Lipomas are the most common mesenchymal tumour. They are believed to arise from primordial adipocytes, not from adult fat cells, therefore increasing in size as a patient accumulates adipose tissue but not decreasing with weight loss. They usually develop as well-circumscribed, encapsulated masses that have a doughy feel and are freely mobile beneath the skin. Lipomas can occur in many locations, but occur most commonly in the subcutaneous tissue of the head, neck, shoulders and back. They can also be found intermuscularly, intramuscularly, interosseously, associated with viscera or at a site of prior trauma. Subtypes include conventional lipomas, fibrolipomas, angiolipomas, spindle cell lipomas, myelolipomas and pleomorphic lipomas. Their slow, usually painless growth can lead to a large size at presentation, especially when located in deep subfascial planes.
Cosmetic deformity or compressive symptoms usually bring lipomatous masses of the upper extremity to medical attention earlier than rapidly growing masses in other locations of the body. Previous studies have defined a giant lipoma of the upper extremity as larger than 5 cm in any one dimension; a tumour of this size warrants a work-up for malignancy (1). Giant lipomas of the upper extremity are rare, but when they occur, an appropriate workup must be done. This should be followed by adequate open surgical excision and repeat examination over time to monitor for recurrence.
A series of eight consecutive patients, four male and four female, who were evaluated at Hartford Hospital, Connecticut, USA from 2003 to 2007 with giant lipomatous masses of the upper extremity is presented. The patients ranged in age from 15 to 70 years with a mean age of 53 years (Table 1). The tumours ranged from 14 cm ×12 cm × 2 cm to 5 cm × 4 cm × 2 cm in size. Each patient underwent excision of the mass with primary closure. Specimens were sent to pathology postoperatively. Seven of the eight patients had benign lipomas; patient 5 had a well-differentiated liposarcoma. Four cases are presented here in more detail.
Most lipomas are benign and can occur alone or in multiple locations. There is a report (2) of an individual having as many as 160 individual lesions. Lipomas can arise spontaneously or as part of a syndrome such as hereditary multiple lipomatosis, adiposis dolorosa, Gardner’s syndrome and Madelung’s disease (3). Lipomas occur more frequently in female patients, presumably due to their tendency to accumulate more adipose tissue; however, we did not observe this trend in our series.
Lipomas usually grow at a very slow rate, and the etiology of rapid growth into giant lipomas is still a matter of debate. It has been suggested that blunt trauma can cause rupture of the fibrous septa and anchorage connections between the skin and deep fascia, allowing the adipose tissue to proliferate (4). Although the patient 7 denied any trauma to the area, there was evidence of remote injury to the left upper extremity on MRI. This may have led to the eventual rapid growth of an already existing intramuscular lipoma.
No matter the mechanism of rapid growth, the main concern when evaluating a giant lipoma in the upper extremity is to rule out malignancy. Liposarcomas are the most common soft tissue sarcomas, comprising 7% to 27% of all soft tissue sarcomas (5). They typically arise in the fourth to sixth decade of life. Liposarcomas consist of lipoblasts and may occur wherever fat is present, but are most commonly found within intramuscular fatty tissue. Histological subtypes of liposarcomas include well-differentiated, myxoid, round cell and pleomorphic liposarcomas. Well-differentiated liposarcomas exhibit low malignant potential, myxoid liposarcomas display intermediate malignant behaviour, and round cell and pleomorphic liposarcomas exhibit aggressive behaviour with early metastasis. Well-differentiated liposarcomas, as seen in patient 5, account for approximately 40% to 45% of liposarcomas (1). Recent rapid growth, size larger than 5 cm and intramuscular location have all been reported to be risk factors for malignancy (1,5,6).
Proper evaluation of a large mass in the upper extremity must include imaging or tissue sampling to rule out malignancy. MRI or biopsy are the two best options available. The possibility of an incompletely representative biopsy leading to misdiagnosis has led some to recommend MRI before attempting biopsy. On MRI, a lipoma appears as a mass with homogenous fat signal intensity surrounded by a pseudocapsule. Gadolinium-enhanced MRI has been reported to allow easy distinction of lipomas from well-differentiated liposarcomas due to increased levels of vascularity seen in septal structures within the lesion (7). High-grade liposarcomas have little fat on imaging, and dedifferentiated liposarcomas show obvious changes from a low-grade to high-grade tumour within the lesion (8). Ultrasound- or computed tomography-guided biopsy can then be used to target areas of radiological concern. Ultimately, surgical excision should be performed, possibly followed by radiation and chemotherapy. If a lipoma is incompletely excised, it may recur, as was seen in patient 2, who had had a lipoma removed from the same location two years previously. Liposarcomas are notorious for local recurrence, and even with attempted total resection, local recurrence rates may be as high as 50% (1).
Suction-assisted lipectomy has been suggested as a treatment option for giant lipomas, but the need for complete removal to prevent recurrence, along with the inability to predict where nerves and other vital structures have been displaced, renders this mode of treatment less attractive.
The proper management of giant lipomas is open excision. Lipomas are usually well encapsulated, allowing relatively straightforward complete removal. Intramuscular location makes removal more technically challenging and may require removal of some surrounding muscle to ensure adequate margins. Finally, a full pathology report on the specimen is required to determine the possible need for further treatment.
Large Lipoma By Dr. Sandra Lee(Video Inside)
A lipoma is slow-growing, benign growth of fat cells. It is contained in a thin, fibrous capsule and found right under the skin. A lipoma is typically not tender and moves around easily with slight pressure. A lipoma is not cancerous and treatment generally is not necessary. There is also a condition called familial lipomatosus, where people develop multiple lipomas, especially on the arms and legs, and other family members have these growths as well.
If the lipoma is on a pressure-bearing area, it may create discomfort and this is when people seek removal. People also request removal because they don’t like the appearance of these bumps. Often a small incision can be made over the lipoma and they can be “popped” out easily. This is a simple in-office surgical procedure under local anesthesia.
Fast facts about blackheads
Blackheads are made of oxidized melanin and not trapped dirt.
Squeezing or scrubbing at blackheads can make them worse.
To reduce blackheads, avoid oil-based skin care products, humid environments, tight clothes, and skin products that contain alcohol.
They tend to appear when hormones lead to the increased production of sebum, an oily substance, by the glands under the skin.