Giant lipoma of atypical localization

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Abstract

Lipoma (from the Greek λίπος ― fat), fatty tumor, wen is a benign tumor of mesenchymal origin, consisting of mature adipocytes, the pathogenesis and etiology of which remain not completely clear.

Diagnosis is based on the clinical presentation of painless, round, movable masses with a characteristic soft, doughy sensation in the subcutaneous tissues, but they can also be found in deeper tissues such as the intermuscular septa, abdominal organs, oral cavity, internal auditory canal, cerebellopontin angle, and chest, as a result of which specialized specialists are involved in the examination of the patient to obtain the results of ultrasound, magnetic resonance imaging. In addition, a histological examination is performed to exclude liposarcoma.

Treatment of a lipoma depends on the location, number, size, and subjective symptoms. Lipomas are excised by endoscopy (anemic, without the risk of noticeable scarring), open method, which makes it possible to prevent recurrence, or outpatient (under local anesthesia).

Due to the high incidence of pathology in the presence of a hereditary predisposition, a thorough examination of the patient’s relatives and the collection of a family history are necessary.

We present a clinical case of giant lipoma in a patient with a rare location of the tumor on the skin of the temporo-zygomatic region of the face.

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INTRODUCTION

Lipoma is a common benign tumor of mature fat cells, occurs in altered places where there is adipose tissue, but most often in 98% are found subcutaneously and in affected soft tissues, 94% are solitary lipomas, occasionally multiple, which is typical for women. as well as patients with neurofibromatosis and endocrine neoplasia. [1] Lipomas occur in patients of all age groups, but usually first appear between the ages of 40 and 60. [2] Often lipomas are found in members of the same family, hereditary tumors are usually located symmetrically. [1] The association of genes on chromosome 12 has been described in the literature and has been identified in some solitary lipomas; in addition, a mutation in the HMGA2-LPP fusion gene has been identified in some cases. [3] The clinical picture of a lipoma is represented by a round, painless nodule of soft consistency (doughy, jelly-like), moving towards the surrounding tissues, with a pronounced capsule. The size of the tumor varies from 1 cm to >10 cm. The lipoma is characterized by slow, asymptomatic growth, discomfort may be associated only with a cosmetic defect or a large tumor size. [2] Deep lipomas have a denser consistency due to pseudopod-like processes, thanks to which the tumor can spread through interfascial spaces, destroy aponeuroses and compress underlying organs. [one]Special forms of lipomas include the following: [1, 2]• perineural lipoma - affects the median nerve and in most cases is accompanied by macrodactyly (enlarged fingers and/or toes);• lumbosacral lipoma – identifies spina bifida and intravertebral lipoma; lipoma of the tendon sheath and synovial membrane of the joint;• intramuscular and intermuscular lipomas infiltrate the muscles;• myolipoma of soft tissues, which is rarely subcutaneous;• angiomyolipomas most often develop in the kidneys. Cutaneous angiomyolipomas are rare, usually as a solitary painless subcutaneous nodule in the limbs in men;• adenolipoma - a variant of lipoma with components of sweat gland structures.  

 

In rare cases, lipomas are associated with one of the symptoms of certain hereditary diseases: [1, 4, 5]- with Cowden's syndrome, multiple lipomas and hemangiomas occur;- with Gardner's syndrome - lipomas along with sebaceous gland cysts, osteomas and intestinal polyps;with Madelung's disease - lipomas that look like a collar, because. with multiple symmetric lipomatosis, lipomas in the occipital region, neck region, upper body and proximal limbs merge;- with Derkum's disease (adiposis dolorosa), multiple painful diffuse lipomas localized in the limbs, trunk, joints, usually developing in adulthood along with ecchymosis, general weakness, fatigue, depression, dementia, amenorrhea, hypogonadism;with the Bannayan-Zonan syndrome, a congenital combination of multiple lipomas, incl. lipomas of internal organs, along with hemangiomas and macrocephaly;- with Frochlik's syndrome - multiple lipomas, obesity and hypogonadism;- with Verneuil-Poten syndrome, lipomas are localized in the supraclavicular areas;- with a "widow's hump" lipoma is localized in the region of the seventh cervical vertebra.Cases are described when lipomas developed in the area of ​​blunt trauma. [3] The pathogenetic relationship between soft tissue injury and the formation of post-traumatic lipomas is under discussion, currently there are two possible explanations for their relationship: the formation of post-traumatic lipomas may result from prolapse of adipose tissue through the fascia as a result of direct impact, and post-traumatic lipomas may form as a result of differentiation and proliferation of preadipocytes mediated by the release of cytokines after soft tissue injury and hematoma formation. [6, 7]The problem of differential diagnosis of lipoma is associated with some difficulties, therefore, most often the tumor is differentiated with the following diseases (see Table No. 1): Table No. 1 Differential diagnosis of lipoma. [1, 8]

Disease

 

Clinical picture

 

Histology

 

difference

 

Liposarcoma

 

It occurs at the age of 50-70 years. Clinical manifestations may be absent for a long time, until the liposarcoma reaches a large size. Most often, the formation is localized in the region of the lower extremities, in their proximal sections.A characteristic feature is mature fat cells and immature, atypical lipoblast cells with spindle or stellate nuclei.

 

It is located deep in the tissues, has areas of myxomatosis, slight polymorphism of fat cells and immature fatty elements of stellate or fusiform shape with lipid droplets in the cytoplasm.

 

Angiomyolipoma

 


It occurs at the age of 34 to 77 years. Clinically, these are small, painless, capsule-delimited subcutaneous nodules. It is located on the fingers of the hands and feet, acral areas of the auricles.

Delimited pseudo-encapsulated node located in the deep sections of the reticular layer of the dermis or in the subcutaneous fatty tissue. It has three components: vascular, smooth muscle and lipomatous.

 

Angiomyolipoma is a fatty tumor with a vascular component and smooth muscle cells.

 

hibernoma

 


It occurs more often at a young age - up to 30 years. Slow growing, painless mass. They are localized in the interscapular region, in the armpits, on the neck, in the inguinal regions and popliteal fossae.

Brown adipose tissue has a lobular structure. The lobules are composed of rounded and/or polygonal well-defined cells with a centrally located nucleus and are separated by connective tissue layers.

 

Macroscopic appearance is characteristic: yellowish-brown color. Another feature is that the cytoplasm of tumor cells is stained differently with fatty dyes, which indicates a diverse composition of fatty inclusions.

 

Angiolipoma

 

Occurs in young people.Clinically painful nodes, sensitive to palpation. It is located on any part of the body, but more often on the forearms.

 

An encapsulated subcutaneous nodule of mature lipocytes and varying numbers of blood vessels.

 

Unlike lipoma, it has a more pronounced tendency to multicentricity.

 

Atheroma

 

Occurs at a young age.Clinically, it is a rounded formation, painless, encapsulated.It is formed on areas of the skin with sebaceous glands - the scalp, neck, axillary fossae.

 

Dense connective tissue capsule lined with squamous epithelium. The contents are epidermal cells, sebaceous secretion and cholesterol crystals.

 

A cyst filled with a curdled mass. In the center of the formation is a clogged duct of the sebaceous gland.

 

Hygroma

 

Occurs at the age of 20-30 years.Clinically noted dull pain on palpation, painless at rest.It is located near the joints and tendons of the upper and lower extremities.

 

Serous fluid interspersed with mucus and non-globular fibrin protein.

 

Cyst filled with serous-mucous or serous-fibrous liquid mass.

 

Diagnosis of superficially located lipomas is based on the use of additional research methods: radiography, computed tomography (CT), ultrasound (ultrasound) and biopsy. X-ray diagnostics is based on the use of long-wave ("soft") X-ray radiation, which allows you to assess the structure of the soft tissues of the body. [3, 9] When radiography of deep-lying lipomas, for example, in muscle tissue, it is necessary to increase the “rigidity” of the X-ray beam.On radiographs, the lipoma looks like an area of ​​uniform enlightenment with clear outlines and regular shape. X-ray computed tomography (CT) allows you to more clearly distinguish adipose tissue from denser soft tissue structures. [3, 9] In ultrasonography (ultrasound), lipomas look like hypoechoic formations with a thin capsule, located in the thickness of adipose tissue. [2, 9]In difficult cases and doubts about the benign nature of the tumor, a puncture biopsy with cytological examination is used. [1, 9] Laboratory examination for lipoma has no independent value for diagnosis. In case of hospitalization to perform a planned surgical intervention for a lipoma, a general clinical laboratory examination (general blood count (CBC), urinalysis (CAM), biochemical blood test (BAC), blood glucose, HIV, syphilis, hepatitis) is performed, which allows exclude contraindications to surgical intervention.The first line of treatment for lipomas is surgical excision, but there are also conservative treatments for lipomas.Excisional treatment in most cases leads to a cure. Before the operation, the edges of the lipoma are outlined, since after the introduction of the anesthetic they can be smoothed out. Then the skin is treated with a solution of povidone-iodine or chlorhexidine so that the outlined contours are not erased. Local anesthesia is performed with a 1-2% solution of lidocaine with adrenaline, further tactics depend on the size of the lipoma. [10, 11]Large and giant lipomas are best removed through incisions in the skin above the tumor. Spindle-shaped excisions are made following the lines of skin tension, the central area of ​​the skin is grasped with a hemostatic forceps or Alice forceps to provide traction during removal of the tumor. The dissection is then carried out under the subcutaneous fat to the tumor, with the tissue dissected under direct visualization, taking special care not to touch the nerves or blood vessels that may be located under the tumor. After separating the lipoma from the surrounding tissue, hemostatic forceps or Alice forceps are attached to the tumor to remove the lipoma by traction. Surrounding tissues are palpated to avoid incomplete removal of the tumor. Adequate hemostasis can be achieved with the help of hemostatic agents and suturing, then a pressure bandage is applied to prevent the formation of a hematoma. [10, 11]- Non-excisional treatment of lipomas is quite common and includes steroid injections and liposuction. Injections of steroids lead to local atrophy of fat, therefore, a decrease in the size of the lipoma, and sometimes its complete regression. Injections are best performed with a diameter of lipomas not exceeding 2 cm. A mixture of 1% lidocaine and 1-3 ml of triamcinolone acetonide (depending on the size of the lipoma) 1:1 at a dose of 10 mg / ml is injected into the center of the lesion. The procedure is repeated once a month, the amount depends on the response, which is expected within three to four weeks. [1, 11]- Liposuction can be used to remove both small lipomas and large ones, especially in those places where large scars are undesirable. Complete removal of a lipoma with liposuction is difficult to achieve. Procedures using a 16G needle and a large syringe are safer than liposuction with a large cannula. [3.11]- the enucleation method is used in cases of small lipomas. To do this, a 3-4 mm incision is made above the lipoma, a curette is placed inside and with its help the lipoma is separated from the surrounding tissues, after which the tumor is enucleated through the incision. [eleven] The prognosis for benign lipomas is favorable. Relapses occur in cases of incomplete removal of the fibrous capsule. [3, 10, 11] CASE DESCRIPTIONPatient K., 43 years old, came to the clinic of skin and venereal diseases with complaints about the presence of a mass formation on the skin of the temporomygomatic region on the left. Subjective complaints of increased sensitivity of the skin surface over the formation (paresthesia), sometimes pain during movement of facial muscles.From the anamnesis: he considers himself ill for 10 years, when he first noted the appearance of a small mobile formation in the form of a “ball” on the skin of the temporal region. The mass gradually increased in size, especially after repeated blunt trauma in that area. He did not go to the doctors and was not treated. Recently, he began to notice a significant increase in education, difficulties in the movement of facial muscles, chewing.Local status: on the skin of the left temporo-zygomatic region there is a node protruding 3 cm above the surrounding skin, the surface of which is covered with hair, 15.5 cm X 10.8 cm in size, bordering the auricle (Fig. 1a, b) On palpation a knot of dense elastic consistency, mobile, painless, with a characteristic sensation of a capsule. Peripheral lymph nodes are not enlarged.Fig. 1 (a) Patient K., 43 years old. Lipoma of the left temporo-zygomatic region (frontal view)Fig. 1 (b) Patient K7, 43 years old. Lipoma of the left temporo-zygomatic region (side view)In order to verify the diagnosis, the patient underwent a comprehensive examination, including: pathomorphological examination of the node biopsy, ultrasound of the mass.Survey resultsPathological studyHistological preparation No. 124/78 pathomorphological picture is represented by a lobed structure consisting of mature fat cells, between which a well-developed capillary network is visualized. (Fig.2(a,b))Fig. 2(a) B-noy K. 43 g Diagnosis: Lipoma. Pathological picture: lobular structure consisting of mature fat cells. with a well-developed capillary network. (staining hematoxylin-eosin, uv.x 120)Fig. 2(b) B-noy K. 43 g Diagnosis: Lipoma. Pathological picture (fragment): mature fat cells are visualized in the preparation. with a well-developed capillary network. (staining hematoxylin-eosin, uv.x 140)Ultrasound findings: an oval, hypoechoic nodular structure surrounded by a fibrous capsule is visualized, which is characteristic of a lipoma.Thus, based on the data of the additional examination, the final diagnosis was made: Solitary giant lipoma of the skin of the face.TreatmentGiven the gigantic size of the tumor and its complex localization in the temporo-zygomatic region, the patient underwent surgical excision of the lipoma under local anesthesia with an oblique approach along the anterior edge of the left sternocleidomastoid muscles. Since the lipoma was fully localized in the subcutaneous fat layer and there were no signs of its germination, the tumor was resected within the subcutaneous fat, followed by revision of the surgical wound and the application of cosmetic sutures. In the postoperative period, facial expressions and sensitivity of all branches of the trigeminal nerve were completely restored. The patient was followed up for 1 year without clinical signs of recurrence. (Fig. 3a,b)Fig. 3 (a) Patient K7, 43 years old. Condition after excision of the lipoma of the left temporo-zygomatic region (side view)

Fig. 3 (b) Patient K7, 43 years old.

Condition after excision of a lipoma of the left temporo-zygomatic region (frontal view).

 

DISCUSSIONIn this article, we have presented an unusual clinical case of a giant lipoma in the temporomyar region, which was successfully treated with surgical removal. The interest of this clinical case lies not only in the atypical localization of the lipoma near the trigeminal nerve, but also in its gigantic dimensions, reaching 15 cm in length and almost 11 cm in width.Noteworthy is the long history of the disease and the intensive growth of the formation after repeated blunt injuries of this area, which the patient reported. Such a clinical picture can cause difficulties in making a differential diagnosis, primarily with liposarcoma.CONCLUSION The pathogenesis of lipoma development due to repeated blunt trauma is poorly understood. With timely access to a doctor, diagnosis and treatment of lipomas in the early stages of development, it will avoid the risks of lipoma germination in the joints, nerves and blood vessels, as well as the development of postoperative complications and cosmetic defects. There is an obvious need for an interdisciplinary approach and a thorough examination of patients with lipomas.  

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About the authors

Elena S. Snarskaya

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Author for correspondence.
Email: snarskaya-dok@mail.ru
ORCID iD: 0000-0002-7968-7663
SPIN-code: 3785-7859
Scopus Author ID: 8714450500

MD, Dr. Sci. (Med.), Professor

Russian Federation, 4 build. 1 Bol’shaya Pirogovskaya str., Moscow, 119991

Lidiya M. Shnakhova

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: lika-slm@mail.ru
ORCID iD: 0000-0003-3000-0987

MD, Assistant

Russian Federation, Moscow

Juliya M. Semiklet

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: semiklet.jul@mail.ru
ORCID iD: 0000-0001-7615-3917

MD

Russian Federation, Moscow

References

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  2. Charifa A, Azmat CE, Badri T. Lipoma pathology. In: StatPearls [Updated 2021 Oct 2]. Treasure Island (FL): StatPearls Publishing; 2021.
  3. Kolb L, Yarrarapu SN, Ameer MA, et al. Lipoma. In: StatPearls [Updated 2021 Oct 2]. Treasure Island (FL): StatPearls Publishing; 2021.
  4. Baldino ME, Koth VS, Silva DN, et al. Gardner syndrome with maxillofacial manifestation: A case report. Spec Care Dentist. 2019;39(1):65–71. doi: 10.1111/scd.12339
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  7. Aust MC, Spies M, Kall S, et al. Posttraumatic lipoma: Fact or fiction? Skinmed. 2007;6(6):266–270. doi: 10.1111/j.1540-9740.2007.06361.x
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Supplementary files

Supplementary Files
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1. Fig. 1. Patient K., 43 years old. Lipoma of the left temporomandibular region: a ― full face; b ― side view.

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2. Fig. 2. The same patient. Pathomorphological picture (hematoxylin-eosin staining): а ― lobular structure consisting of mature fat cells with a well-developed capillary network (×120); b ― in the presented fragment of the preparation, mature fat cells with a well-developed capillary network are visualized (×140).

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3. Fig. 3. The same patient. Condition after excision of the lipoma of the left temporomandibular region: a ― full face; b ― side view.

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Copyright (c) 2023 Snarskaya E.S., Shnakhova L.M., Semiklet J.M.

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