Case notes

An asymptomatic 61 year old woman was referred for evaluation of a suspected inguinal hernia. She had a voluminous indolent pubic mass that had developed over several years ( Figure , A). Investigation with 64-slice multidetector-row computed tomography (CT) demonstrated a peripherally hypervascularized mass, 16 cm in maximum diameter, supplied by the left pudendal artery and the left anterior obturator artery, which arose, in this patient, from the left inferior epigastric artery; these arteries shunted into multiple veins that drained into the pudendal vein ( Figure , B and C; Video Clip ). Preoperative digital subtraction angiography confirmed the feeding arteries and enabled presurgical embolization with Spongostan, a hemostatic agent, and coils ( Figure , D). Surgery ensued 48 hours later. FLOAT NOT FOUND FLOAT NOT FOUND

A, The patient had a voluminous mass in the left groin region. B, Arterial phase 64 slice MDCT showed the mass and the peripheral arterial vessels. C, Volume-rendering MDCT reconstruction demonstrated vascularization of the mass with a dilated left obturator artery ( arrow ); veins drained into the left femoral vein. D, Digital subtraction angiography with right retrograde transfemoral access and selective catheterization of the left external iliac artery confirmed rich vascularization of the lesion. E, The mass contained dilated vessels and stromal tissue. F, Spindle-shaped to stellate cells, a myxoid matrix, and blood vessels with thickened hyalinized walls were evident on histologic examination; the slide in the insert identified diffuse strong positivity for CD34, vimentin, and desmin.

MDCT, multidetector-row computed tomography.

Rebonato. Painless but problematic. Am J Obstet Gynecol 2013.

Conclusions

An immunohistochemical analysis of the surgical specimen led to a diagnosis of cellular angiofibroma (CAF) ( Figure , E). The mass, consisting of spindle-shaped to stellate cells in an abundant myxoid matrix, was nourished by an erratic network of medium- and large-sized blood vessels with thickened hyalinized walls ( Figure , F). Benign tumors of the vulva are classified, according to their origin, as epithelial or mesenchymal cell tumors. CAF is an uncommon benign mesenchymal tumor that mainly occurs in the genital region, although extragenital locations have also been noted. Atypical features and sarcomatous transformation of CAF have been reported as well.

Clinical presentation can mimic other genital tract neoplasms, including malignancy, or as in this patient’s case, inguinal hernia. A definite diagnosis is often made after surgical excision and biopsy. Preoperative embolization combined with surgery is safe and may be curative in patients with voluminous vascularized masses. Doppler ultrasonography, multidetector-row CT, and magnetic resonance imaging can aid in making the differential diagnosis and evaluating the size of the lesion and its vascularization.

After a 1 week hospitalization, our patient was discharged in good condition without postsurgical complications. At follow-up 1 year later, she was asymptomatic and had no evidence of recurrence.