A Pathologically Benign, but Clinically Pathologic Neck and Mediastinal Lipoma

   

John C Lin^1*, Shamsuddin Khwaja¹, Kirellos Zamary², Tyler C Ky³, Amna Ali⁴ and Kyle McCullough⁴

Received: January 25, 2022 | Published: February 25, 2022

Copyright ^©️ 2022 genesis pub by Lin CJ, et al.  CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0  International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

Abstract

Lipomas are benign mesenchymal tumors that are generally found in the subcutaneous tissue but have been reported in virtually all organs throughout the body. We present a rare fibrolipoma of a 78-year-old female involving the neck and the mediastinum causing airway and cardiovascular compression.  This patient underwent a staged resection, first addressing the neck component to relieve the airway compression, then addressing the intrathoracic portion via a right thoracotomy.

Introduction

Lipomas are benign, well-circumscribed, mesenchymal-derived tumors that are generally found in the subcutaneous tissue but have been reported in virtually all organs throughout the body. Only 13% are found in the head and neck, and even less in the mediastinum or chest. Lipomas are reported to represent only 1.6-2.3% of all mediastinal tumors. Although often slow growing and asymptomatic, at larger sizes they may contribute to symptoms of dyspnea, dysphagia, cardiac arrythmias, or even cause death from mass effect.

Clinical Summary

The patient is a 78-year-old female with a history of mediastinal tumor status post resection 20 years ago via a median sternotomy, who presented to the ED with dyspnea and cough. She was noted to have a large left neck mass and within an hour of presentation was intubated for acute hypoxic respiratory failure.  A CT scan (Figure 1, Figure 2) demonstrated 21x29 cm mass extending from the neck, through the thoracic inlet and displacing several mediastinal structures with extension to the diaphragm. There was tracheal and esophageal deviation to the right associated with partial airway obstruction. Although clinical and radiological findings were suspicious for a sarcoma, two biopsies confirmed fibrolipoma.

Figure 1: Mass extending from the neck, through the thoracic inlet (red arrow).

Figure 2: Mass within the thoracic cavity displacing several mediastinal structures with extension to the diaphragm (red arrow).

The patient was taken to the OR following resuscitation. She underwent a staged resection, first via a cervical approach, followed by transthoracic mediastinal debulking. Resection of the mass was performed via a left neck incision from the sternocleidomastoid to the thoracic inlet. The tumor measured 10x15cm and was noted to be firm and well-circumscribed.  She tolerated the procedure well, was extubated on the fifth post-operative day and discharged on the ninth post-operative day.

The following month, she was taken for a mediastinal tumor debulking via a right thoracotomy. Due to her age, the lipoma’s slow growth, the involvement of the aortic arch and its branches, we decided to limit the debulking to the right chest.  The mass was well-circumscribed, and was dissected free from the esophagus, the azygous vein, the pericardium, and the diaphragm (Figure 3). She tolerated the procedure and was extubated on the second post-operative day. Her postoperative course was complicated by a chylothorax which improved with a low-fat diet. She was subsequently discharged home. The patient’s six-month follow-up CT scan demonstrated a stable mass in the left chest measuring 13.7x13.2x11.4 cm.  Now, six years later at the age of eighty-five, she continues to deny any dysphagia or dyspnea. The mass has since grown to 17.5x11.2x14 cm but the patient remains asymptomatic.