718-22.  Back to cited text no. 4
    
5.
Kacar S, Kuran S, Temucin T, Odemis B, Karadeniz N, Sasmaz N, et al. Rectal angiolipoma: A case report and review of literature. World J Gastroenterol 2007;13:1460-5.  Back to cited text no. 5
    
6.
Hattori H. Epidural angiolipoma is histologically distinct from its cutaneous counterpart in the calibre and density of its vascular component; a case report with review of the literature. J Clin Pathol 2005;58:882-3.  Back to cited text no. 6
    
7.
Andaluz N, Balko G, Bui H, Zuccarello M. Angiolipomas of the central nervous system. J Neurooncol 2000;49:219-30.  Back to cited text no. 7
    
8.
Oge HK, Söylemezoglu F, Rousan N, Ozcan OE. Spinal angiolipoma: Case report and review of literature. J Spinal Disord 1999;12:353-6.  Back to cited text no. 8
    
9.
Liebeskind AL, Azar-Kia B, Batnitzky S, Schechter MM. Intraspinal lipomas. Neuroradiology 1974;7:198-200.  Back to cited text no. 9
    
10.
Hungs M, Paré LS. Spinal angiolipoma: Case report and literature review. J Spinal Cord Med 2008;31:315-8.  Back to cited text no. 10
    
11.
Boockvar JA, Black K, Malik S, Stanek A, Tracey KJ. Subacute paraparesis induced by venous thrombosis of a spinal angiolipoma: A case report. Spine (Phila Pa 1976) 1997;22:2304-8.  Back to cited text no. 11
    
12.
Labram EK, el-Shunnar K, Hilton DA, Robertson NJ. Revisited: Spinal angiolipoma – three additional cases. Br J Neurosurg 1999;13:25-9.  Back to cited text no. 12
    
13.
Preul MC, Leblanc R, Tampieri D, Robitaille Y, Pokrupa R. Spinal angiolipomas. Report of three cases. J Neurosurg 1993;78:280-6.  Back to cited text no. 13
    
14.
Samdani AF, Garonzik IM, Jallo G, Eberhart CG, Zahos P. Spinal angiolipoma: Case report and review of the literature. Acta Neurochir (Wien) 2004;146:299-302.  Back to cited text no. 14
    
15.
Provenzale JM, McLendon RE. Spinal angiolipomas: MR features. AJNR Am J Neuroradiol 1996;17:713-9.  Back to cited text no. 15
    
16.
Preul MC, Leblanc R. MRI in the diagnosis of spinal extradural angiolipoma. Br J Neurosurg 1993;7:328.  Back to cited text no. 16
    
17.
Leu NH, Chen CY, Shy CG, Lu CY, Wu CS, Chen DC, et al. MR imaging of an infiltrating spinal epidural angiolipoma. AJNR Am J Neuroradiol 2003;24:1008-11.  Back to cited text no. 17
    
18.
Stanford University School of Medicine. Surgical Pathology Criteria – Lipoma Variant: Angiolipoma; 2016. Available from: http://www.surgpathcriteria.stanford.edu/softfat/lipoma/angiolipoma.html. [Last accessed on 2016 Apr 28].  Back to cited text no. 18
    
19.
Cina SJ, Radentz SS, Smialek JE. A case of familial angiolipomatosis with Lisch nodules. Arch Pathol Lab Med 1999;123:946-8.  Back to cited text no. 19
    
20.
Bancroft LW, Kransdorf MJ, Peterson JJ, O'Connor MI. Benign fatty tumors: Classification, clinical course, imaging appearance, and treatment. Skeletal Radiol 2006;35:719-33.  Back to cited text no. 20
    
21.
Sciot R, Akerman M, Dal Cin P, De Wever I, Fletcher CD, Mandahl N, et al. Cytogenetic analysis of subcutaneous angiolipoma: Further evidence supporting its difference from ordinary pure lipomas: A report of the CHAMP Study Group. Am J Surg Pathol 1997;21:441-4.  Back to cited text no. 21
    
22.
Bordet R, Ghawche F, Destée A. Epidural angiolipoma and multiple familial lipomatosis. Rev Neurol (Paris) 1991;147:740-2.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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
    Viewed456    
    Printed20    
    Emailed0    
    PDF Downloaded21    
    Comments [Add]    

Recommend this journal