PMC3625550_01
Preoperative clinical images. Mass in the right buttock and lumbar region.
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Upon arriving at our center, physical examination revealed a large, firm, amorphous, fluctuant, soft tissue mass measuring 60 x 50 x 30 cm. that originated from the lumbar region and extended to the gluteal fold and overhanging from the posterior aspect of her thigh (Figure 1). 
Preoperative MRI images. MRI was technically difficult due to the dimensions of the tumor.
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T2-weighted images, and several fluid collections were identified (Figure 2). The images demonstrated multiple serpiginous flow voids in keeping with prominent vasculature. The mass did not infiltrate the underlying gluteal musculature.
The hypervascularization of the tumor is confirmed by the arterial feed from the ipsilateral intercostal and lumbar arteries (a), ipsilateral gluteal arteries (b), and branches from the contralateral internal iliac artery (c).
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The diagnostic angiogram confirmed the presence of multiple vessels supplying the tumor (Figure 3). Branches of the right profunda femoris and the left internal iliac arteries (Figure 3(c)) were also visualized.
Selective catheterization is performed to do a selective embolization with polyvinyl alcohol particles and also with microcoils in some branches. (a) Lumbar artery. (b) Gluteal artery.
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The feeding vessels identified were the right intercostal and lumbar arteries (Figure 4), the right superior and inferior gluteal arteries, and the right circumflex iliac artery.
Final angiogram (postembolization). (a) Abdominal aortogram. (b) Left internal iliac artery.
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The final angiogram showed almost complete devascularization of the tumor (Figure 5).
Preoperative clinical images. Large areas of skin necrosis after embolization.
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Twenty-four hours after the second intravascular embolization, the patient was transferred to the operating room for surgical resection (Figure 6).
Intraoperative clinical images. (a) The use of the Endo GIA. (b) Tumoral excision. (c) Local skin flap.
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To reduce intraoperative bleeding, we decided to use the system Stapling Endo (Endo GIA) (Figure 7(a)). The huge pedunculated gluteal mass was removed completely (Figure 7(b)). Local skin flaps were extensively mobilized and primary closure obtained (Figure 7(c)).
Gross pathology images. Diffuse presence of a myxoid-like white tan tissue, infiltrating into the surrounding fat.
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The specimen weighed 16,700 gr. and measured 60 x 45 x 27 cm (Figure 8).
Tumor histology. Plexiform neurofibroma with no evidence of malignancy.
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Histological examination revealed a plexiform neurofibroma with no evidence of malignancy (Figure 9).
Postoperative (6-month followup) clinical images.
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TX, USA) was placed with 150 mmHg continuous suction and the patient responded well. The surgical wound healed and the patient was discharged after a total of 5 weeks and was followedup in clinic with physical examination and serial local MRI every 3 months (Figure 10).
Postoperative MRI images (2-year followup). Not recurrence or tumor progression.
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Local MRIs have not revealed recurrence or tumor progression (Figure 11).