Surgical Treatment of Intramuscular Myxoma

Abstract

Purpose: Intramuscular myxoma (IM) is a rare benign myxoid tumor that may be challenging to differentiate from sarcoma in small amounts of biopsied material. Although IM appears to be well-circumscribed macroscopically, it infiltrates the adjacent edematous muscle microscopically. The recommended treatment is resection, but there is controversy with regard to the appropriate surgical margin. This study aimed to clarify which surgical procedure that should be applied when the preoperative diagnosis is IM and how to manage treatment if the postoperative diagnosis turns out to be a sarcoma.

Methods: We retrospectively examined 55 IM patients treated from January 1982 to December 2014. Patient characteristics, tumor location, tumor size, radiograph, preoperative and postoperative pathological reports, surgical techniques, treatment outcome, and complications were reviewed. The patients were followed up on for at least 5 years. All patients were confirmed not to have Mazabraud syndrome.

Results: In the 55 IM patients examined, the mean patient age was 48 years and most were female. The most common tumor locations were in the muscles of the thighs (47%) and buttocks (20%). The mean tumor diameter was 5 cm. Wide resection and marginal resection were performed in 24 and 31 patients, respectively. The mean follow-up duration was 19 years. No local recurrence, malignant transformation, or complications were observed.

Conclusions: Marginal resection is suitable in patients whose preoperative diagnosis is IM, as it is able to prevent local recurrence and allows for the preservation of muscle and muscle fascia. If the postoperative diagnosis turns out to be myxoid sarcoma, minimum surgical contamination makes additional wide resection less invasive.

Keywords: Inadvertent resection; Intramuscular myxoma; Marginal resection; Wide resection.

Fig. 1

Surgical technique of wide and marginal resection. a Wide resection is defined as the removal of tumor along with at least 1 cm of normal tissue. b Marginal resection is a surgical plane that runs through the reactive zone which only the core part is resected while preserving surrounding tissue included muscle and muscle fascia

Fig. 2

An intramuscular myxoma at vastus intermedius muscle. a, b Homogeneous hypointense mass with fat at the inferior pole and rim (arrows) in coronal-T1-w. c Inhomogeneous hyperintense and peripheral edema (arrows) in coronal-T2-FS. d Mild enhancement (arrow) in coronal-T1-FS-Gado. e–g Mass at axial-T1-w, T2-w, and T1-FS-Gado (arrow). h Grey-white mucoid mass with peripheral edema (arrows)

Fig. 3

A 60-year-old male patient. a Homogeneous hypointense mass at adductor magnus muscle (arrow) in coronal-T1-w. b Inhomogeneous hyperintense (arrow) with septation (arrowhead) and cystic area (asterisk) in coronal-T2-FS. c Mild heterogeneous enhancement (arrow) in coronal-T1-FS-Gado. d, e Mass attaches to the bone and vascular structures (arrows) in axial-T2-w and T1-FS-Gado

Fig. 4

Intra-operative appearance of a mass located in the adductor magnus muscle. a–c Mass at adductor magnus muscle, marginal resection, and preserved muscle fascia (arrow). d Pale yellow-white appearance (arrow) and bilocular cystic area (arrowheads). e Microscopic findings, spindle cells with normochromic nuclei in a myxoid stroma background (papanicolaou stain of cytology smear)