We present an unusual case of a 61-year-old man with a large and slow-growing soft tissue mass in the palmar aspect of the left hand. There was no association with pain or history of trauma. No other known diseases, namely rheumatological diseases.
Magnetic Resonance imaging (MRI) was performed, demonstrating a well-defined 5cm subcutaneous soft tissue mass in the volar aspect of the hand.
It shows predominantly isointense signal compared to skeletal muscle on T1-weighted images (T1-WI) (figure 1) and heterogenous signal on fat-suppressed DP-weighted images (FS DP-WI), with intermingled hyperintense and isointense areas. Several serpentine high signal intensity areas on FS DP-WI were also observed, abutting the periphery of the mass (figure 2).
A well-defined hypointense peripheral rim was seen on both T1-WI and FS DP-WI.
After intravenous administration of paramagnetic contrast, the mass showed strong and heterogeneous enhancement, with hyperintense areas on STIR-WI displaying the greater degree of enhancement on dynamic study (figure 3).
No signs of invasion of the tendons or bone were seen.
Angioleiomyoma is a relatively rare, benign, vascular smooth muscle tumor originating from the tunica media of veins and arteries. They can occur in the dermis, subcutaneous fat or fascia, and can be located anywhere in the body, more frequently in the lower limbs. [1-3]
There is a slight female predominance (male/female ratio: 1.0/1.7), occurring more frequently in the fourth to sixth decades of life. [3]
Angioleiomyomas are usually small, firm, mobile, slow-growing masses. Patients typically report several years of symptoms before presentation, with pain as the most striking clinical feature, reported in 44-60% of patients. [1,4,5]
Ultrasound and, specially, MRI can provide valuable preoperative information. Apart from inherent smooth muscle bundles and blood vessels, these tumors may also contain areas of hyalinization, fat or calcifications, that can be identified by imaging modalities. Radiography and CT images usually show a well-defined and otherwise nonspecific cutaneous or subcutaneous mass, with soft tissue density which may or may not present calcifications or fat. [3]
On ultrasound examination angioleiomyoma demonstrate well-defined margins, oval shape and hypoechoic homogeneous structure with vascularity. [4]
On T1-WI MRI images, these tumors appear either homogeneously or heterogeneously iso-intense to muscle. On T2-WI MRI images they usually exhibit heterogenous linear, serpentine, and branching regions of high signal intensity, corresponding to numerous vessels. Due to these vessel component, such areas generally show strong enhancement, while isointense areas, corresponding to fibrous tissue, are usually non-enhancing. A peripheral hypointense rim is frequently seen on both T1-WI and T2-WI and corresponds pathologically to a fibrous capsule. Tortuous vascular structures abutting the mass may also be identified and constitute a clue for the diagnosis. [4, 6, 7]
Preoperative core needle biopsy is often helpful in the diagnosis, but the lesions are usually excised due to associated pain and to obtain definitive diagnosis. [8]
Simple marginal excision is usually performed as local recurrence after excision is extremely rare. [3]
Angioleiomyoma should be considered in the differential diagnosis of a painful or painless slow-growing superficial mass in the hand or foot. This is particular the case when MRI characteristic feature of T2-WI linear, serpentine or branching regions of hyperintensity within a lesion show strong enhancement. The identification of tortuous vascular structures abutting the mass also indicates this diagnosis.
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Angioleyomioma
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The patient is a 61-year-old male who presents with a long-term, slowly growing soft tissue mass on the palmar side of the left hand, without significant pain or history of trauma. Imaging findings are as follows:
Based on the imaging findings and the patient’s clinical features (such as slow growth, no significant pain, and subcutaneous location in the palm), the possible diagnoses include (but are not limited to):
Considering the patient’s age, sex distribution, clinical symptoms (although painless, a painless presentation is possible), and MRI findings showing significant vascular components within the lesion and a well-defined capsule, angioleiomyoma best fits the overall presentation of this case. Typically, the diagnosis can be confirmed by imaging and pathology. If there is still uncertainty, a biopsy or intraoperative frozen section can be performed for definitive confirmation.
Treatment Strategy:
1) Surgical Resection: Angioleiomyoma is a benign tumor, and a standard marginal excision is typically sufficient, with a very low recurrence rate.
2) Postoperative Follow-Up: Regular follow-up and imaging evaluations are recommended to monitor for any signs of regrowth.
Rehabilitation and Exercise Prescription:
1) Early Postoperative Stage: Protective immobilization is recommended to avoid vigorous hand activities. Use of protective gear during mild activities is advised to prevent excessive strain on the palm that could cause pain or wound dehiscence. Gradually perform gentle hand movements such as making a fist and extension to maintain joint flexibility.
2) Intermediate Rehabilitation (2–4 weeks post-surgery): Once the wound has stabilized and healed, gradually increase both active and passive range-of-motion training for the hand and wrist, such as grip exercises and finger dexterity exercises. Intensity and frequency are increased gradually, approximately 10–15 minutes per session, 2–3 times a day.
3) Late Rehabilitation (4–8 weeks post-surgery): Progress to moderately higher-load gripping and resistance exercises (e.g., using a soft grip ball or resistance band), gradually increasing exercise load and frequency. If significant swelling or pain arises, promptly adjust the intensity.
4) Individualized Management: For patients with other comorbidities (e.g., cardiovascular or metabolic conditions), further evaluation of cardiopulmonary endurance and wound healing is necessary. Reduce exercise intensity and frequency accordingly to ensure safety.
5) FITT-VP Principle: Adjust frequency, intensity, time, type, volume, and progression in an orderly manner to set individualized goals and gradually improve function.
Disclaimer: This report is for reference purposes only and does not replace in-person consultation or professional medical advice. If you have further questions, please seek medical care promptly and follow your specialist’s guidance.
Angioleyomioma
