TWO CASES OF LIPOMA*

GEORGE WEBB, M.D., P.A.C.S.

BROOKLYN, N. Y.

B ECAUSE of the unusuaI size and Iocation of the Iipomata in the 2

cases described beIow their record is considered of vaIue.

CASE I. A. N. male, aged thirty-two, white, was admitted to the Prospect Heights HospitaI May 2, 1930 with the history of a sweIIing of the right thigh of twenty years’ duration. Three months ago the sweIIing began increasing in size and causing some pain. Recent trauma couId not be estabIished in the history. During the years of the WorId War the thigh had been subjected to constant irritation ‘in the saddle.

PhysicaI examination was entireIy negative, except for the IocaI findings of the right thigh. This was 7 cm. Iarger in circumference than the Ieft at a point midway between the greater trochanter and the upper border of the pateIIa. This enIar&ement was due to a tumor occupy- ing the entire antero-media1 aspect of the thigh. With the muscIes of the thigh reIaxed the tumor was soft, not movabIe on the underIying tissue, the size and shape of a smaI1 watermelon, giving an indefinite sense of fI uctuation. This pseudo4 uctuation dis- appeared, however, when the muscles of the thigh were tensed. No IobuIes couId be made out. The paIpation was quite painIess. T.P.R. as we11 as a11 Iaboratory findings were within norma Iimits.

Preoperative Diagnosis: Deep-seated inter- muscuIar Iipoma of the right thigh.

Operation: Under gas-oxygen anesthesia an incision 20 cm. Iong was made over the most prominent part of the swelling in the Iong axis of the thigh. The fascia was incised to the same extent exposing the vastus externus. The fibers of this muscIe were separated in its upper and lower portions and through these windows the fatty growth was enucIeated. The Iipoma extended from Scarpa’s triangIe to the point of insertion of the fIexors of the thigh on the media1 aspect of the knee. It lay immediateIy upon the femur and was intimateIy connected with the periosteum by dense fibrotic

bands. The capsuIe of the Iipoma was we11 deveIoped and very vascuIar. At the Iower poIe of the tumor the vesseIs formed a pro- nounced pedicIe which was Iigated. The dead space was obIiterated by pIicating the vastus muscIe which measured about twice its norma Iength. A Penrose drain was placed into the Iower angIe of the wound, reaching into the region of the vascular pedicIe. The fascia and skin were closed in Iayers and the patient was urged to use the limb in bed.

The pathologist reported the tumor as a simple lipoma with increased fibrous interstitial tissue and markedIy rich vascuIarity. The tumor weighed 6 Ib., and measured 21 X 16 X 16 cm. The accompanying iIIustrations give a good idea of the cIinica1 and pathoIogica1 characteristics of the tumor.

The convalescence was entireIy uneventfu1. The drain was removed within forty-eight hours and three weeks following the operation the patient was entireIy free of pain and we11 able to use the leg.

Though adipose tumors of this size and even Iarger are quite commonIy met with in the subcutaneous tissues they are extremeIy rare within the deeper struc- tures. As far as their reIationship to the surrounding muscIes is concerned attempts have been made to cIassify them into intramuscuIar and intermuscuIar varieties depending upon whether the tumor is situated between individua1 muscIes or muscIe groups or whether it is confined within the beIIy of any one muscIe. Since the characteristic quaIities of the tumor remain identica1 in both cases it seems un- necessary to maintain any such artificia1 cIassification and the term deep-seated would be sufficiently descriptive of this type of growth.

The diagnosis of deep-seated Iipomata is usuaIIy simple, if their Iong history, the absence of pain and fluctuation and their

* Submitted for publication July 13, 1931. 522

NEW SERIES VOL. XVI, No. 3 Webb-Lipoma American Journal of Surgery 523

characteristicafty eIastic consistency are noted. Some difhcuhy in their differentia- tion may be encountered in the thigh a.nd the back where the overIying groups of muscIes are large and paIpation is diffrcuIt. In these Iocations adipose tumors may be mistaken for coId abscesses. The function of the overIying muscles wiI1 usuahy cIear this point up, inasmuch as their contrac- tion is norma in extent and painIess over a fatty tumor and guarded, incompIete and painfu1 over an inflammatory exudate. The occasion shouId never arise for ex- pIoratory puncture of such sweIIings for diagnostic purposes.

HistoIogicaIIy these deep-seated Iipomata differ but sIightIy from the subcutaneous variety. The capsuIe is usuaIIy very we11 deveIoped, the amount of fibrous tissue and the vascuIar suppIy are generaIIy definiteIy increased. Their treatment is obviousIy surgica1 remova1.

CASE II. h&-s. C. H. white, thirty-four years old, was admitted to the Coney IsIand HospitaI with the compIaint of subsiding pain in the right lower quadrant of three days’ duration accompanied by nausea, vomiting and constipation.

For the past ten years the patient had com- pIained of a duI1 ache in the right lower quadrant, increasing on vioIent exercise and at night when Iying on her right side. Occa- sionally this pam had been referred to the epigastrium and was then accompanied by nausea. Patient has aIways been somewhat constipated and has passed severa blood- streaked stools within the past six months. Her appetite has aIways been good and her weight has remained constant. Both her marita1 and menstrual histories were negative.

Three days prior to admission to the hospital the patient experienced a severe pain in the right lower quadrant, and vomited once. Her temperature remained norma and her howeIs moved twice that day. The stoo1 was Iiquid but free of blood. Toward the evening of the same day the vomiting recurred, the pain increased and became cramp-Iike in character. A physician diagnosed an attack of acute appendicitis and ordered opiates and an ice bag. Next day she feIt considerabIy improved. The stoo1 was normal but the pain in the Iower

abdomen persisted a11 day. On the morning of the third day operation for subsiding appen- dicitis was advised by the attending physician,

FIG. I. View of Iipoma before operation.

whereupon the patient was admitted to the Coney Island Hospital.

She was found to be suffering considerable pain. The right lower extremity was held flexed. The head and chest were negative. The abdomen was soft except for the right Iower quadrant where there was pronounced muscIe spasm on paIpation. The suprapubic area was soft and painless, whereas there was marked tenderness over h4eBurney’s point. There was an indefinite mass paIpabIe at this point which could not be outlined satisfactorily because of muscle spasm. Pelvic examination was negative. There was no vagina1 discharge. HemogIobin 85 per cent. Red blood corpuscles, 800,ooo; white blood corpuscles, I I ,000. Differential count normal. Urine negative. Temperature, 99.4%., pulse, 80, respiration 11. A preopera- tive diagnosis of subsiding acute appendicitis was made.

At operation the gal1 bIadder was found to be soft, compressible and did not contain any caIcuIi. The stomach, spIeen and peIvic organs were normaI. The cecum was gIued to the parietal peritoneum and contained a mass about the size of a tangerine within its lumen. This mass did not pit on pressure, was elastic and was firmIy attached to the posterior aspect of the cecum whereas the anterior wall of the cecum couId be freeIy moved over the surface of the tumor. The iIeoceca1 region was slightly invaginated into the ascending coIon and was edematous. The appendix was norma in size,

524 American Journal of Surgery Webb-Lipoma JUNE, 193.2

coIor and position. There were no periappen- an isoperistahic anastomosis done. The abdo- dicea adhesions. .Upon recognition of the men was then cIosed without drainage. tumor in the intestine the ileum was cIamped The pathoIogist reported the tumor as a

FIG. 2. Tumor removed from Case I.

off 8 cm. from the iIeoceca1 junction. The cecum was mobiIized by incising the peritoneum in the IateraI Iumbar gutter and cIamped we11

a b

.~~!r~~!!~~~~~~~~~~~~~~~~.;i~~_~

FIG. 3. Specimen of submucous lipoma of cecum. a, Area of necrosis. 6, Mucosa of cecum. c. Mucosa of &urn.

above the tumor mass. Both bowe1 ends were cIosed with three Iayers of catgut sutures and

Note pressure furrow (arrow) of femur.

simpIe Iipoma, submucous, having an area of necrosis about the size of a siIver doIIar on its free surface inside the Iumen of the cecum.

The ConvaIescence was entireIy uneventfu1 and at a reexamination six months Iater the patient was entireIy free of abdomina1 symptoms.

A tota of 181 Iipomata of the gastro- intestina1 tract have been described in the Iiterature of which 16 only were confined to the cecum. The present case, as we11 as the two pubIished by RatcIiff,’ shouId be added to the previous ones bringing the grand tota up to 184. The symp- tomatoIogy of a benign tumor of the cecum in a quiescent stage is most indefinite. The obvious, outstanding symptom would be obstruction in its chronic, subacute or acute form. This may be produced by bIocking of the Iumen of the bowe1 by the tumor mass itseIf, if Iarge enough, or by invagination of the bowe1 by constant traction in the Iine of peristaIsis. In the Iatter form it wouId be reasonabIe to expect peritonea1 reaction of a miId nature

IRatcIiff, R. A. Submucous Iipoma of the colon. Guy’s Hosp. Rep., 80: 453, rg3o.

NEW SERIES VOL. XVI, No. 3 Webb-Lipoma American Journal of Surgery 525

in response to the continuous IocaI circuIa- tory disturbances. Thus a variety of gastro- intestina1 symptoms may appear, such as nausea, vomiting, constipation or diarrhea, none of which rnay be regarded as pathog- nomonic of benign tumors of the boweI. The diagnosis therefore cannot be antici- pated on the history aIone as it is possibIe in other gastrointestina1 diseases. PaIpation of a tumor and x-ray evidence of a fiIIing defect in the cecum might heIp materiaIIy to make a definite diagnosis, but both of these signs can seIdom be obtained. The patients seek relief usuaIIy when an acute caIamity has occurred. We are then con- fronted with the picture of an acute obstruction in the presence of which few men are wiIIing to order a gastrointestina1 x-ray examination, or the peritonitis syn- drome is in the foreground which effectuaIIy precIudes detailed and successful paIpation and x-ray studyy.

In the case described here an indefinite mass was made out at examination but it was attributed to the probable appendicea1 exudate. RoentgenoIogicaI examination did not seem to be indicated in the presence of a definite diagnosis of a subsiding appendicitis.

These cases have been reported because of their comparative rarity and for the purpose of recording them. From the second case, however, we have an impor- tant lesson to Iearn. That is, that a seem- ingIy simpIe appendectomy, undertaken onIy too frequentIy by men of meager surgical experience, may turn out to be a formidabIe major procedure. It devoIves therefore upon every surgeon wishing to do justice to his patient to be prepared to make an intra-abdomina1 diagnosis of any unusua1 pathoIogica1 condition and to be competent to carry out the indicated major procedure.

REFERENCES OF DR. SHUTE*

MAUCLAIRE. Bull. et mem. Sot. nat. de cbir., 53: 583,

MCILROY, A. L. J. Obst. and Gyn. Brit. Emp., 18: 368, 1927.

1910. MENGE, K., and VON OETTINGEN, K. In Veit-Stoeckel’s

Handbuch der Gyn., Ed. 3, x930, I : 549.

MICHEL, B. Zentralbl. j. Gynaek.. 46: 905, 1902. MICHEL, B., and GUIBAL, J. Bull. Sot. d’obst. et de

gynec., 17: 160, 1928. MICHON, M. L. Lyon med., 136: 7, 1925. MICHON, M. L. Gynec. et d’obst., 21: 103, 1930. MICHON, hl. L. Lyon cbir., 27: 359, 1930. MICHON, M. L. and COMTE. Lyon med., 137: 40, ~926. MICHEL, G., and VERMELIN, H. Bull. Sot. d’ obst. et.

de gynec., 17: ~57, 1928. MICHAEL, P. R. Abst. in J. de Cbir., p. 369, March

25, 1925. MICHALIKOWA, E. Abst. in Zentralbl. j. Gynaek.,

53: 2883, rgzg. MILES, L. M. Minn. Med., IO: 453, 1927. MOREL. Bull. et mem. Sot. anat. de Paris, Dec. 1903.

Abst. in J. Obst. Ed Gyn. Brit. Emp., 5: 483, 1904. MUIR, J. B. G. Brit. M. J., 2: 730, 1930. MURRAY, I-I. L. Abst. in Zentralbl. j. Gynaek., 48: 392,

1924. MVNROE, H. S. J. M. A. Georgia, 6: 169, 1917. MURARD, J. Bull. et mem. sot. nat. de cbir., 55: 1319, 1929. NASH, W. G. Lancet, I: 78. 1922. NEUGERAUER, F. Zentralbl. j. Gynaek., 46: 1961, 1922.

NICHOLSON, E. Abst. in Zentralbl. j. Gynaek., 52: No.

NORRIS, C. C. Am. J. Obst., 63: 850, 1911. OGOREK, M. Arch. j. Gynaek., 102: 300, 1914.

32, 2071, 1928.

OGOREK, M. Arch. j. Gynaek., 103: 284, 1914. OHMSTEDE. Abst. in Zentralbl. j. Gynaek., 53: No. 39,

2500, 1929. PAUCOT and MERURISSE. Bull. Sot. d’obst. de Paris,

17: 721, 1928. PAYR, E. Deutscb. Ztscbr. j. Cbir., 85: 392, 1906. PIREAUX. Arch. med. Beiges, 79: 161, 1926. POZZI, S. Rev. de Gyn. et de Cbir. Abdom., 4: rg5, Igoo. ROBINSON, A. L. Clin. Jour., 57: 476, 1928. ROCHER and JEANNENEY. Bull. et mem. Sot. nat. de

cbir., 52: 294, 1926. ROGERS, L. &it. M. J. I: 778, 1925. ROLL. Abst. in Smith and ButIer: Am. J. Obst. e+

Gynec., 2: 507, 1921. ROST, W. L. Arch. Paed., 40: 787, 1923. RUDER. Zentralbl. j. Gynaek., 45: 45, 1920. SCHAUTA, F. Lebrbucb d. Gesam. Gyniik., Bd. T., pp.

405-410, 1897. SCIIREINER, R. Zentralbl. j. Gynaek., 52: No. 18: 1139,

1928. SCHROER, H. Abst. in Zentralbl. j. Gynaek., 51: 3139,

1927. SCHWEITZER, B. Zentralbl. j. Gynaek., 44: No. 19, 487.

1920.

SCHWARTZ, J. Zentralbl. f. Gynaek., 46: 1959, 1922. SCHEID, F. Zentralbl. j. Gynaek., 46: 1485, 1922.

[For remainder of References see p. 528.1

* Continued from p. 521.