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Infiltrating angiolipoma of the foot: magnetic resonance imaging features and

review of the literature

Article in Skeletal Radiology · January 2018

DOI: 10.1007/s00256-017-2870-8

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Skeletal Radiology (2018) 47:859–864
https://doi.org/10.1007/s00256-017-2870-8

CASE REPORT

Infiltrating angiolipoma of the foot: magnetic resonance imaging

features and review of the literature
Eui Dong Yeo 1 & Bo Mi Chung 2 & Eun Ju Kim 3 & Wan Tae Kim 2

Received: 8 November 2017 / Revised: 25 December 2017 / Accepted: 27 December 2017 / Published online: 10 January 2018
# ISS 2018

Abstract
Angiolipoma is a benign soft tissue tumor with two subtypes: non-infiltrating and infiltrating. Although histologically benign,
infiltrating angiolipoma can invade surrounding structures. The foot is a very rare location for angiolipoma, with only four cases
reported in the English literature, including one infiltrating type. Here, we report a very rare case of infiltrating angiolipoma of the
foot with magnetic resonance imaging (MRI) and ultrasonography (US) findings. A 7-year-old boy presented with a slowly
growing foot mass. MRI showed an unencapsulated mass involving the third web space extending to the foot dorsum and sole.
The mass was isointense to subcutaneous fat and was mixed with internal T1 low-signal-intensity enhancing areas. On US, we
observed a heterogeneously hypoechoic mass with internal vascularity. Imaging and clinical features of angiolipoma and the
radiologic differential diagnoses of a fat-containing mass in the pediatric foot are reviewed here. When there is an ill-defined foot
mass with a fat component and variable enhancing portions in a child, infiltrating angiolipoma should be included in the
differential diagnosis along with other fat-containing tumors.

Keywords Angiolipoma . Infiltrating angiolipoma . MRI . Foot mass

Introduction ultrasonography (US) findings [5]. Here, we report a very rare

Angiolipoma is a benign soft tissue tumor with two subtypes:
non-infiltrating and infiltrating. Although angiolipomas are a
histologically benign soft tissue tumor, infiltrating-type
angiolipomas are partially or entirely unencapsulated and
can infiltrate the surrounding soft tissues or bones [1]. The
foot is an unusual location for angiolipoma with only four
previously reported cases [2–5]. To our knowledge, there
has been only one case report of infiltrating angiolipoma of
the foot, without magnetic resonance imaging (MRI) or
* Bo Mi Chung
bom1086@naver.com
1
Department of Orthopaedic Surgery, Veterans Health Service
Medical Center, 53, Jinhwangdo-ro 61-gil, Gangdong-gu,
Seoul 05368, Republic of Korea
2
Department of Radiology, Veterans Health Service Medical Center,
53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368, Republic of
Korea
3
Department of Pathology, Veterans Health Service Medical Center,
53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368, Republic of
Korea
case of an infiltrating angiolipoma with demonstration of MRI
and US features in a 7-year-old boy who presented with slow-
ly growing foot mass. We reviewed the imaging and clinical
features of angiolipoma and the radiologic differential diagno-
ses of fat-containing masses in the pediatric foot. When poorly
demarcated soft tissue tumor of foot with macroscopic fat on
MRI is encountered, infiltrating angiolipoma could be consid-
ered preoperatively.
Case report
A 7-year-old boy presented with a mass at the third web space
of the right foot. The mass was movable, soft, and non-painful
on palpation. Reddish and bluish skin discolorations were
seen at the plantar and dorsal aspect. No negative impact on
function or neurologic abnormality was noted. The mass had
been noted at the time of birth and had been growing slowly.
Past medical and family history and general physical exami-
nation were negative.
Radiograph of the foot demonstrated a soft tissue mass at
the third web space with a curly deformity of the fourth toe.
No mineralization or bone destruction was noted (Fig. 1).
860
Fig. 1 Plain radiograph of the foot demonstrated a soft tissue mass
(asterisk) at the third web space with curly deformity of the fourth toe.
No mineralization or bone destruction was noted
MRI revealed a mass involving the third web space and adja-
cent dorsal and plantar aspects of the forefoot at the subcuta-
neous layer, measuring 3.5 cm in the maximal dimension. A
coronal T1-weighted image revealed a fatty mass isointense to
subcutaneous fat, with hypointense tubular, tortuous struc-
tures (Fig. 2a). The fatty component showed signal suppres-
sion on a T2-weighted, fat-suppressed image and showed no
enhancement. The non-fatty component demonstrated slightly
high signal intensity (SI) on a T2-weighted, fat-suppressed
image and showed enhancement on a contrast-enhanced T1-
weighted image with fat suppression (Fig. 2b, c). It was a
poorly demarcated mass, and the boundary between the fatty
component of the mass and subcutaneous fat was not definite.
There was no apparent bone infiltration. On US, the lesion
was a heterogeneous echoic mass with ill-defined margin.
Internal vascularity was seen on color Doppler US (Fig. 3a, b).
During surgery, a 6-cm web space incision was made. After
incision, a lobulated and yellowish lesion was seen mixed
with dark-red structures, which thought to be vessels. The
mass had an ill-defined margin and was not bordered by the
deep intermetatarsal ligament. Partial excision was performed,
preserving neurovascular structures. Microscopically, the
mass was comprised of mature adipose and proliferated vas-
cular tissue without signs of atypia in either of the two com-
ponents. There were capillary proliferations within the adi-
pose tissue, and there were areas of large vessels with blood
pools or thrombi (Fig. 4a–c). The features were considered in
keeping with angiolipoma. No immunohistochemistry analy-
sis or genetic marker study was performed. The entire margin
could not be evaluated because partial excision was
Skeletal Radiol (2018) 47:859–864
performed; however, based on imaging and operative and his-
tologic findings, the final diagnosis was infiltrating
angiolipoma. The patient’s postoperative course was uncom-
plicated, and there was no local recurrence after 6-month fol-
low-up.
Discussion
Angiolipoma is a benign soft tissue tumor that was established
as a distinct entity in 1960 by Howard and Helwig [6]. It is a
well or poorly encapsulated mass and consists of mature adi-
pocytes and varying degrees of angiomatous proliferation.
The presence of fibrinous microthrombi is a distinctive feature
that differentiates this from other lipomas [4, 7]. In 1966,
Gonzlez-Crussi et al. distinguished between non-infiltrating
and infiltrating types [8]. The non-infiltrating type is more
common, and it typically presents as multiple, small
(<2 cm), slowly growing, painful lumps that are rarely asso-
ciated with overlying skin discoloration. These are generally
seen in pubescent patients [7, 9]. The infiltrating type is par-
tially or entirely unencapsulated and can infiltrate surrounding
tissues, leading to muscular pain and neural deficits [6].
Angiolipomas occur most frequently in the forearm,
followed by the trunk and upper extremity [8]. Angiolipoma
of the foot is a very rare entity, and only four case reports have
been published in the English literature (Table 1) [2–5]. Two
out of four previously reported cases were non-infiltrating
type angiolipoma, one case was infiltrating type, and the type
was not specified in one case report. None of the masses
caused functional or neurologic disability, but two of four
patients complained of difficulty in putting on shoes or walk-
ing. Three out of four cases had grown slowly [2–5]. Our
patient had a painless mass that had slowly grown since birth,
which is in accordance with previous reports. Skin change is
reported to be uncommon, but our patient showed skin discol-
oration at the plantar and dorsal aspects of the foot. This was
probably due to the superficial location and predominant vas-
cular component. Due to its tendency for local recurrence, the
preferred treatment for infiltrating angiolipoma is complete
excision. In cases of recurrence or inadequate resection, adju-
vant radiotherapy is considered [3, 10]. However, in cases
where adequate excision would result in compromised func-
tion or morbidity, treatments need to be individualized
[11–13]. In our case, partial excision was performed, preserv-
ing neurovascular structures and tendons. There have been
few reports of infiltrating foot angiolipoma, so it is difficult
to compare treatment choices; however, many authors report-
ed a good prognosis even with subtotal removal of spinal
infiltrating angiolipomas, as these lesions are slowly growing
and do not undergo malignant transformation [11–13].
On MRI, the fatty component of angiolipoma shows high
SI on T1-weighted images and signal suppression on fat-
Skeletal Radiol (2018) 47:859–864 861

Fig. 2 MR coronal images. T1-

weighted (a), fat-suppressed T2-
weighted (b), and fat-suppressed
T1-weighted images with
enhancement (c) show an ill-de-
fined, infiltrative mass
involving the third web space,
foot dorsum, and sole. It is a fatty
mass isointense to subcutaneous
fat (asterisks) with internal T1
hypointense, enhancing tortuous
structures (arrowheads)

Fig. 3 Transverse images in

grayscale (a) and color Doppler
ultrasonography (b). The ill-
defined mass (arrows) was
heterogeneously hypoechoic
compared to subcutaneous fat and
had internal vascularity
862
Fig. 4 a The angiolipoma was comprised of mature adipose and
proliferated vascular tissue without signs of atypia in either of the two
components [hematoxylin and eosin (H&E) low magnification]. b
Capillary proliferations (arrowheads) are interspersed within the adipose
suppressed images. The vascular component shows areas of
low SI on T1-weighted images and high SI on fat-suppressed
T2-weighted images. The ratio of these components varies
and is reflected by MRI features. More vascular components
lead to more prominent T1 hypointense, enhancing regions
seen in the mass [1, 7]. In this case, there was a rich vascular
component microscopically, which corresponded with MRI
findings that showed predominant, tortuous T1 hypointense
areas. On US, angiolipomas are reported as hyperechoic le-
sions compared to muscle, and flow is present in less than
25% of cases [14]. Our case showed an ill-defined mass with
echogenicity slightly higher than that of muscle and lower
than that of subcutaneous fat with internal vascularity, which
was in accordance with the literature.
Soft tissue tumors usually have a nonspecific imaging ap-
pearance, but identification of intralesional macroscopic fat
enables radiologists to narrow the differential diagnosis,
which would be most commonly benign. Fat-containing soft
Skeletal Radiol (2018) 47:859–864
tissue (asterisks) (H&E middle magnification). c Vascular proliferations
were filled with blood pools or thrombi (long arrows) (H&E middle
magnification)
tissue tumors in the pediatric population include adipocytic
tumors (lipoma, angiolipoma, lipoblastoma, liposarcoma),
fibroblastic/myofibroblastic tumors (fibrous hamartoma of in-
fancy, lipofibromatosis), and vascular tumors (involuting
hemangioma) [9, 15–17]. Lipoma is a homogeneous fatty
mass identical to subcutaneous fat with or without a thin,
fibrous capsule or septa with low SI [9]. The substantial pro-
portion of the enhancing area in our case enabled us to rule out
a simple lipoma. Lipoblastoma and, more rarely, liposarcoma
are usually encapsulated masses with enhancing or necrotic
components, in contrast to the non-encapsulated mass in our
case [9, 15]. Fibrous hamartoma of infancy presents as a poor-
ly defined subcutaneous fat-containing mass with a heteroge-
neous SI area of fibro-collagenous tissue and primitive mes-
enchymal cells. An organized pattern of alternating bands is
characteristic, and the most frequent sites are the upper ex-
tremity, upper trunk, and neck. The characteristic MRI pattern
and prevalent sites could be helpful for differentiation [9, 16].
Skeletal Radiol (2018) 47:859–864
Table 1 Summary of published case reports
Case summary Authors
F/12 painless mass at the 1st and Gravante G et al. 2006
2nd toes, recurred and slowly
grew after wide excision
M/47 soft nodular mass at the Theodoros B Grivas et al. 2008 Non-infiltrating type X-ray, CT, MRI Marginal excision Full paper
plantar aspect of forefoot, with
painful gait. Detected 25 years prior
and slowly increased in size
F/33 painless mass at foot dorsum on Tighe C et al. 1994
the 1st and 2nd metatarsals, grew
slowly for 1 year, produced difficulty
putting on shoes
M/51 mass with ulceration distal to the Wertheimer SJ et al. 1992
metatarsal head. Amputation state at
metatarsophalangeal joint level
In our case, the mass was a non-encapsulated, fat-containing
mass in the foot, and the differential diagnoses included
lipofibromatosis and involuting hemangioma.
Lipofibromatosis is a heterogeneous mass with varying com-
position of fat and fibroblastic cells that most frequently oc-
curs at the hands and feet. They present as heterogeneously
hyperintense masses on T1-weighted image with poorly de-
marcated margins. There are T1-low SI septa or small nodules
that show high SI on fat-suppressed T2-weighted images,
though there is never a fluid signal. Enhancement is variable
depending on the proportion of fibroblasts [9, 17]. The en-
hancing portion of our case was linear or tubular, favoring a
vascular component rather than fibroblasts. Involuting hem-
angiomas are ill-defined fatty masses that are often indistin-
guishable from adjacent subcutaneous fat, with varying
amounts of vascular components. The differential diagnosis
with imaging features is difficult. In addition, there is contro-
versy about the entity of infiltrating angiolipomas and heman-
giomas with fatty overgrowth. Gonzlez-Crussi et al. classified
unencapsulated lipomatous lesions with a vascular component
in the skeletal muscles and deep soft tissue as infiltrating
angiolipomas [8]. However, Enzinger and Weiss state that
many of the so-called infiltrating angiolipomas reported in
the literature might have been intramuscular hemangiomas
with fatty overgrowth [1]. Some authors think that there is a
continuum between the intramuscular hemangioma and the
infiltrating lipoma, with the infiltrating angiolipoma
representing an intermediate stage between the two [18].
However, the characteristic clinical features of the phasic
and evolusive pattern can help. These lesions become appar-
ent in the first few weeks or months of life, rapidly grow until
about 1 year of age, and then slowly involute over the next
several years [9]. The mass grew slowly in our case, which is
not the typical clinical course of an involuting hemangioma.
Microscopically, there were capillary proliferations inter-
spersed in the adipose tissue component and encapsulated
863
Type Modality Treatment
Not specified X-ray, MRI Wide excision Letter to editor
Non-infiltrating type X-ray Marginal excision Full paper
Infiltrating type X-ray Wide excision Full paper
areas containing both adipose tissue and a vascular compo-
nent, which is consistent with angiolipoma.
Immunohistochemically, endothelial cells in angiolipomas
are positive for endothelial markers (CD34, CD31). Some
authors observed an increased number of mast cells and the
presence of cytokines produced by mast cells including vas-
cular endothelial growth factor (VEGF) in immunostaining
and suggested that it might be responsible for vascular prolif-
eration in angiolipoma [19, 20].
Infiltrating angiolipoma is a rare soft tissue tumor in the
foot, with few previously reported cases. When there is an ill-
defined foot mass with a fat component and variable enhanc-
ing portions in a child, infiltrating angiolipoma should be in-
cluded in the differential diagnosis along with other fat-
containing tumors. Despite the ill-defined margin of the mass,
detection of macroscopic fat on MRI can help narrow the
differential diagnosis, suggest benign nature preoperatively,
and prevent aggressive and potentially disfiguring wide
resection.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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