- Case report
- Open Access
- Open Peer Review
Intra-articular angiolipoma of the knee: a case report
© Nishimori et al; licensee BioMed Central Ltd. 2010
- Received: 27 December 2009
- Accepted: 13 April 2010
- Published: 13 April 2010
We report a case of intra-articular angiolipoma of the knee. This case report describes our experience in excising an intra-articular angiolipoma of the knee joint. Complete resection under arthroscopy was performed in a 30-year-old man. Two years after the surgery, no evidence of recurrence was seen. Intra-articular angiolipomas should be considered in the differential diagnosis of intra-articular masses in adolescents with recurrent hemarthrosis without trauma.
- Posterior Cruciate Ligament
- Posterior Cruciate Ligament Reconstruction
Angiolipomas are uncommon benign soft-tissue tumors that typically arise in the subcutaneous tissues of young patients . The forearm is decidedly the most common location, with almost two thirds of all angiolipomas found here . A recent review of the literature revealed several reports of these tumors occurring in locations other than subcutaneous regions [3–5].
Intra-articular angiolipoma of the knee is a very rare cause of knee pain, hemarthrosis and dysfunction. To our knowledge, there has been no reported case of intra-articular angiolipoma of the knee in English. We report on this exceedingly rare case and review the previous angiolipoma reports.
After arthroscopic excision, the patient remained asymptomatic at the 24-month follow-up, and repeat MRI scans of the knee showed no evidence of recurrence.
Angiolipomas were first reported by Bowen in 1912 , and in 1960 Howard et al.  were the first to establish angiolipomas as a new entity by reporting 248 cases. Angiolipomas are considered to be vascular lipomas, and they account for 5% to 17% of all lipomas [1, 7]. To the best of our knowledge, this is the first case report in English on intra-articular angiolipomas of the knee. Gonzalez-Crussi et al.  proposed classifying angiolipomas into infiltrating and non-infiltrating types, but lesions described as being deep infiltrating angiolipomas have now been recognized by the WHO as being intramuscular hemangiomas .
The etiology of angiolipomas remains unclear, and the relationship between lipomas, angiolipomas, angiomyolipomas and haemangiomas needs to be further elucidated. Most authors accept that these different lesions may arise from the abnormal development of a primitive pluripotential mesenchymal cell from which adipose tissue, smooth muscle and vascular endothelium develop .
Histologically, an angiolipoma consists of two predominant tissue elements, adipocytes and interspersed vascular structures. The lesion is always encapsulated by subcutaneous yellow nodules with reddish areas corresponding to vessels. The vessels are small-caliber capillaries and often contain fibrin thrombi. This is a characteristic feature of this lesion, with surrounding mature fat [2, 10]. For differential diagnoses, the distinction in part depends on the density of the vessels. In the case of a hypo vascular lesion, it may be difficult to distinguish it from a lipoma, but the existence of fibrin thrombi may help with this distinction. In the case of a hyper vascular lesion, one possible differential diagnosis is a hemangioma. It might be difficult to distinguish it from a hemangioma, but there is no lipomatous component in a hemangioma, which will help to make the correct diagnosis.
Our patient had recurrent intra-articular hemarthrosis without significant trauma. Clinically, recurrent intra-articular hemorrhage without trauma is defined by a synovial hemangioma, pigmented villonodular synovitis (PVS), idiopathic hemorrhage and hemophilic arthropathy. The differential diagnosis, of synovial hemangioma or localized PVS for intra-articular bleeding could be reached after detecting an intra-articular tumor-like mass on MRI.
Regarding the differential diagnosis of these entities on MRI, the characteristics of synovial hemangioma on MRI are that iso signal intensity contrasted to muscle on T1-weighted images, a strong high signal intensity with low signal intensity septa on T2-weighted images and inhomogeneous enhancement of internal lesions on T1-weighted images with Gd-enhancement [2, 11]. In contrast, the characteristics of PVS on MRI are that an iso-intense or low signal intensity compared with muscle on T1-weighted and T2-weighted images and inhomogeneous enhancement on T1-weighted images with Gd-enhancement [2, 12].
In this case, the tumor exhibited slightly high signal intensity in contrast to muscle with low intensity area on T1-weighted images, a fluctuating high and low signal intensity with low signal septa around the tumor on T2-weighted images and inhomogeneous enhancement on T1-weighted images with Gd-enhancement. From differences of these characteristics on MRI, we might be able to distinguish this case from the other tumors. However, MRI is useful, albeit imperfect, in distinguishing these tumors with accuracy. Therefore, diagnosis could be made arthroscopically and accurately with histopathological evaluation.
Surgical excision is curative, and there is no evidence of malignant transformation . We depicted the mass lesion located posterior to the PCL. As we made a posteromedial portal which we usually use for PCL reconstruction, we could excise the tumor safely under arthroscopy. However, if it is impossible to excise the tumor under arthroscopy, the approach to the tumor must be unequivocally changed, from arthroscopic resection to arthrotomy.
In conclusion, an intra-articular angiolipoma of the knee can be the cause of knee pain and recurrent hemarthrosis. Diagnosis can be made arthroscopically, but histopathological evaluation is more accurate. Excision should be performed either arthroscopically if the tumor is completely visible, or using arthrotomy.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Lin JJ, Lin F: Two entities in angiolipoma. A study of 459 cases of lipoma with review of literature on infiltrating angiolipoma. Cancer. 1974, 34: 720-727. 10.1002/1097-0142(197409)34:3<720::AID-CNCR2820340331>3.0.CO;2-K.View ArticlePubMedGoogle Scholar
- Weiss SW, Goldblum JR: Enzinger and Weiss's soft tissue tumors. 2001, St Louis, Mo: Mosby, 4Google Scholar
- Vilela P, Saraiva P, Goulao A: Intracranial angiolipoma as cause of subarachnoid haemorrhage. Case report and review of the literature. Neuroradiology. 2005, 47: 91-96. 10.1007/s00234-004-1290-3.View ArticlePubMedGoogle Scholar
- Ozer E, Schuller DE: Angiolipoma of the neck. Otolaryngol Head Neck Surg. 2006, 135: 643-644. 10.1016/j.otohns.2005.01.047.View ArticlePubMedGoogle Scholar
- Okuyama T, Yoshida M, Watanabe M, Kinoshita Y, Harada Y: Angiolipoma of the colon diagnosed after endoscopic resection. Gastrointest Endosc. 2002, 55: 748-750. 10.1067/mge.2002.122958.View ArticlePubMedGoogle Scholar
- Bowen JT: Multiple subcutaneous hemangiomas, together with multiple lipomas, occurring in enormous numbers in an otherwise healthy, muscular subject. AmJMedSci. 1912, 144: 189-192.Google Scholar
- Howard WR, Helwig EB: Angiolipoma. Arch Dermatol. 1960, 82: 924-931.View ArticlePubMedGoogle Scholar
- Gonzalez-Crussi F, Enneking WF, Arean VM: Infiltrating angiolipoma. J Bone Joint Surg Am. 1966, 48: 1111-1124.PubMedGoogle Scholar
- Christopher DUK, Mertens F: Adipocytic tumors. WHO Classification of tumors. Pathology and genetics: tumors of soft tissue and bone. 2002, Lyon, France: IARCGoogle Scholar
- Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, Kransdorf MJ: From the archives of the AFIP: benign musculoskeletal lipomatous lesions. Radiographics. 2004, 24: 1433-1466. 10.1148/rg.245045120.View ArticlePubMedGoogle Scholar
- Greenspan A, Azouz EM, Matthews J, Decarie JC: Synovial hemangioma: imaging features in eight histologically proven cases, review of the literature, and differential diagnosis. Skeletal Radiol. 1995, 24: 583-590.PubMedGoogle Scholar
- Hughes TH, Sartoris DJ, Schweitzer ME, Resnick DL: Pigmented villonodular synovitis: MRI characteristics. Skeletal Radiol. 1995, 24: 7-12. 10.1007/BF02425937.View ArticlePubMedGoogle Scholar
- Ochi M, Adachi N, Sumen Y, Uchio Y, Iwasa J: A new guide system for posteromedial portal in arthroscopic knee surgery. Arch Orthop Trauma Surg. 1998, 118: 25-28. 10.1007/s004020050304.View ArticlePubMedGoogle Scholar
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