A 43 year old male presented with giant fibrolipoma of the left thigh, recurrent for the 4th time. On contrast CT & MRI the tumor had massive adipose and non adipose components and enhanced heterogeneously with multiloculated mass engulfing the left femur and the femoral neurovascular bundle. The lesion was initially thought to be liposarcoma or spindle cell lipoma. At surgery the tumor was multiloculated with dense adhesions from the previous surgeries engulfing the left femur and the neurovascular bundle. Histologically, the tumor was diagnosed as fibrolipoma. Subcutaneous and intramuscular fibrolipoma are rare, and are defined as subtype of lipoma.
Lipomas are the commonest soft tissue tumor; subclassified according to particular morphological features as conventional lipoma, fibrolipoma, angiolipoma, spindle cell lipoma, myolipoma, pleomorphic lipoma, and nuerolipoma. Some of the variants have characteristic chromosomal abnormalities. For example, conventional lipoma often show rearrangement of 12q,14-15 and 13q and spindle cell and pleomorphic lipomas have rearrangement of 16q and13q1-3.
A 43 year old male patient presented with recurrent mass in the left thigh, operated three times before. The patient was complaining of diffuse swelling and pain that was increasing with walking and exercise. The patient underwent surgical excision of the lesion in 2005, 2006 and 2008 respectively. General examination revealed no abnormalities. The left thigh examination showed a diffuse swelling with an old healed longitudinal scar over the anterolateral aspect of the left thigh and wasting of the quadriceps muscles with superficial varicosities. There was no specific area of tenderness, and the knee displayed weak extension against resistance, and diminished knee reflex (Figure 1).
The distal limb examination revealed no abnormalities, normal neurological and vascular examination apart from the superficial varicosities at the distribution of the long saphenous system. The patient was admitted to the hospital, routine laboratory investigations was done, CT-scan, MRI & Doppler study of the left lower limb were done. CT-scan with contrast of both femur showing a large septated hypodense lesion in the left thigh occupying the whole length of the thigh anteriorly and posteriorly, anteriorly involving the vastus intermedious as well as vastus lateralis and sartorius extending to upper femur posteriorly involving the adductor magnus and hamstrings, displacing the femoral vessels, but the vessels had normal appearance (Figure 2). All the routine blood investigations were performed and the results were within normal limits. The decision was to proceed for surgery (Figure 3).
The operation started under spinal anesthesia, supplemeneds by general anesthesia in the last one hour of the surgery. The left thigh was approached through the old incision, which was excised, the deep fascia was opened laterally to fascia lata and medially to the rectus muscles. The extension of the wound was performed from the top of the incision inferomedially. Multiple lipomas were dissected laterally underneath tensor fascia lata up to the greater femoral trochanter, medially a multiloculated lipoma surrounding the femoral vessels was noticed. The femoral vessels were dissected and isolated. Two lipomas which were deep and attached to anteromedial aspect of femur adhered to the periosteum extending down up to the lower 1/3 of femur. Long saphanous vein was ligated. Total excision was done. The weight of the excised tumor was 2.7kg. The wound was closed in layers . The patient underwent smooth postoperative period and was discharged well after two days.
The histopathological report documented that the tumor contained mature adenocystes with fibrous tissue with no malignancy and consistent with fibrolipoma (Figure 4 & 5).
Most lipomas are painless except angiolipoma which is painful4. Multiple lipomas are sometimes related to certain conditions like neurolipomatosis, and Dercum’s disease (adiposis dolorosa)1,5-6. According to the anatomical position lipomas can be subcutaneous, subfascial like in the palmer or plantar fascia, subsynovial from the fat pad around the joint, intraarticular, intramuscular mainly in the thigh or around the shoulder, sometimes hardly distinguished from fibrosarcoma. Subserous lipoma can grow beneath the pleura. Submucous lipoma occurs underneath the mucous membrane of respiratory or alimentary tract, larynx, tongue, and intestine. In the intestine is likely to cause intussusception. Intraglandular lipoma may be found in the pancreas under the renal capsule and in the breast. Retroperitoneal lipomas can be seen in the retroperitoneal space, some of which turn into liposarcoma1,4-6.
Fibrolipoma is a subtype of the intramuscular lipomas. Owing to transmitted pressure, the tumor becomes firmer when the adjacent muscles are contracted. Weakness or aching results owing to mechanical interference with the muscular action. The surgery is sometimes challenging and needs a meticulous technique. Yet there is a chance of recurrence.
My sincere thanks to Dr. Haridas and Dr. Qabas Malik for their support for this surgery and Dr. Wasna Ali, pathologist who gave the histopathological report
1. SabistonDC. Textbook of surgery, 18th edition. Philadelphia, Saunders publishers 2007;786-97.
2. GreenfieldLJ. Scientific principles & practice of Surgery, 3rd edition. Washington, Lippincott Williams &Wilkins 2001;2380.
3. Norton JA, Bollinger RR, Change AE, et al. Surgery : Basic Science and Clinical Evidence, 1st edition. new York, springer 2001;2170.
4. Kumar V, Abbas A, Fausto N. Robbins and cotran pathologic bases of disease, 7th edition.Philadelphia, Saunders, 2004;1552.
5. Russell RCG, Williams NS, Bulstrode CJK. Bailey and loves short practice of surgery, 23rd edition.London,Arnold, 2000;150-2.
6. Arianne P, Christopher L, Jan-Willem L, et al. Nosocomial Infections after Peripheral Arterial Bypass Surgery. World J Surg 2007;31(8):1687-92.
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