Axillary giant lipoma with brachial plexus compression: Rare presentation with diagnostic dilemma and review literature

Satya Prakash Meena; Ashok Puranik; Pawan Kumar Garg; Meenakshi Rao

doi:10.4103/JME.JME_119_20

CASE REPORT

Year : 2022 | Volume : 3 | Issue : 2 | Page : 161-163

Axillary giant lipoma with brachial plexus compression: Rare presentation with diagnostic dilemma and review literature

Satya Prakash Meena¹, Ashok Puranik¹, Pawan Kumar Garg², Meenakshi Rao³
¹ Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
² Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
³ Department of Pathology and laboratory medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission	09-Jul-2020
Date of Decision	29-Jul-2020
Date of Acceptance	06-Feb-2021
Date of Web Publication	04-Jun-2021

Correspondence Address:
Dr. Satya Prakash Meena
Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_119_20

How to cite this article:
Meena SP, Puranik A, Garg PK, Rao M. Axillary giant lipoma with brachial plexus compression: Rare presentation with diagnostic dilemma and review literature. J Med Evid 2022;3:161-3

How to cite this URL:
Meena SP, Puranik A, Garg PK, Rao M. Axillary giant lipoma with brachial plexus compression: Rare presentation with diagnostic dilemma and review literature. J Med Evid [serial online] 2022 [cited 2023 Jun 3];3:161-3. Available from: http://www.journaljme.org/text.asp?2022/3/2/161/355004

Introduction

Lipoma is a benign soft-tissue tumors and originates from mesenchymal tissue. Giant lipomas are larger than 5 cm size and axilla is a rare location of giant lipoma.^[1] Lipoma can present anywhere in the body, hence it is called a universal tumor. More than 50% of soft-tissue tumors are lipoma and the most common location are extremities, back, shoulder, and nape of neck.^[2] Usually, patients need medical attention when they have difficulty to wear clothes and feel social embarrassment due to cosmetic reasons. Few cases have been reported for median, ulnar, radial, or brachial plexus compression with large lipoma.^[3] The aim of reporting this case is an axilla is rare location of giant lipoma and our case had the largest size of axillary giant lipoma, causing brachial plexus compression neuropathy.

Case Report

A 53-year age male patient presented with a complaints of swelling left axilla and arm for 10 years. The swelling was also associated with complaints of forearm pain during movement and numbness over the same hand for 4 months. The patient had no difficulty in joint movements or deformity of the fingers, however, had appreciable weakness in the handgrip. Clinical examination revealed, a large swelling of size 35 cm × 10 cm size, located in the left axilla, extending to the upper arm, lateral chest wall, and anterior shoulder [Figure 1]. Peripheral pulsation in the left upper limb was normal. The muscle power was grade 4/5, however, no muscular atrophy seen. The sensory loss, numbness, and paresthesia present over the ulnar aspect of the left forearm and hand. All blood investigations were normal. Magnetic resonance imaging (MRI) scan and Computed tomography angiogram revealed a soft-tissue mass (size 32 cm × 8.2 cm × 8.2 cm) with a septated fatty component seen in the floor of the axilla extending up to the medial group muscle of the upper two-third arm and the and lateral chest wall. The mass was causing displacement of the left subclavian, axillary, brachial artery, closely abutting the radial nerve and encasing the neurovascular bundle in the axilla [Figure 2]. The patient had no muscle invasion, bony involvement, and tumor extension in the lung parenchyma. Radiological findings suggested lipomyosarcoma and revealed no metastatic lesion in chest and abdomen. Preoperative tru-cut biopsy suggested atypical lipomatous lesion likely Liposarcoma. The patient underwent excision biopsy in general anesthesia. After a lazy S-shaped incision, meticulous dissection was done in intermuscular planes of the arm, anterolateral chest wall, floor of axilla in-between axillary vessels and brachial plexus. Intraoperative findings revealed a large axillary tumor extends to the anterolateral chest wall and anterior shoulder. The brachial plexus and axillary vessels were compressed due to the pressure of large and long-standing tumor in narrow space of axilla. The lipomatous tumor had displaced the brachial plexus about 12 cm distal to the axilla, hence the normal anatomy of axilla was obscured. The frozen section suggested benign pathology. The whole tumor was encapsulated, soft to firm in consistency, and excised completely without any difficulty and complication. The tumor did not have any component of muscle and was not invading the muscles in the local area. The specimen measured in 32 cm × 12 cm × 8 cm, weighing 1800 g [Figure 3]a. In the postoperative period, the patient had weakness of interosseous, lumbricals, abductor policis brevis, opponens policies muscles, and sensory loss of part innervated by the ulnar nerve. The patient was discharged on a postoperative day 5 with mild weakness of the left upper limb. Final histopathology revealed partially encapsulated lesion comprising of lobules and sheet of adipocytes separated by fibrovascular septa, along with a myxoid area with elongated cells having a blended nucleus. No fibroblast or malignant cells were seen [Figure 3]b. Axillary lymph node showed reactive lymphoid hyperplasia suggestive of mixolipomatus with secondary changes. The patient underwent active physiotherapy and improved well with motor and sensory function within 6 months. He had no recurrence at 1 year of follow-up [Figure 3]c.

Figure 1: A large swelling in the left axilla extends to upper arm, lateral chest wall, anterior shoulder

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Figure 2: Computed tomography angiography image of thorax and left arm axial (a-c), coronal (d) and coronal maximum intensity projection (e) images showing a large well-defined fat density mass (white arrow) extending from left axillary region to upper 2/3^rd of the left arm. The mass is showing internal soft-tissue component and septations. The mass is causing displacement of the left subclavian, axillary, and brachial artery (black arrows) with no invasion

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Figure 3: Image showing the excised specimen of size 32 cm × 8 cm × 12 cm size. Arrow marking showing region of lipomatous tumor compressed between axillary vessels and brachial plexus. (a) Low power view of a capsulated tumor composed of lobules of mature adipocytes (H and E, ×10) (b) Postoperative follow-up image of the patient (c)

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Discussion

The mechanism of giant lipoma formation was not clear, but favoring the proposed theory is that after any blunt trauma, rupture of fibrous septa accompanied with separation of anchorage between deep fibrous layer and skin, which cause of uncontrolled adipocytes proliferation. About 10% benign lipomas have an axillary location without brachial plexus compression neuropathy. MRI is the most preferred imaging for soft-tissue swelling for better soft-tissue resolution and distribution.^[4] Usually, lipomas are solitary and remain asymptomatic, although large internal lipomas can cause pain or pressure symptoms on other organs and may undergo sarcomatous changes.^[5] Few reports suggested that a tumor larger than 5 cm, located in intramuscular or subfascial plane is relatively has sarcomatous differentiation.^[6],[7] There are various types of minimally invasive treatments of lipoma like liposuction; however, surgical excision is the most favored treatment to prevent neurovascular injury and recurrence. Previous literatures reported a wide range postoperative period to resolve neurogenic symptoms, however, most of the patients were improved after getting active physiotherapy. The largest size of axillary giant lipomatous tumor of benign pathology has been reported as 23.35 kg weight and 50 cm × 30 cm size, however not associated with any neurological symptoms.^[8] Another two cases were reported for thoracic outlet syndrome due to large lipoma with brachial and vascular compression.^[9]

In our case, radiological imaging's reported a lipomyosarcoma and encasing neurovascular bundles in the axilla. Neurological symptoms and preoperative histopathology also favor the diagnosis of liposarcoma. However, the intraoperative findings and histopathology report suggested as benign lipomatous tumor. Due to the diagnostic dilemma of this patient, surgical excision was a great challenge for us.^[10],[11] The preferred treatment of liposarcoma is radical local excision and the patient has more chances of morbidity. The largest reported axillary lipoma, causing brachial plexus compression was 15 cm × 11 cm × 2 cm in size.^[3] Some of the literatures also have reported giant liposarcoma of axillary location, causing brachial plexus compression.^[12] Therefore, we are reporting the largest size of axillary giant lipoma with brachial plexus compression neuropathy and experience of preoperative diagnostic dilemma.

Conclusion

Axillary location and brachial plexus compression are very rare presentation of benign lipomatous tumors. To the best of our knowledge, we are reporting largest size of axillary giant lipoma associated with brachial plexus compression neuropathy. Preoperative diagnosis with imaging and biopsy may difficult to rule out liposarcoma due to the complexity of location.

Ethics

Informed consent has been obtained from the patient for publication of the case report and accompanying images. Ethical committee permission not required.

Acknowledgments

We thank Dr. Mahaveer Rodha, Additional Professor, Trauma and Emergency (General Surgery) for his careful proofreading of the final manuscript.

Declaration of patient consent

The patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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