Bilateral superficial angiomyxomas of lower limbs: Unique presentation of a benign cutaneous tumor

Abstract is not required for Clinical Images (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 3, March 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(3):230–232. www.ijcasereportsandimages.com da Costa et al. 230 CASE REPORT OPEN ACCESS Bilateral superficial angiomyxomas of lower limbs: Unique presentation of a benign cutaneous tumor P. Gaspar da Costa, L. Lêdo, S. Braz, A. Teixeira, L. Soares-de-Almeida, J. Meneses Santos


CASE REPORT
A 93-year-old female presented with painless grouped cutaneous nodules and tumors, ranging from 0.5-3 cm in diameter (Figure 1), which had slowly developed over the last five years. Examination revealed multiple firm, non-tender lobulated nodular lesions, varying from fleshcolored to erythematous, symmetrically distributed over the dorsal face of all toes and the dorsal face of both feet. A 6-mm skin punch biopsy was performed and showed poorly circumscribed myxoid dermal nodules containing a few of bland spindle-cells (Figure 2A-B), mucin deposits ( Figure 2C) and small blood vessels ( Figure 2D), without inflammatory cell infiltrate. These findings were consistent with the diagnosis of superficial angiomyxoma. Tumor resection was not proposed because of lesions extension and no other treatment was performed.

DISCUSSION
Superficial angiomyxoma is a rare benign cutaneous tumor that affects patients of all ages, with a peak incidence in 4th and 5th decades, and has a slight predilection for males [1,2]. First reported by Allen et al. in 1988 it is usually reported as a solitary skin nodule,

CLINICAL IMAGES PEER REVIEWED | OPEN ACCESS
papule or polypoid lesion under 5 cm in diameter, most commonly presenting on the trunk, followed by the lower limbs and, finally, the head, neck and the upper limbs.  Superficial angiomyxoma with unusual location such as the oral cavity mucosa and external genitalia and subungual neoplasms have also been reported [2,3]. Histologically, lesions are described as well circumscribed dermal tumors with an abundant mucinous stroma, spindle-shaped and/or stellate cells and a prominent vascular pattern with multiple small to medium-sized thin-walled vessels. A sparse to moderate mixed inflammatory infiltrate is usually present within the myxoid matrix.
The myxomas described in the Carney complex are very similar to superficial angiomyxomas [4]. Their recognition is important because it can be the first manifestation of the syndrome. The patient had neither lentigines on the face, nor signs of endocrine overactivity.
Treatment consists of surgical excision. We did not find in literature any alternative therapy to surgical resection. These tumors are not known to metastasize. However, they have a 30-40% local recurrence rate mainly after incomplete excision [1,2].

CONCLUSION
Multiple superficial angiomyxoma is a very rare occurrence. To the best of our knowledge, there is no similar case, as the one reported here, described in the English literature. The dimension of the tumors and their symmetrical distribution on the lower limbs make this case a unique superficial angiomyxoma.

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