2/27/2017 Giantlipomasoftheupperextremity

CanJPlastSurg.2007Autumn15(3):141144. PMCID:PMC2687496

Language:English|French

Giantlipomasoftheupperextremity
BrianAllen,MD, 1,2ChristineRader,MD, 1,2andAlanBabigian,MD1
1
HartfordHospital,Hartford,Connecticut,USA
2
UniversityofConnecticut,Farmington,Connecticut,USA
Correspondence:DrBrianAllen,85SeymourStreet,Hartford,Connecticut06106,USA.Telephone8605487338,fax8605242654,email
BrAllen@resident.uchc.edu

Copyright2007,PulsusGroupInc.Allrightsreserved

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto: Goto:

Lipomasareslowgrowingsofttissuetumoursthatrarelyreachasizelargerthan2cm.Lesionslargerthan5cm,
socalledgiantlipomas,canoccuranywhereinthebodybutareseldomfoundintheupperextremities.Theauthors
presenttheirexperienceswitheightpatientshavinggiantlipomasoftheupperextremity.Inaddition,areviewof
theliterature,andadiscussionoftheappropriateevaluationandmanagementareincluded.

Keywords:Giantlipoma,Liposarcoma,Upperextremity

Lipomasarethemostcommonmesenchymaltumour.Theyarebelievedtoarisefromprimordialadipocytes,not
fromadultfatcells,thereforeincreasinginsizeasapatientaccumulatesadiposetissuebutnotdecreasingwith
weightloss.Theyusuallydevelopaswellcircumscribed,encapsulatedmassesthathaveadoughyfeelandare
freelymobilebeneaththeskin.Lipomascanoccurinmanylocations,butoccurmostcommonlyinthe
subcutaneoustissueofthehead,neck,shouldersandback.Theycanalsobefoundintermuscularly,
intramuscularly,interosseously,associatedwithvisceraoratasiteofpriortrauma.Subtypesincludeconventional
lipomas,fibrolipomas,angiolipomas,spindlecelllipomas,myelolipomasandpleomorphiclipomas.Theirslow,
usuallypainlessgrowthcanleadtoalargesizeatpresentation,especiallywhenlocatedindeepsubfascialplanes.

Cosmeticdeformityorcompressivesymptomsusuallybringlipomatousmassesoftheupperextremitytomedical
attentionearlierthanrapidlygrowingmassesinotherlocationsofthebody.Previousstudieshavedefinedagiant
lipomaoftheupperextremityaslargerthan5cminanyonedimensionatumourofthissizewarrantsaworkup
formalignancy(1).Giantlipomasoftheupperextremityarerare,butwhentheyoccur,anappropriateworkup
mustbedone.Thisshouldbefollowedbyadequateopensurgicalexcisionandrepeatexaminationovertimeto
monitorforrecurrence.

CASEPRESENTATIONS Goto: Goto:

Aseriesofeightconsecutivepatients,fourmaleandfourfemale,whowereevaluatedatHartfordHospital,
Connecticut,USAfrom2003to2007withgiantlipomatousmassesoftheupperextremityispresented.The
patientsrangedinagefrom15to70yearswithameanageof53years(Table1).Thetumoursrangedfrom14cm
12cm2cmto5cm4cm2cminsize.Eachpatientunderwentexcisionofthemasswithprimaryclosure.
Specimensweresenttopathologypostoperatively.Sevenoftheeightpatientshadbenignlipomaspatient5hada
welldifferentiatedliposarcoma.Fourcasesarepresentedhereinmoredetail.

TABLE1
Caseseries

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Patient2
A63yearoldmanpresentedwithamassonhisrightforearm.Thepatientreportedhavingafattytumour
removedfromthesamelocationtwoyearsearlierinPuertoRico.Hehadnoticedrecurrenceofthemass
approximatelyoneyearaftertheinitialsurgery,andmagneticresonanceimaging(MRI)hadrevealedamass
betweenthebrachioradialisandsupinatormusclesoftherightarm,suspiciousforlipoma.Hehadelectedto
observethemassatthattimebutatpresentationreportedthelesiontobelargerthanever,andcomplainedofnew
onsetpainandtendernessinhisrightforearmwithmotioninhiselbow.Physicalexaminationrevealedascarfrom
thepreviousexcisiononthevolaraspectofhisforearm.Amildlytendermasswaspalpatedjustbelowthescar.
Sensationandmotorfunctionwereintactthroughouthisrighthandandforearm.

ArepeatMRItwoyearsaftertheinitialexcisiondemonstratedamasswithhomogeneousfatsignalvolartothe
brachioradialis,andposteriorandradialtothepronatorteresmuscle.Atthistime,thepatientunderwentaradical
excisionofa4cm3cm2cmmasswithprimaryclosure.Finalpathologyrevealedalipoma.

Thepatientlaterreturned,complainingofrecurranceofthemass.Physicalexaminationrevealeda3.5cm3.2cm
mildlytender,wellcircumscribedsubcutaneousmassjustproximaltothemostrecentincision.Whenpalpated,the
patientreportednumbnessandtinglingintheulnardistributionofhisfingers.ArepeatMRIdidnotdemonstrate
recurrenceofthefattylesionhowever,areexisionwasperformedprimarilyforsymptomaticrelief.Radical
excisionofa4cm3cm1cmmasswithprimaryclosurewasachieved.Finalpathologyrevealedarecurrence
ofhislipoma.

Patient4
A15yearoldgirlpresentedwithamassonherleftforearm.Shehadfirstnoticedthelesionfouryearsearlierand
reportedthatithadbeensteadilyenlargingovertheprevioustwomonths.Onexamination,therewasaspongy,ill
definedmasscoveringnearlytheentirevolaraspectofherleftforearm.Therewerenooverlyingskinchanges,and
herleftarmhadintactneurovasculature.

MRIrevealedalarge,wellcircumscribed,homogeneousfattymass.Thelesionwaslocatedintramuscularly,within
andvolartotheextrinsicflexormusclesofthelefthand(Figure1).Therewasnopostgadoliniumenhancementof
thelesion.Aradicalexcisionandprimaryclosurewereperformed(Figure2).Themasswassenttopathology
intraoperativelyandrevealeda14cm12cm2cmlipoma.Postoperatively,thepatientrecoveredwellwithno
functionaldeficits.

Figure1)
Patient4.Preoperativemagneticresonanceimagingshowingalargefatty
massvolartotheflexormusclesofthelefthand

Figure2)
Patient4.Intraoperativeimagesoftheexcision.Finalpathologyrevealeda
14cm12cm2cmlipoma

Patient5
A53yearoldwomanpresented,complainingofrecentspontaneousrapidgrowthofamassinherrightforearm.
Thislesionhadbeenpreviouslybiopsiedbyasurgicaloncologist,revealingalipomawithmyxoidchange.On
physicalexamination,shehadanobviousmassonherrightforearm.Thelesionwaswellcircumscribedand
appearedsomewhatfixedtodeepertissues.Herforearmandhandhadintactneurovasculature,withno
compromiseinmotorfunctionduetothemass.

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MRIrevealedamasswithinthebrachioradialismuscleoftherightarm.Themixedfattyandsofttissuedensityof
themass,alongwiththepostgadoliniumenhancementanddeeplocation,wassuspiciousforliposarcoma(Figure3
).Thepatientunderwentradicalexcisionofa12cm6cm2cmwellencapsulatedmassthatwasadherentto
themuscleonthedorsalaspectofthelesion(Figure4).Primaryclosurewasachieved.Finalpathologyrevealeda
welldifferentiatedliposarcoma.Thepatienthealedwellwithnocomplications.

Figure3)
Patient5.PreoperativeT1andT2weightedmagneticresonanceimage
showingamasswithintherightbrachioradialismuscle

Figure4)
Patient5.Intraoperativeimagesoftheexcision.Finalpathologyrevealeda
12cm6cm2cmwelldifferentiatedliposarcoma

Patient7
A61yearoldmanbeingfollowedforafootwoundreportedthegrowthofamassinhislefttricepsoverthe
previousseveralweeks.Themasswasnontender,andherecallednoantecedenttrauma.Onphysicalexamination,
adeep,wellcircumscribedmasswaspalpatedintheregionofthelefttriceps.Themasswasfreelymovable,with
nooverlyingskinchanges.

MRIrevealedamasswithinthelefttricepsconsistentwithalowgradelipomatouslesion,likelyanintramuscular
lipoma(Figure5).Ofnote,therewasmildfattyatrophyseenwithinthebicepsmuscle,likelyrelatedtoremote
injury.Thepatientunderwentradicalexcisionofthelesion,whichwasfoundtobe10cm6cm3cminsize(
Figure6).Finalpathologyrevealedlipoma.

Figure5)
Patient7.Preoperativemagneticresonanceimageshowingan11cm2.9
cmovalshapedmasslocatedintramuscularlyinthelefttriceps

Figure6)
Patient7.Intraoperativeimagesoftheexcision.Finalpathologyrevealeda
10cm6cm3cmlipoma

DISCUSSION Goto: Goto:

Mostlipomasarebenignandcanoccuraloneorinmultiplelocations.Thereisareport(2)ofanindividualhaving
asmanyas160individuallesions.Lipomascanarisespontaneouslyoraspartofasyndromesuchashereditary
multiplelipomatosis,adiposisdolorosa,GardnerssyndromeandMadelungsdisease(3).Lipomasoccurmore
frequentlyinfemalepatients,presumablyduetotheirtendencytoaccumulatemoreadiposetissuehowever,wedid
notobservethistrendinourseries.

Lipomasusuallygrowataveryslowrate,andtheetiologyofrapidgrowthintogiantlipomasisstillamatterof
debate.Ithasbeensuggestedthatblunttraumacancauseruptureofthefibrousseptaandanchorageconnections
betweentheskinanddeepfascia,allowingtheadiposetissuetoproliferate(4).Althoughthepatient7deniedany
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traumatothearea,therewasevidenceofremoteinjurytotheleftupperextremityonMRI.Thismayhaveledto
theeventualrapidgrowthofanalreadyexistingintramuscularlipoma.

Nomatterthemechanismofrapidgrowth,themainconcernwhenevaluatingagiantlipomaintheupperextremity
istoruleoutmalignancy.Liposarcomasarethemostcommonsofttissuesarcomas,comprising7%to27%ofall
softtissuesarcomas(5).Theytypicallyariseinthefourthtosixthdecadeoflife.Liposarcomasconsistoflipoblasts
andmayoccurwhereverfatispresent,butaremostcommonlyfoundwithinintramuscularfattytissue.Histological
subtypesofliposarcomasincludewelldifferentiated,myxoid,roundcellandpleomorphicliposarcomas.Well
differentiatedliposarcomasexhibitlowmalignantpotential,myxoidliposarcomasdisplayintermediatemalignant
behaviour,androundcellandpleomorphicliposarcomasexhibitaggressivebehaviourwithearlymetastasis.Well
differentiatedliposarcomas,asseeninpatient5,accountforapproximately40%to45%ofliposarcomas(1).Recent
rapidgrowth,sizelargerthan5cmandintramuscularlocationhaveallbeenreportedtoberiskfactorsfor
malignancy(1,5,6).

Properevaluationofalargemassintheupperextremitymustincludeimagingortissuesamplingtoruleout
malignancy.MRIorbiopsyarethetwobestoptionsavailable.Thepossibilityofanincompletelyrepresentative
biopsyleadingtomisdiagnosishasledsometorecommendMRIbeforeattemptingbiopsy.OnMRI,alipoma
appearsasamasswithhomogenousfatsignalintensitysurroundedbyapseudocapsule.Gadoliniumenhanced
MRIhasbeenreportedtoalloweasydistinctionoflipomasfromwelldifferentiatedliposarcomasduetoincreased
levelsofvascularityseeninseptalstructureswithinthelesion(7).Highgradeliposarcomashavelittlefaton
imaging,anddedifferentiatedliposarcomasshowobviouschangesfromalowgradetohighgradetumourwithin
thelesion(8).Ultrasoundorcomputedtomographyguidedbiopsycanthenbeusedtotargetareasofradiological
concern.Ultimately,surgicalexcisionshouldbeperformed,possiblyfollowedbyradiationandchemotherapy.Ifa
lipomaisincompletelyexcised,itmayrecur,aswasseeninpatient2,whohadhadalipomaremovedfromthe
samelocationtwoyearspreviously.Liposarcomasarenotoriousforlocalrecurrence,andevenwithattemptedtotal
resection,localrecurrenceratesmaybeashighas50%(1).

Suctionassistedlipectomyhasbeensuggestedasatreatmentoptionforgiantlipomas,buttheneedforcomplete
removaltopreventrecurrence,alongwiththeinabilitytopredictwherenervesandothervitalstructureshavebeen
displaced,rendersthismodeoftreatmentlessattractive.

Thepropermanagementofgiantlipomasisopenexcision.Lipomasareusuallywellencapsulated,allowing
relativelystraightforwardcompleteremoval.Intramuscularlocationmakesremovalmoretechnicallychallenging
andmayrequireremovalofsomesurroundingmuscletoensureadequatemargins.Finally,afullpathologyreport
onthespecimenisrequiredtodeterminethepossibleneedforfurthertreatment.

CONCLUSIONS Goto: Goto:

Alllipomasintheupperextremitiesmeasuringlargerthan5cminasingledimensionshouldbesurgicallyremoved
duetomalignantpotential.Preoperatively,imagingisimportanttodelineatetheextentofthelesionandtoassistin
operativeplanning.WerecommendMRIforitsabilitytodiscerntissueplanes.Surgicalremovaloflipomasmay
requiresignificantdissectionandmobilizationofneurovascularstructuresforsuccessfulresection,andpreoperative
discussionswithpatientsregardingpotentiallossoffunctionareessential.Anylipomatousmassmayrecurwith
incompleteexcision,andliposarcomasmayrequirealargerrepeatexcision,chemotherapyorradiation.

REFERENCES Goto: Goto:

1.CribbGL,CoolWP,FordDJ,ManghamDC.Giantlipomatoustumoursofthehandandforearm.JHandSurg
[Br]200530:50912.[PubMed]

2.PhalenGS,KendrickJI,RodriguezJM.Lipomasoftheupperextremity.Aseriesoffifteentumorsinthehand
andwristandsixtumorscausingnervecompression.AmJSurg.1971121:298306.[PubMed]

3.SalamGA.Lipomaexcision.AmFamPhysician.200265:9014.[PubMed]

4.TerziogluA,TuncaliD,YukselA,BingulF,AslanG.Giantlipomas:Aseriesof12consecutivecasesanda
giantliposarcomaofthethigh.DermatolSurg.200430:4637.[PubMed]

5.CelikC,KarakousisCP,MooreR,HolyokeED.Liposarcomas:Prognosisandmanagement.JSurgOncol.
198014:2459.[PubMed]
file:///C:/Users/LENOVO/Documents/Giant%20lipomas%20of%20the%20upper%20extremity.html 4/5
2/27/2017 Giantlipomasoftheupperextremity

6.SilistreliOK,DurmusEU,UlusalBG,OztanY,GorguM.Whatshouldbethetreatmentmodalityingiant
cutaneouslipomas?Reviewoftheliteratureandreportof4cases.BrJPlastSurg.200558:3948.[PubMed]

7.YangYJ,DamronTA,CohenH,HojnowskiL.Distinctionofwelldifferentiatedliposarcomafromlipomain
twopatientswithmultiplewelldifferentiatedfattymasses.SkeletalRadiol.200130:5849.[PubMed]

8.IlaslanH,SundaramM.Advancesinmusculoskeletaltumorimaging.OrthopClinNorthAm.200637:37591.
[PubMed]

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