Lipomatous tumours of the head and neck: a spectrum of biological behaviour

Retrospective analysis of radiological investigation of surgically excised head and neck lipomas

PURPOSE

Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification.

METHODS

Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed.

RESULTS

Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001.

CONCLUSION

As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

Intramuscular Lipoma of the Sternocleidomastoid Muscle: A Rare Entity Revisited

Intramuscular lipomas, typically found in subcutaneous tissue, rarely affect deeper muscular planes, especially those of the head and neck region. The following are 3 cases of intramuscular lipomas involving the sternocleidomastoid muscle. The first 2 patients presented with painless, palpable masses confirmed by diagnostic imaging as well-circumscribed intramuscular lipomas. One was treated surgically, while the other was managed conservatively with monitoring and close follow-up. The third patient reported dysphagia associated with occasional dyspnea and mild pain. The mass was identified as infiltrative lipoma and was resected surgically. Complete tumor removal with no recurrence at 6 months was observed for the first and last cases. The second case was serially followed at 3 and 6 months with no interval changes. We report the largest case series on intramuscular lipomas of the sternocleidomastoid muscle to enhance our understanding of this rare entity.

Large Lipoma of the Lateral Space of the Neck

Giant lipoma is characterized by asymptomatic growth and compared with other parts of the body rarely occurs on the neck. If the tumor is localized in the lateral segment of the neck, it can show symptoms in the form of dysphagia and dyspnea. Preoperatively, it is important to perform computed tomography (CT) diagnostic to determine the size of the lesion and makes the plan for operative treatment. The paper presents the case of a 66-year-old patient with a tumor in the neck area as well as swallowing disorders and suffocation during sleep. Palpation revealed a tumor of soft consistency, and based on a CT scan of the neck, the differential diagnosis confirmed giant lipoma. Clinical picture and CT findings of giant neck lipoma are clear in most cases. Due to the atypical localization and size, the tumor should be removed to prevent possible functional disturbances. The treatment is operative, and a histopathological examination should exclude malignancy.

A Rare Case of Well-Differentiated Parapharyngeal Liposarcoma

Parapharyngeal liposarcoma is a rare malignant tumor, the pathogenesis of which is uncertain. Parapharyngeal liposarcoma often causes nonspecific clinical features, including dysphagia, globus sensation, and/or respiratory disturbances. The parapharyngeal space is a rare location for head and neck liposarcoma, and these lesions may therefore be confused with a variety of other tumors that can originate in this area. Here, we report a case of liposarcoma originating from the prestyloid parapharyngeal space and discuss the possible differential diagnosis on radiographic findings.

A Challenging "Achy" Neck

Lipomas are common benign mesenchymal tumours that may occur in many regions of the body. Giant neck lipomas are uncommon, especially when they arise from the neck and extend into the thorax. In this case report, we present a unique case of a giant submuscular lipoma involving the posterior neck triangle extending down to the scapular tip. A 43-year-old male presented with a six-month history of two slow-growing masses involving the left neck and scapular region. MRI demonstrated a single large fat suppressing lesion underlying the left trapezius muscle extending down to the scapula with homogenous signal return and smooth outline measuring 4.5x7.5 cm by 16 cm. Histology showed features consistent with lipoma. Giant lipomas in the neck post a significant diagnostic and surgical challenge. The importance of pre-operative planning and patient involvement in decision-making are essential.

Transoral Endoscopic Resection of Oropharyngeal Pedunculated Giant Fibrolipoma Using Harmonic Scalpel: A Case Report

Lipoma is the most common soft tissue benign tumor in the body. It can occur in the head and neck area as well. Fibrolipoma is a variant of lipoma that contains fibrous tissue. Fibrolipomas of the head and neck are relatively rare, and their presentation depends largely on their size and location; some slowly growing tumors might go unnoticed until they reach significant size and become symptomatic. Here, we report a case of 64-year-old male who presented with large pedunculated oropharyngeal fibrolipoma that originated from the posterior oropharyngeal wall and extended downward into the postcricoid area and cervical esophagus. It was excised transorally using rigid endoscope, and ACE Harmonic scalpel was utilized to excise this 16.7 cm long mass. The postoperative pain was minimal, the surgical site showed complete healing, and oral diet was resumed easily in 5 days.

Primary orbital pleomorphic liposarcoma in a child: A case report

Purpose

To report a rare case of primary orbital pleomorphic liposarcoma and present a relevant literature review.

Observations

An 11-year-old boy presented with an enlarging, painless lower right eyelid mass that was noted 4 months ago. Imaging revealed a 3.2 × 2.1 × 3.7-cm-sized well-circumscribed lobulated mass. Biopsy revealed a pleomorphic spindle cell neoplasm that was consistent with a pleomorphic liposarcoma. A systemic evaluation found no evidence of distant metastasis. Despite four chemotherapy cycles, the mass size increased at follow-up. Total orbital exenteration was performed 1 year after confirming a diagnosis of pleomorphic liposarcoma. At the 6-month follow-up, the patient was alive with no signs of recurrence.

Conclusions

Pediatric pleomorphic liposarcoma is a very rare entity. Its definite diagnosis relies on histopathological results. In the absence of systemic metastasis, total orbital exenteration is the optimal approach for local control.

Intramuscular lipoma of the temporalis muscle extending to the infratemporal fossa: surgical pitfalls and short literature review

Lipomas are benign tumours of mesenchymal origin, representing one of the most common tumours of the body. They are often observed between the fourth and the sixth decade of life and in 13% of the cases they occur in the head and neck region. In case of symptoms, surgical removal is the treatment of choice; when the formation involves the temporal region, the surgical approach is often challenging due to the presence of the neurovascular structures, such as the temporalis branch of the facial nerve and their potential extension to the nearby structures under the zygomatic arch to either the infratemporal fossa or the buccal region. Recurrence can occur frequently only if there is incomplete removal of lipoma. In this paper, the authors discuss surgical pitfalls of a very rare case of a large-sized symptomatic lipoma extended to the infratemporal and pterygomaxillary fossa, surgically removed via trans-zygomatic hemicoronal approach.

The recurrence of well-differentiated liposarcoma from benign giant intramuscular lipoma: A case (CARE-compliant) report

RATIONALE

Recurrent liposarcoma, previously confirmed as lipoma, has rarely been reported. However, the risk factors for recurrence and the correlation between benign lipoma and malignant liposarcoma remain unclear. In this case study, we suggest a precise diagnostic strategy to minimize recurrence and malignant transformation.

PATIENT CONCERNS

A 60-year-old male patient with a history of left chest wall swelling without any symptoms underwent excisional surgery, and the mass was confirmed as a benign lipoma in 2015. In 2019, the patient returned to the hospital with symptoms of a palpable mass on the left chest wall.

DIAGNOSIS

The mass was considered a recurrent lipomatous tumor with the possibility of malignant transformation. Magnetic resonance imaging (MRI) revealed a deep-seated, septate, intramuscular, irregular margin, and large lipomatous tumor invading the ribs, pleura, and adjacent muscle, suggestive of malignancy. The MRI findings were similar to those 4 years ago, except for margin irregularity and invasion to adjacent tissue.

INTERVENTIONS

Wide en bloc excisions encompassing the 5th to 7th ribs, pleura, and adjacent muscle were followed by reconstruction with a pedicled latissimus dorsi muscle flap.

OUTCOMES

The recurrent large lipomatous tumor was confirmed as well-differentiated liposarcomas through histological and MDM2-FISH immunohistochemical staining. Postoperatively, follow-up visits continued for 1.5 years without recurrence.

LESSONS

We suggest that deep-seated, septate, and giant lipomatous tumors should be considered as risk factors for recurrence with the possibility of malignancy and misdiagnosis. It is important to inform patients of all these possibilities and plan close and long-term follow-up.

From head and neck lipoma to liposarcoma: a wide spectrum of differential diagnoses and their therapeutic implications

PURPOSE OF REVIEW

To overview the array of differential diagnoses among lipomatous tumours of the head and neck with special focus on their evaluation, three-dimensional assessment, and their available treatments.

RECENT FINDINGS

The head and neck is an infrequent localization for lipomatous tumours, even though they represent the most common mesenchymal lesions. Lipoma, spindle cell/pleomorphic lipoma (SC/PL), atypical lipomatous tumour/well differentiated liposarcoma (ALT/WDLPS), de-differentiated liposarcoma (DDLPS), myxoid liposarcoma (MLPS), and pleomorphic liposarcoma (PLPS) are the most distinctive histotypes. Lipoma and SC/PL present alterations of chromosomes 12 and 13, ALT/WDLPS and DDLPS both show the Mouse Double Minute 2 amplification, whereas MLPS presents a CHOP gene fusion. Diagnosis of PLPS is purely morphological as there is no pathognomonic genetic alteration identified to date. Radiological assessment can be challenging for the presence of nonadipose components within the lesion. Surgery is the mainstay of treatment, even though achieving true radicality in terms of a large cuff of healthy tissue surrounding the tumour is not always realistic in the head and neck. Adjuvant radiation, eventually in combination with systemic chemotherapy, has been shown to improve overall survival in patients with positive margins, high-grade, deep, and more than 5 cm lesions. Further studies should be aimed at the evaluation of the role of hadron therapy, as well as targeted drugs against overexpressed proteins.

SUMMARY

Adequate differential diagnosis of the histotypes collected under the umbrella term of head and neck lipomatous tumours plays a fundamental role in treatment and follow-up of these lesions and requires specific expertise with referral to high-volume centres.

Giant Lipoma of the Anterior Neck Causing Dyspnea

Lipomas are the most common benign mesenchymal tumors, composed of mature adipocytes, and may occur anywhere in the body where fatty tissue is present. Neck lipomas are rare and usually appear as solitary, small (<5 cm), and asymptomatic lesions located in the subcutis of posterior neck. Giant anterior neck lipomas are exceptionally rare and, other than cosmetic concerns, seldom present with respiratory symptoms. A 37-year-old female patient was referred for a long-standing anterior and right-sided neck swelling, which had markedly increased in size causing cosmetic disfigurement, neck discomfort, and transient episodes of dyspnea when lying on the side opposite the neck mass. Under general anesthesia, the lesion was completely dissected and removed through the elliptical cervical incision over the right supraclavicular fossa, while carefully preserving the surrounding neck structures. The postoperative recovery was uneventful and the patient was satisfied with the cosmetic outcome and relief of her respiratory symptoms.

Lipoma Rarely Involving Multiple Suprahyoid Fascial Spaces: A Large Lesion Removed With Bimanual Transcervical Finger Dissection Using a "Push-Pull Down" Maneuver

Lipoma involving multiple fascial spaces is extremely rare and poses a challenge to surgeons using less invasive procedures. Although blunt dissection using a finger is often used in excisional surgeries as a supplementary maneuver, few cases have been described using the bimanual technique for the removal of these extensive lesions.Herein, the authors present a large lipoma of the oral floor extending to the unilateral submandibular and parapharyngeal spaces, which was excised only via a submandibular approach using the "push-pull down" maneuver, blunt finger dissection of the tumor with counter-pushing on the overlying mucosa to the submandibular direction facilitated tumor separation. The tumor was consequently pulled down and removed without an additional intraoral incision.Based on accurate preoperative examinations, this maneuver, provides a less invasive surgery for well-encapsulated benign tumors involving multiple fascial spaces.

Primary parotid liposarcoma

INTRODUCTION

Primary liposarcoma is very rare in the parotid gland. To date, only 8 cases of primary parotid liposarcoma have been reported. The aim of this study is to report on a case of primary parotid liposarcoma highlighting the complexity of its treatment and analyze treatment outcomes of other reported cases.

CASE SUMMARY

We report a case of parotid liposarcoma arising in the left parotid gland of a 66 year-old man, causing local morbidity, recurrence, repeated surgical treatment and death 5 months after initial treatment.

DISCUSSION

Parotid liposarcoma is marked by a high probability of local recurrence of up to 70% and is prone to distant metastatic spread, as was the case in our patient. Based on limited experience from published literature, optimal treatment entails radical surgery with negative margins. Postoperative radiotherapy is an option for patients with large high-grade tumors, positive margins and involvement of complex anatomic subsites. High-grade tumors have a worse outcome despite the addition of surgery and postoperative radiotherapy.

Primary dedifferentiated liposarcoma of the orbit, a rare entity: Case report and review of literature

Head and neck liposarcomas are rare entities accounting for less than 5% of all liposarcomas. The primary orbital location is even rarer, with about 40 cases described in the English literature. According with the widely accepted classification of Enzinger and Weis there are 5 histologic variants of liposarcomas: well differentiated, myxoid, dedifferentiated, round cell and pleomorphic. The first two are considered low-grade and display a favourable prognosis (>90% 5-year DSS and OS), whereas the dedifferentiated, round cell, and pleomorphic are defined high-grade and burdened with poorer prognosis (5-year DSS ranging 45-73%). Dedifferentiated liposarcomas (DDL) of the head and neck region are exceedingly rare, therefore there are scattered and contrasting data regarding their clinical history, treatment modality, and prognosis. We presented a case of DDL arising in the the left orbit (fourth case of primary orbital DDL described), free from disease after 5-year follow-up. Clinical history, treatment, and characteristics of the presented case were described and discussed in the light of how reported in the literature, in the attempt to bring further insight in the nature and management of this rare pathological entity.