Lipoma Presentation and Treatment

What is Lipoma?

A lipoma is the commonest and most benign of all tumors. It is composed of fat cells of adult type. It can occur anywhere in the body, that is why it is often called ‘universal tumor’ or ‘ubiquitous tumor’.

More than half of lipomas encountered are subcutaneous in location. Subctaneous tissue of the trunk, nape of the neck and the limbs are most common sites for subcutaneous lipomas.

Lipoma presents as that present as soft, lobulated masses enclosed by a thin, fibrous capsule.

Other fatty tumors

• Lipoblastomas are found exclusively in infants and children. They have a benign clinical course and a low recurrence rate after excision.
• Hibernomas – Tumors of brown fat arise in the back, hips, or neck in adults and infants.
• Atypical lipomatous tumors – Low-grade sarcomas, little metastatic potential but strong recurrence
• Liposarcomas – True mesenchymal malignancies.

Lipomas occur in 1% of the population.

Exact etiology of lipomas remains uncertain

Types of Lipoma

Mainly there are three varieties

• Encapsulated lipoma
• Diffuse lipoma
• Multiple lipomas:

Encapsulated Lipoma

These lipomas are circumscribed encapsulated soft masses, made nearly entirely of fat. Sometimes other tissues like blood vessels [Naevolipoma], muscle fibers or fibrous tissue [Fibrolipoma], neural tissue [Neurolipoma] may be present.

Diffuse Lipoma

This is a rare variety and does not possess the typical features of lipoma, hence it is often called pseudolipoma. It is seen in the subcutaneous and intramuscular tissues of the neck. It is not a typical tumor but an overgrowth of the fat in this region.

It does not possess the capsule which is typical of a lipoma. It gives rise to a disfiguring swelling at the neck.

Multiple Lipomas

Presence of multiple lipomas is also called lipomatosis. The tumors remain small or moderate in size and are sometimes painful as these often contain nerve tissue and are called neurolipomastosis. These are mostly seen in the limbs and in the trunk.

Lipomata of different sizes and shapes may be seen. Macroscopically and microscopically these are not different from solitary lipoma.

Multiple lipomas can be associated with hereditary multiple lipomatosis, Gardner’s syndrome, and Madelung’s disease.

Dercum’s disease (adiposis dolorosa) is a variety of this condition in which there are tender lipomatous swellings particularly affecting the trunk.

Anatomical Locations of Lipoma

Subcutanous

This is the commonest variety. Although any part of the body can be affected, yet it shows particular tendency to occur in the back, nape of the neck and on the shoulders. Subcutaneous lipoma is usually sessile, but occasionally may become pedunculated. The characteristic features of such lipoma are described below.

Subfascial

Lipoma may occur under the palmar or plantar fascia and is often mistaken as tuberculous tenosynovitis. Such lipomas may also occur in the areolar layer under the epicranial aponeurosis in the scalp. Subfascial lipoma can be confused with a dermoid cyst, particularly so, as such lipoma may also erode the underlying bone as the dermoid cyst. Treatment is urgent excision of the tumor.

Intermuscular

Such lipoma occurs between the adjacent muscles and becomes firmer on feel when the adjacent muscles contract. Mechanical interference with the action of the muscles is often complained of. Fibrosarcoma is also common in such situation and is difficult to differentiate from this condition clinically. Intermuscular lipoma is mostly seen in the thigh or around the shoulder. Treatment is early excision as it is difficult to differentiate from fibrosarcoma.

Subserous

This is rare and is sometimes found beneath the pleura or peritoneum. When it is beneath the pleura it presents as a benign thoracic tumor. Retroperitoneal lipoma is also rare and is often misdiagnosed as hydronephrosis, pancreatic cyst or teratomatous cyst. A retroperitoneal lipoma may attain a big size. Very occasionally one may find a lipomatous mass rather than a lipoma at the fundus of the sac of a femoral hernia. This is a condensation of extraperitoneal fat rather than a typical lipoma.

Submucous

is also rare. It may occur in the respiratory or elementary tract. It is also seen in the tongue. In the respiratory tract it may cause respiratory obstruction. In the intestine it may lead to intussusception.

Intra-articular

inside the joint. It is extremely rare.

Subsynovial

such lipoma occurs deep to the synovial membrane in the fatty pad. It is seen in the knee-joint. In this case it is often compared with Baker’s cyst or a bursitis.

Parosteal

Occurs under the periosteum of a bone

Extradural

This is a type of spinal tumor. Intracranial lipoma does not occur as there is no fat in the extradural tissue within the skull.

Intraglandular

There are 3 glands in which a lipoma may be seen (i) the breast (ii) the pancreas and (iii) under the renal capsule.

Lipomas may develop in virtually all organs throughout the body including the thyroid, adrenal glands, pancreas, and parathyroid glands, intralingual, parotid, orbitonasal, maxillary sinusoidal, and parapharyngeal space. Mediastinum, uterus, ovaries, and broad ligament, heart superior vena cava, brain, and spinal cord are also known to be involved.

Presentation of Lipoma – Symptoms and Signs

Lipoma often do not cause any symptoms. In cases of subcutaneous lipoma, a concerned patient may present with a non painful palpable or visible swelling.

Symptoms in other sites depend on the location –

• Airways – respiratory problems related to bronchial obstruction
• Oropharynx – swallowing discomfort or airway difficulty at the time of intubation
• Esophageal –
  • Dysphagia, regurgitation, vomiting, and reflux
  • Aspiration and respiratory infections
• Mediastinal – Impingement on the superior vena cava can lead to superior vena cava syndrome
• Intestinal – Obstruction, intussusception, volvulization, or hemorrhage
• Joint – Joint dysfunction and pain
• Spinal cord – cord compression

On examination, subcutaneous lipoma is a soft to firm swelling and the overlying skin is freely mobile. When one gently slides the fingers off the edge of the tumor, the tumor is felt to slip out from under. This is called slip sign or slippage sign.

Differential Diagnosis

• Sebaceous cyst
• Abscess
• Hibernomas
• Angiomyolipomas

Lab Studies

Plasma D-dimer level could contribute to the differentiation between lipoma and well-differentiated liposarcoma,

Imaging Studies

No imaging studies are required in most subcutaneous lipomas.

Lesions in the gastrointestinal tract may be visible on contrast studies.

For atypical locations, ultrasonography, computed tomography, and magnetic resonance imaging could aid in diagnosis.

Ultrasound

Lipoma appear as soft mass with variable echogenicity.

Heterogenous echotexture,  or large size is may raise the suspicion of liposarcoma.

CT

CT shows low attenuation though it cannot reliably differentiate between lipoma and liposarcoma.

MRI

MRI is the imaging choice for lipomas and also to differentiate it from liposarcoma.

Lipomas follow subcutaneous fat signal on all sequences:

Treatment

Lipomas are not amenable to any drug treatment. They need to be removed if required.

Indications for Lipoma Removal

Lipomas are removed for the following reasons:

• Cosmetic
• Confirmation of diagnosis and to rule out liposarcoma
• When they are cause of symptoms
• > 5 cm

Lipomas must be removed extracapsular plane and removed along with capsule to avoid risk of recurrence. In case of large lipoma or suspicious lesions, a biopsy must be done to confirm/rule out diagnosis.

In case of gastrointestinal tract endoscopic removal can be done if feasible, otherwise surgical removal may be done

For unusual locations, the method of removal must be according to site and approach of the tumor.

Prognosis of Lipoma

Lipoma carries an excellent prognosis. Recurrence is uncommon unless the excision was incomplete.