|Year : 2017 | Volume
| Issue : 2 | Page : 46-49
Giant lipomas. A report of two cases
CD Emegoakor1, CN Echezona1, ME Onwukamuche2, HO Nzeakor1
1 Department of Surgery, Eldorado Multispecialist Hospital, Awka, Nigeria
2 Department of Pathology, Eldorado Multispecialist Hospital, Awka, Nigeria
|Date of Web Publication||6-Sep-2017|
C D Emegoakor
Department of Surgery, Eldorado Multispecialist Hospital, Awka
Source of Support: None, Conflict of Interest: None
Lipomas can be found in any region of the body and are the most common benign tumors of the adipose tissue. Giant lipomas have been reported to be any lipoma more than 10 cm in size along its widest diameter or more than 10 g in weight. Here we present two case reports of otherwise healthy patients who presented with unusually large tumors at different points in the same facility. Hence, it was needed to report our findings: A 27-year-old man with a 3-year history of a huge right gluteal swelling; A 56-year-old man with a 30-year history of a right lower limb mass. Physical examination and relevant radiological investigations were conducted to characterize and ascertain the extent of the two masses. They were excised surgically and underwent histology to confirm diagnosis. Despite the availability of improved health services, giant lipomas still exist.
Keywords: Giant lipoma, liposarcoma, mesenchymal tumours
|How to cite this article:|
Emegoakor C D, Echezona C N, Onwukamuche M E, Nzeakor H O. Giant lipomas. A report of two cases. Niger J Gen Pract 2017;15:46-9
|How to cite this URL:|
Emegoakor C D, Echezona C N, Onwukamuche M E, Nzeakor H O. Giant lipomas. A report of two cases. Niger J Gen Pract [serial online] 2017 [cited 2019 Aug 23];15:46-9. Available from: http://www.njgp.org/text.asp?2017/15/2/46/214113
| Introduction|| |
Lipomas are among the most common mesenchymal tumors in humans occurring more frequently in adults aged between 40 and 60 years. They could be found in almost all organs of the body in which fat exists, hence, the term “ubiquitous or universal tumor.”
Most lipomas are typically small, slow growing tumors weighing only a few grams, not painful to touch, and do not evolve into malignant tumors.
Serpell JW et al. defined the giant lipomas lesions that are over 10 cm in maximum diameter or weigh over 1000 g.
Lipomas may be solitary or multiple. Solitary lipomas occurring in equal frequency among males and females with a female preponderance for multiple lipomas.,
Murphey et al. found that the majority of lipomas were located in the trunk, followed by the head and neck region, and lower extremities, whereas Munk et al. noted a prevalence of lipomas in the upper back, neck, proximal extremities (especially the shoulder), and abdomen.
Lipomas may either be superficial or deep. The former being more common and further classified as encapsulated or nonencapsulated. The deep lipomas are usually larger, displace surrounding tissues, and are either interosseous, visceral, intermuscular, or intramuscular.
Most lipomas remain asymptomatic, especially deep lipomas, and thus may attain considerable sizes. Depending on anatomic location, lipomas may hinder movement, get inflamed, cause lymphedema, pain, and compression syndrome.
| Case Presentation|| |
Case 1: A 27-year-old male who presented with a 3-year history of a right gluteal swelling, which was initially slow growing but had shown a sustained and progressive increase in size in the preceding 6 months before presentation.
There was a associated history of a fall on the same side in a motorbike road traffic accident about a year before the onset of the swelling.
A month prior to presentation, the apex of the mass started darkening and subsequently ulcerated. There was no history of pain, no affectation of gait, no history of similar lesions, nor a family history. However, the presence of the huge mass constituted a nuisance to him, and he wanted it removed.
Physical examination revealed a firm mass on the right gluteal region, nontender, measuring about 20 × 14 cm, with a hyperpigmented and ulcerated apex which was attached to skin at this apex, but not at its base [Figure 1].
Laboratory investigations and lipid profile were normal. Radiographs to determine the extent of the lesion revealed no osseous changes or bony involvement. An ultrasound done revealed an oval echogenic mass with lipoma-like features.
A preoperative provisional diagnosis of a liposarcoma to rule out lipoma was made.
Wide excision of the mass under regional anesthesia was done. [Figure 2] is the excised lipoma. Wound closure was done secondarily and postoperative recovery was uneventful.
Case 2: A 56-year-old male with a 30-year history of a slow growing right lower limb mass.
There was no history of similar masses, no history of underlying systemic disease, no specific predisposing factors, and no family history of similar lesions. He had no gait abnormalities or pain, and no history of rapid increase in size of the mass.
Physical examination revealed a 22 × 17-cm mass on the anterolateral aspect of his right thigh with distinct edge and mildly thickened skin over its apex. The mass was not attached to the skin or underlying muscles. It was also lobulated, firm to touch with a smooth surface [Figure 3].
Laboratory investigation and radiological findings were unremarkable. Surgical excision was done, and the mass measured 25 × 16 cm. No infections, hematomas, or neurological complications were detected postoperatively. [Figure 4] shows the wound after excision.
The two samples were histologically analyzed and definitive diagnoses of lipoma made.
| Discussion|| |
Lipomas are the most common benign tumors of the adipose tissue. They are well-differentiated neoplasms, consisting of adult adipocytes surrounded by a fibrous capsule.
They are believed to arise from mesenchymal primordial fatty tissue and are thus, not of adult fat cell origin.
They tend to increase in size with increasing weight, but weight loss does not decrease their size. Thus, it appears they are not available for metabolism even in starvation.
Giant lipomas have been reported in literature as measuring up to 10 cm and weighting up to 1000 g. The largest lipoma recorded in English literature was reported in 1894 weighing 22.7 kg [Table 1].
|Table 1: Recorded cases of Giant Lipomas and their locations in the body|
Click here to view
The two cases in this report weighed, 6850 and 5100 g.
The exact etiology of lipomas is unknown.
Subcutaneous lipomas are associated with hypercholesterolemia, obesity, trauma, familial tendency, and chromosomal abnormalities.
Trauma appears to be an important etiologic factor in the pathogenesis of lipomas.
It has been proposed that rupture of the fibrous septa after trauma alongside tears of the anchorage may result in proliferation of adipose tissue.
It has also been presumed that local inflammation secondary to trauma may induce differentiation of preadipocytes and disrupt the normal regulation of adipose tissue.,
We did not detect hypercholesterolemia, but there was history of trauma in one of the cases. None of our patients were obese.
Giant lipomas are primarily a cosmetic problem.
Their size and weight may cause limitations in movement and demonstrate signs of compression of adjacent structures. A lipoma adjoining the motor nerve of an extremity may cause neuromuscular dysfunction.,
In our index cases, there was no compression syndrome, varying degrees of functional limitation such as discomfort and ugly sight constituted a major esthetic burden.
The main challenge in the diagnosis of a giant lipoma is the possibility of it being a liposarcoma.
This is further complicated by the fact that lipomas share certain similarities with well-differentiated liposarcomas. They present as palpable bulks with a variable consistency and are generally not painful.
Clinical criteria that would make a liposarcoma more likely include a size more than 5 cm, deep to deep fascia, irregularity, pain, and thickened septa. The intermuscular location of a lipoma is also a risk factor for malignancy. However, the transformation of a large lipoma to a liposarcoma is rare.
Diagnostic imaging plays an important role in assessing soft tissue masses. Radiographs may reveal osseous changes, and cartilaginous or osseous matrix within the masses. Ultrasonography is usually the first diagnostic procedure due to its low cost and availability. Ultrasonography of the index cases showed them to likely be lipomatous growths.
Kransdorf et al. noted that distinguishing between a well-differentiated liposarcoma and lipoma is challenging. (MRI) Magnetic Resonance Imaging and Computerized Tomography (CT) depict well-differentiated liposarcomas as having thickened septae (>2-mm thick) and nodular or global areas of nonadipose tissue within the lesion.
Immunostaining is scarcely helpful for the diagnosis of liposarcoma. The FISH is a fundamental tool for the diagnosis of liposarcoma due to the amplification of MDM-2 and CDK4 genes located in the chromosomes. These genes are not amplifies in lipomas or a majority of soft tissue sarcomas.
Final diagnosis rests on histopathologic evaluation. The presence of lipoblast or atypical adiopocytes would raise the concern for liposarcoma. Some reports have suggested that large tumors (>10 cm) are more likely to contain sarcomas, making a preoperative biopsy advisable in such cases.
Dercum's disease or adiposis dolorosa is a rare condition of unknown etiology characterized by multiple, often painful, lipomas and is seen more in obese women. Its diagnosis is often delayed and rests on ultrasound, and above all magnetic resonance imaging.
Ultrasound depicts a markedly hyperechoic mass, whereas MRI shows nodular increased fluid signals (bluish-like appearance of subcutaneous fat) with no evidence of edema or inflammation. Although this conditionis rare, one of the patients had a history of pain and associated obesity, but only a solitary mass.
An even rarer condition, Madelung's disease is seen more commonly in adult alcoholic males. It is characterized by an unusual massive accumulation of fat deposits located symmetrically around the shoulders, neck, upper arms, and trunk.
However, there was no reason to suspect these conditions among our patients as none satisfied the criteria.
Surgical excision was employed in our two index cases as it enabled removal of the entire mass relieving these patients of the cosmetic burden.
However, lipomas can possibly be removed by liposuction.,
This has the advantage of leaving very small scars.
Certain drawbacks remain though, because liposuction is limited by tissue density, localization of the lesion, and the impossibility of accurately removing the fibrous capsule, thus predisposing the patient to recurrences.
Further nonnegligible complications include nerve damage, hematomas, and blood-vessel rupture.
Conversely, surgical excision enables removal of the fibrous capsule and further histologic evaluation.
| Conclusion|| |
We have thus presented three cases of unusually large lipomas. In resource-limited countries where delay in presentation is the rule, these lesions may attain huge sizes but may still simply be lipomas.
Financial support and sponsorship
Conflict of interest
There are no conflict of interest.
| References|| |
Hakim E, Kolander Y, Meller Y, Moses M, Sagi A. Gigantic lipomas. Plast Reconstr Surg 1994;94:369-71.
Delvis CJ, Gruhn JG. Giant lipoma of the thigh. Arch Surg 1967;95:151.
Okay G, Serhat M, Mahir M. Giant lipoma of the back affecting quality of life. Ann Med Surg (Lond) 2015;4:279-82.
Sanchez MR, Colomb FM, Moy JA. Giant lipoma: Case report and review of Literature. J Am Acad Dermatol 1993;28:266-8.
Serpell JW, Chen RY. Review of large, deep lipomatous tumors. ANZ J Surg 2007;77:524-9.
Nigri G, Dente M, Valabrega S, Beccaria G, Aurelio PD, Angelo F, et al.
Giant inframuscular lipoma disclosed l4 years after a blunt trauma: A case report. J Med Case Rep 2008;2:318.
Kransdorf MJ. Benign Soft-Tissue Tumors In A Large Referral Population: Diagnoses By Age, Sex And Location; AJR AM J Roentgenol 1995;164:395-402.
Murphy MD, Carrol JF, Fleming OJ, Pope TL, Gannon FH, Kransdorf MJ. From the archives of the AFIP: Benign musculoskeletal lipomatous lesions. Radigraphics 2004;24:1433-66.
Munk PL, Lee MJ, Janzea DL, Connel DG, Logan PM, Poon PY, et al.
Lipoma and liposarcoma: Evaluation using CT and MRI imaging. ASM Am J Roentgenol 1997;169:589-94.
Roberts CC, Liu PT, Colby TV. Encapsulated versus non – Encapsulated superficial fatty masses; a proposed MR imaging classification. AJM Am J Roentgenol 2003;180:1419-22.
Di B, Enedetto G, Aquinati A, Astolffi M, Bertani A. Giant compressing lipoma of the thigh. Plast Reconstr Surg 2004;114:1983-5.
Kshirsagar AY, Nangare NR, Gupta V, Vekeriya MA, Patankar R, Mahna A, et al.
Multiplegiant intra abdominal lipomas: A rare presentation. Int J Surg Case Rep 2014;5:399-402.
Terzioglu A, Thncali D, Yuksel A, Bingul F, Aslan G. Giant lipomas: A series of 12 consecutive cases and a giant liposarcoma of the thigh. Dermatol Surg 2004;30:463-67.
Brandler T. Large fibrolipoma. Br Med J 1894;1:574.
Martin HS. Massive lipoma of the subcutaneous tissue of the back: Report of case. JAMA 1928;90:2013-15.
Bissel AH. Large lipoma of the back. Am J Sug 1929;6:366-7.
Silistreli OK, Durmus EU, Ulsal BG, Ozatan Y, Gorgu M. What should be the treatment modality in giant cutaneous lipomas? Review of the literature and report of 4 cases. Br J Plast Surg 2005;58:394-8.
Ilhan H, Tokar B, Işiksoy S, Koku N, Pasaoglu O. Giant mesenteric lipoma. J Pediatr Surg 1999;34:639-40.
Copcu E, Sivrioglu NS. Post traumatic lipoma, analysis of 10 cases and explanation of possible mechanism. Dermatol Surg 2003;29:215-20.
Meggit BF, Wilson JN. The battered buttock syndrome – Fat fractures – A report on a group of traumatic lipomata. Br J Surg 1972;59:165-9.
Nakamura Y, Teramoto Y, Sato S, Yamada K, Fujisada Y, Fujimoto M, et al.
Axillary giant lipoma: A report of 2 cases and published work review. J Dermatol 2014;41:841-4.
Singh M, Saxena A, Kumar L, Karande SK, Koihe Y. Giant lipoma of the posterior cervical region. Case Rep Surg 2014;2014:2.
Eryilmaz M, Yigit T, Ozturk G, Safali M, Aksu AY. Giant spindle cell lipoma of the posterior neck. Dermatol Surg 2007;33:1258-61.
Guerrissi J, Klersfeld D, Sampietro G, Valdivieso J. Limitation of thigh function by a giant lipoma. Plast Reconstr Surg 1994;94:410-1.
Ferraro GA, Salzillo R, De Francesco F, D'Andrea F, Nicoletti G. Approach and management of a giant lipoma in the left lumbar region. Int J Surg Case Rep 2015;14:189-93.
Jones AP, Learis CJ, Didley P, Hide G, Rogbiv M. Lipoma or liposarcoma? A cautionary case report. J Plast Reconstr Aesthet Surg 2012;65:11-4.
Rydholm A, Berg NO. Size, site and clinical incidence of lipoma. Factors in the differential diagnosis of lipoma and sarcoma. Acta Orthop Scand 1983;54:929-34.
Knapp EL, Kransdorf MJ, Letson GD. Diagnostic imaging update: Soft tissue sarcoma. Cancer Control 2005;12:22-6.
Lin J, Jacobson JA, Fessel DP, Weadock WJ, Hayes CW. An illustrated tutorial of musculoskeletal sonography. Am J Roentgenol 2000;175:1711-9.
Kransdorf MJ, Bancroft LW, Peterson JJ, Murphy Foster WC, Temple HT. Imaging of fatty tumors: Distinction of lipoma and well differentiated liposarcoma. Radiology 2002;224:99-104.
Binh MB, Sastre-Garau X, Guillou L, Coindre JM, De Pinieux G, Terrier P, et al.
MDM2 and CDK4 immunostaining are useful adjuncts in diagnosing well differentiated liposarcoma subtypes, a comparative analysis of 559 soft tissue neoplasms with genetic data. Am J Surg Pathol 2005;29:1340-7.
Bouchrea A, Fabienne L, Benhamon CL. Dercum's disease: A new case report. Joint Bone Spine 2004;71:147-9.
Tins BJ, Mathews C, Tyrell PNM. Adiposin Dolorosa (Dercum's disease) MRI and U/S/S appearances. Clin Radiol 2013;68:36-8.
Lee HW, Kim TH, Cho JW, Ryu BY, Kim HK, Choi CS. Multiple symmetric lipomatosis: Korean experience. Dermatol Surg 2003;29:235-40.
Nichter LS, Gupta BR. Liposuction of giant lipoma. Ann Plast Surg 1990;24:362-5.
Rubenstein R, Roenigk H Jr, Garden JM, Goldberg NS, Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol 1985;11:1070-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]