Lipomas

Background

Lipomas are the most common soft-tissue tumor. These slow-growing, benign fatty tumors form
soft, lobulated masses enclosed by a thin, fibrous capsule. Although it has been hypothesized that
lipomas may rarely undergo sarcomatous change, this event has never been convincingly
documented. It is more probable that lipomas are at the benign end of the spectrum of tumors,
which, at the malignant end, include liposarcomas (see Pathophysiology).

Because more than half of lipomas encountered by clinicians are subcutaneous in location, most
of this article will be devoted to that subgroup. Additional information about other locations (eg,
intramuscular, retroperitoneal, gastrointestinal [GI]) will be included as appropriate.

Pathophysiology

Lipomas are common benign mesenchymal tumors. They may develop in virtually all organs
throughout the body. The anatomy depends on the tumor site. Subcutaneous lipomas are usually
not fixed to the underlying fascia. The fibrous capsule must be removed to prevent recurrence.

In the GI tract, lipomas present as submucosal fatty tumors. The most common locations include
the esophagus, stomach, and small intestine. Symptoms occur from luminal obstruction or
bleeding.

Duodenal lipomas are mostly small but may become pedunculated with obstruction of the lumen.
They may cause pain, obstructive jaundice, or intussusception in younger patients. [1] Mucosal
erosion over the lipoma may lead to severe bleeding (see the image below). Small intestinal
lipomas occur mainly in elderly patients. They tend to be pedunculated submucosal lesions. They
are more common in the ileum than in the duodenum or jejunum. As with duodenal lipomas,
severe hemorrhage or intussusception may occur.
 Upper gastrointestinal series shows duodenal lipoma with central
ulceration where the overlying mucosa has thinned, ulcerated, and bled.

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Colonic lipomas are usually discovered on endoscopy. Gentle palpation with a biopsy forceps
reveals the soft nature of the submucosal mass. A biopsy specimen of the mucosa may reveal
underlying fat, the so-called naked fat sign. As with lipomas in other locations, colonic lipomas
may cause pain with obstruction or intussusception.

As noted above, a fatty protrusion of preperitoneal fat termed a "lipoma of the spermatic cord" is
a common finding on groin exploration for hernia repair.

Numerous case reports document the presence of lipomas in other, rare locations, with these
tumors having been found virtually everywhere in the body. [2, 3, 4, 5, 6] Lipomatous involvement of
endocrine organs, including the thyroid, adrenal glands, pancreas, and parathyroid glands, has
been described. Maxillofacial lipomas, including intralingual, parotid, orbitonasal, maxillary
sinusoidal, and parapharyngeal space masses, have also been documented.

In rare instances, intraosseous and intra-articular involvement occurs. Involvement of the

structural components of the mediastinum, including the airways and pleura, has also been
reported. Gynecologic lipomas may occur in the uterus, ovaries, and broad ligament. Critical
organ involvement of the heart (causing ventricular tachycardia), superior vena cava, brain, and
spinal cord may pose a significant clinical challenge. [7, 8]

Mixed histologies, such as angiolipomas and fibrolipomas, are often encountered and are usually
benign. Differentiation from liposarcoma may be difficult.
Other fatty tumors include lipoblastomas, hibernomas, atypical lipomatous tumors, and
liposarcomas. Lipoblastomas occur almost exclusively in infants and children. They have a
benign clinical course and a low recurrence rate after surgical excision. Hibernomas, also rare,
derive their name from the morphologic resemblance to the brown fat of hibernating animals.
They presumably arise from fat that may occur in the back, hips, or neck in adults and infants.
Atypical lipomatous tumors are generally considered to be low-grade sarcomas, with a strong
propensity to recurrence but little metastatic potential. Liposarcomas are true mesenchymal
malignancies.

Etiology

Speculation exists regarding a potential link between trauma and subsequent lipoma formation. [9]
One theory suggests that trauma-related fat herniation through tissue planes creates so-called
pseudolipomas. It has also been suggested that trauma-induced cytokine release triggers pre-
adipocyte differentiation and maturation. To date, no definitive link between trauma and lipoma
formation has been prospectively demonstrated.

While the exact etiology of lipomas remains uncertain, an association with gene rearrangements
of chromosome 12 has been established in cases of solitary lipomas, as has an abnormality in the
HMGA2-LPP fusion gene. [10]

Epidemiology

Lipomas occur in 1% of the population. Most of these are small subcutaneous tumors that are
removed for cosmetic reasons. These subcutaneous lipomas will be considered separately from
lipomas in other locations in the discussion below. In the intestine, lipomas constitute 16% of
benign, small neoplasms; this percentage is lower than that of leiomyomas (18%) and higher
than that of adenomas (14%).

Prognosis

The outcome and prognosis are excellent for benign lipomas. Recurrence is uncommon but may
develop if the excision was incomplete.

Pang et al compared outcomes in 238 patients who underwent total or near-total (T/NT) resection
for dorsal, transitional, or chaotic spinal cord lipomas (with 16-year follow-up), along with
complete reconstruction of the neural placode, with results from 116 patients who underwent
partial resection for spinal cord lipomas (with 11-year follow-up). [11, 12]

Although in the T/NT and partial resection groups the rate of immediate symptom stabilization
or improvement was similar (more than 95%), the combined cerebrospinal fluid leakage and
wound complication rate was only 2.5% for T/NT resections, compared with 6.9% for partial
resections. Moreover, the overall progression-free survival probability (Kaplan-Meier analysis)
was 82.8% for T/NT resection patients at 16 years postoperative, compared with 34.6% for
partial resection patients at 10.5 years post operation. Evidence indicated that the superior results
in the T/NT resection patients were associated with the fact that lower cord-sac ratios were
achieved in these patients than in the partial-resection group. [11, 12]

History and Physical Examination

Lipomas are most often asymptomatic. When they arise from fatty tissue between the skin and
deep fascia, typical features include a soft, fluctuant feel; lobulation; and free mobility of
overlying skin. A characteristic "slippage sign" may be elicited by gently sliding the fingers off
the edge of the tumor. The tumor will be felt to slip out from under, as opposed to a sebaceous
cyst or an abscess that is tethered by surrounding induration. The overlying skin is typically
normal.

Symptoms in other sites depend on the location and can include the following:

Lipomas in the major airways can cause respiratory distress related to bronchial obstruction;
patients may present with either endobronchial or parenchymal lesions
Previously undiagnosed lipomas of the oropharynx may also lead to airway difficulty at the time
of intubation
Patients with esophageal lipomas can present with obstruction, dysphagia, regurgitation,
vomiting, and reflux; esophageal lipomas can be associated with aspiration and consecutive
respiratory infections
Cardiac lipomas are located mainly subendocardially, are rarely found intramurally, and are
normally unencapsulated; they appear as a yellow mass projecting into the cardiac chamber
Intramediastinal lipomas may impinge on the superior vena cava, thereby leading to superior
vena cava syndrome
Intestinal lipomas may manifest as classic obstruction, intussusception, volvulization, or
hemorrhage
Lipomas arising from fat in the intramuscular septa cause a diffuse, palpable swelling, which is
more prominent when the related muscle is contracted
Lipomas in intra-articular joint spaces or intraosseous sites, such as the calcaneus, may lead to
joint dysfunction and pain that preclude normal ambulation
Lipomas may also arise in the dural or medullary components of the spinal cord, thereby leading
to cord compression and attendant sequelae [7]
Lipomas occur frequently in the breast but not as frequently as expected considering the extent
of fat that is present
Lipomas may arise from the subcutaneous tissues of the vulva; they usually become
pedunculated and dependent

Complications

Subcutaneous lipomas are primarily cosmetic issues. Lipomas in other locations may cause
luminal obstruction or hemorrhage. The images below show a duodenal lipoma that caused
gastrointestinal hemorrhage and required removal.
 Upper gastrointestinal series shows duodenal lipoma with central
ulceration where the overlying mucosa has thinned, ulcerated, and bled.

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Duodenal lipoma resected through a

duodenotomy. Overlying mucosa with central ulceration removed and lobulated fatty tumor shelled out
intact with capsule. The mucosa was then sutured closed, and the duodenotomy closed. The stitch was
placed to orient the specimen for pathologic examination.
Diagnostic Considerations

Lipomas must be differentiated from other masses or tumors.

In the subcutaneous location, the primary differential diagnosis is a sebaceous cyst or an abscess.
Sebaceous cysts are also rounded and subcutaneous. They can be differentiated from lipomas by
their characteristic central punctum and the surrounding induration. Treatment requires removal
of a small ellipse of overlying skin to avoid entering the cyst. Abscesses typically have overlying
induration and erythema. Incision and drainage is the appropriate management.

Hibernomas are uncommon tumors that arise from brown fat. They are also benign but with a
slightly greater tendency to bleed during excision and to recur if intralesional excision is
performed.

Atypical lipomatous tumors are considered to be well-differentiated liposarcomas. They have a

predilection for local recurrence but do not generally metastasize. This diagnosis should be
suspected when a fatty tumor is encountered in an intramuscular or retroperitoneal location.

Liposarcomas are malignant tumors that arise from adipocytes. They may recur locally and may
metastasize. Fatty tumors of the retroperitoneum or in intramuscular locations should be
considered to be potential liposarcomas until proven otherwise.

In the breast, a lipoma will be mammographically radiolucent. It must be differentiated from a

similar benign tumor, a mammary hamartoma, and a pseudolipoma (a soft-tissue mass that may
surround a small, scirrhous cancer).

Conversely, lipomatous lesions in the adrenal gland that have calcifications on radiologic
examinations have been confused with teratoma. Many of these are angiomyolipomas.

In the spermatic cord, a finger of retroperitoneal fat termed a "lipoma of the cord" is frequently
encountered during hernia repair. Removal is advocated to allow the internal inguinal ring to be
tightened around the cord and to minimize the risk of recurrence of the hernia. During
laparoscopic exploration for a palpable inguinal mass, no identifiable peritoneal orifice may be
found if the inguinal mass purely consists of a lipoma of the cord.

Laboratory Studies

A study by Yoshiyama et al suggested that the plasma D-dimer level could contribute to the
differentiation between lipoma and well-differentiated liposarcoma, two lesions that are
similar in terms of clinical, radiologic, and pathologic characteristics. [13]

Imaging Studies

For most subcutaneous lipomas, no imaging studies are required.

Lesions in the gastrointestinal (GI) tract may be visible on GI contrast studies (see the image
below).

Upper gastrointestinal series shows duodenal lipoma with central

ulceration where the overlying mucosa has thinned, ulcerated, and bled.

View Media Gallery

Imaging studies for lipomas in atypical locations (or those for which the differential diagnosis
includes sarcoma) include ultrasonography, computed tomography (CT), and magnetic
resonance imaging (MRI). [14]

In a retrospective review of the use of ultrasonography by two musculoskeletal radiologists to

evaluate 714 superficial soft-tissue tumors, Hung et al reported a sensitivity of 95.2% and a
specificity of 94.3% for lipoma. [15]

When CT is employed, a radiodensity of less than 50 Hounsfield units is indicative of a soft-

tissue tumor composed of fat, though no reliable distinction can be made between a benign
lipoma and a malignant liposarcoma. [6]

MRI has been recommended as a reliable preoperative investigation. [16, 17, 18, 19, 6] It has been
employed in intramuscular lipoma, pediatric lipoblastomas, and others. The findings of
intramuscular lipomas, for example, range from small, homogeneous masses to large,
inhomogeneous lesions with infiltrative margins. However, like CT, MRI does not allow an
absolute, reliable distinction between a lipoma and a liposarcoma. [20] A study by Thornhill
suggested that the addition of computer-assisted diagnosis may improve the ability of MRI to
make this distinction. [21]
Because all lipomas are radiolucent, soft-tissue radiography can be diagnostic, but it is indicated
only when the diagnosis is in doubt.

Biopsy

Biopsies are normally not indicated for small subcutaneous lesions, because the entire tumor is
usually removed. All imaging techniques have been combined with fine-needle aspiration
(FNA); this combination increases the accuracy of diagnosis. Obtaining tissue samples from
different tumor components is important, because it provides samples for histopathologic
analysis by means of various techniques, including fluorescence in situ hybridization (FISH).

Histologic Findings

Lipomas are benign mesenchymal tumors derived from adipocytes. Several variants have been
described, including the following:

Adenolipomas, a variation of lipomas that may occur in the breast, often have a marked fibrotic
component; they are best regarded as a hamartoma
Angiolipomas contain many small vessels
Cardiac lipomas may calcify following fat necrosis; microscopically, they are composed of fatty
tissue with interlacing muscle fibers

FNA biopsies of a lipoblastoma contain multivacuolated lipoblasts, myxoid areas, and a

plexiform capillary network.

Approach Considerations

Lipomas are removed for the following reasons:

Cosmetic reasons
To evaluate their histology, particularly when liposarcomas must be ruled out
When they cause symptoms
When they grow and become larger than 5 cm

Obtain biopsies of large lipomas or of those tethered to fascia to rule out a liposarcoma.

No contraindications to removing a lipoma exist, unless the patient is unfit for surgery or
anatomic location makes removal unfeasible (as in the case, for example, of an intraspinal
lipoma). Benign lipomas are simply "shelled out," with complete removal of the capsule in an
extracapsular plane. This is an inadequate operation for a liposarcoma, and hence, performing an
initial biopsy to exclude this lesion may be considered for large fatty tumors or for those in the
retroperitoneum or the intramuscular spaces.
Endoscopic Therapy

Nonsurgical therapy includes endoscopic excision of tumors in the upper gastrointestinal (GI)
tract (ie, esophagus, stomach, or duodenum) or the colon. Colonoscopic snare removal has been
described but may be associated with perforation if the base is broad. Japanese authors reported a
safe technique in which a bipolar snare was used and the mucosa of the defective region was
clipped. [22] Otherwise, surgical removal is indicated.

Surgical Therapy

Complete surgical excision with the capsule is advocated to prevent local recurrence, whether the
lipoma in question is subcutaneous or intracardiac in origin. These lesions may be lobulated, and
it is essential that all lobules be removed.

Specific therapy depends on the location of the tumor. [23]

Subcutaneous lipomas are removed for cosmetic reasons, and hence, a cosmetically pleasing
incision should be used. [24] The incision is usually placed directly over the mass and is oriented
to lie in a line of skin tension. Liposuction is an alternative that allows removal of the lipoma
through a very small incision, the location of which may be remote from the actual tumor. [25, 26,
27, 28]
The lesion may also be approached by means of advanced, minimal-access tissue dissection
methods, with the use of a dissecting balloon. [29] The latter two methods allow the incision to be
placed in an inconspicuous location. For example, axillary incisions may be used to remove
lipomas from the back.

Liposuction may be employed more often in small facial lipomas, because favorable aesthetic
results have been obtained through strategically placed incisions. Liposuction is indicated for the
treatment of medium-sized (4-10 cm) and large (>10 cm) lipomas; in small lipomas, no
advantage has been reported, because these tumors can be extracted through small incisions. [25,
26, 27, 28]

Lipoma formation has been reported as an unusual complication of liposuction and has also been
found to occur following trauma. [9, 30] The mechanism in these cases is unknown. Research on
genetic markers of atypical lipomatous tumors and liposarcomas is ongoing. These tumors have
been shown to express receptors for leptin. [31]

For more unusual locations, the method of removal must be tailored to the site and may require
the expertise of a consultant, as follows:

Local removal is indicated in intestinal lipomas causing obstruction or hemorrhage; uncertainty

of diagnosis for an intramural intestinal mass also warrants resection, because liposarcomatous
disease of the bowel has been described
If esophageal lipomas cannot be endoscopically removed, surgical excision is indicated, whether
by a transhiatal or a transthoracic approach
 Lipoma-related narrowing of the major airways warrants removal of the instigating mass;
likewise, intraparenchymal lipomas of the lung may require thoracotomy and the expertise of a
thoracic surgeon
Breast lipomas are excised if their nature is in doubt, whether by means of wire or
ultrasonographic localization or by means of direct palpation
Vulvar lipomas may be locally excised
Lipomas in critical locations, such as the heart, may require a more physiologically and
technically demanding procedure for removal, including median sternotomy with bypass
Intraosseous lipomas may be removed by means of endoscopy in combination with orthopedic
expertise

Tumors can usually be enucleated. They may recur if not properly removed, which should
include removal of the capsule. Hibernomas tend to be highly vascular. Lipomas in other
locations may present unique difficulties during removal; for example, in a person presenting
with a frontalis-associated subfascial lipoma as a protruding mass on the lateral forehead, the
lipoma may be difficult to dissect because of the highly vascular muscle that invests it. Lipomas
of the GI tract can frequently be shelled out of their submucosal location.