Exceptional etiology of a huge pedunculated chest wall tumor with over 40 years of evolution: A case report

Abstract

Introduction and importance

Chest wall tumors are common and predominantly benign. Exceptionally, long-standing evolution over decades can lead to the development of giant tumors, posing substantial technical and strategic challenges in determining the optimal surgical approach.

Presentation of case

We report a rare case of a giant pedunculated chest wall lipoma that had been growing for over 40 years in a 73-year-old man. CT scan revealed a mass with a 5 cm-suprascapular-implantation base, hanging posteriorly and mimicking a pseudo-limb, measuring 17 × 7 cm in diameter and 34 cm in length. Complete surgical resection was performed, and histopathology confirmed a benign lipoma with no signs of malignancy.

Clinical discussion

To our knowledge, this is the first reported case of a huge lipoma with more than 40 years of evolution and an unusual pedunculated presentation resembling a third upper limb.

Conclusion

This case is exceptional due to its pedunculated appearance resembling an additional limb, and a slow evolution over more than 40 years. Complete surgical resection ensures a favorable prognosis.

Highlights

• •Huge pedunculated chest-wall tumor with over 40 years of evolution
• •Huge lipoma of 34 ∗ 17 ∗ 7 cm attached above the scapula and extending along the back
• •Case discussed at the multidisciplinary thoracic oncology tumor board
• •Complete en-bloc resection with wide safety margins
• •Skin closure without flap coverage or reconstruction or plastic surgery referral

1. Introduction

Primary chest wall tumors arise from muscle, fat, blood vessel, nerve sheath, cartilage, or bone of the chest wall. Primary chest wall tumors, which account for approximately 5 % of all thoracic neoplasms, have an incidence of less than 2 % in the general population; among them, 50–80 % are malignant, with 55 % arising from bone or cartilage and 45 % from soft tissue [1,2]. Chest wall lipomas are rare, and those of giant size (greater than 10 cm in diameter or weighing over 1 kg) are exceptionally reported in the literature [[3], [4], [5], [6]]. We present a case of a giant 34 cm-pedunculated chest-wall lipoma with more than 40 years of progression. This case report has been reported in line with the SCARE checklist [7].

2. Case presentation

A 73-year-old man from a rural area, with a history of diabetes, presented with a right suprascapular dorsal mass evolving for over 40 years. The mass had been progressively enlarging and became pendulous in the retro-scapular area. Despite increased heaviness and discomfort, the patient had neglected the mass until skin ulcerations developed due to friction with clothing and contact with the bed. Physical examination revealed a pedunculated mass, measuring approximately 5 cm at its base of attachment, located above the scapula and extending along the back. The lesion was firm in consistency, mobile at its pedunculated segment, but exhibited deep fixation to the superior and posterior thoracic wall, suggesting adherence to underlying thoracic structures (Fig. 1). The patient's vital signs were stable and within normal limits. Laboratory investigations, including tumor markers, were unremarkable. Two ulcerated areas of 9 and 7 cm, respectively, became superinfected with foul-smelling discharge. A chest CT-scan revealed a heterogeneous mass of fat density, without a distinct capsule, arising from a suprascapular implantation base and extending along the posterior scapular region (Fig. 1). The pedunculated, multilobulated, hypervascular mass measured 34 cm in length and 17 × 7 cm in diameter. The implantation base measured 5 cm, seemingly arising from the right trapezius muscle. The imaging features suggested a lipoma or possibly a liposarcoma, given the heterogeneous and hypervascular appearance. Biopsy was not considered, as the tumor could be completely resected with adequate margins (>3 cm). The case was discussed at the multidisciplinary thoracic oncology tumor board in our university hospital. A decision was made to proceed with a complete en bloc resection with wide safety margins, given the possibility of a sarcoma. In the event that primary closure of the resulting defect would not be feasible, the thoracic surgery team performing the procedure would be assisted by the plastic surgery team for possible reconstruction using a musculocutaneous flap. A wide arciform 10 cm incision was made along the lower border of the mass (Fig. 2). The tumor was lifted upward to begin dissection through non-fibrous areas. No signs of deep chest wall invasion were noted. Nevertheless, en-bloc resection was performed, including adjacent muscle tissues around the tumor base up to the deep chest wall. Skin closure was straightforward without the need for flap coverage or reconstruction or plastic surgery referral, using a Redon drain. The surgical procedure lasted 128 min, encompassing the incision closure and the application of the final dressing. Given the depth of the resection and the residual cavity in the suprascapular area, prolonged drainage was maintained to avoid seroma formation. The specimen weighed 1100 g (Fig. 3). Postoperative recovery was uneventful, and the drain was removed 10-days after surgery. Histopathology confirmed a benign giant lipoma with no signs of malignancy. No recurrence or complications were noted after a one year follow-up.

Fig. 1.

Clinical presentation of the pedunculated tumor of chest-wall and its aspect on CT scan showing heterogeneous fatty density mass (17 × 7 × 34 cm) with a 5-cm base implantation.

Fig. 2.

Tumor en-bloc resection and wound closure after specimen removal.

Fig. 3.

Specimen after complete en-bloc resection on both sides.

3. Discussion

Chest wall tumors are rare lesions originating from vascular, peripheral nerve, bone, cartilage, or adipose tissues. Lipomas account for 5 % of soft tissue tumors and are considered giant when the minor axis exceeds 10 cm or the weight exceeds 1 kg [8,9]. Thoracic-wall lipomas are more frequent in women [10], unlike in our case. These tumors typically present between 50 and 70 years of age and are characterized by large, deep, poorly circumscribed masses with broad implantation bases [3]. Most reported giant lipomas have a broad base with the chest-wall [[3], [4], [5], [6]]. To our knowledge, this is the first reported case of a giant pedunculated lipoma attached to the posterior chest wall. Diagnosis is based on clinical presentation (often asymptomatic), modes of revelation (compression symptoms), evolution (ulceration or superinfection as in our case), imaging findings, and intraoperative observations [3,5,6]. Chest X-ray has limited utility in pedunculated or extra-thoracic lesions. CT is the preferred imaging modality to assess morphology, composition, location, extent, and possible loco-regional invasion [10]. In our case, CT showed a multilobulated, hypervascular, fat-density mass with enhanced vessels suggesting liposarcoma. Although rarely used in routine practice, magnetic resonance imaging (MRI) can offer additional diagnostic value in giant or atypical chest wall lipomas [11]. MRI helps delineate the lesion's margins, internal structure, and its relationship to adjacent muscles and neurovascular structures, and can assist in distinguishing benign lipomas from liposarcomas based on signal characteristics and presence of thick septa or nodular enhancement [12,13]. While lipomas appear as homogeneous, mature fat with high T1 signal intensity, well-differentiated liposarcomas—typically seen in patients aged 40–50—exhibit thick (>2 mm), irregular enhancing septa, nodular nonadipose areas, and contain less than 75 % fat, with variable gadolinium enhancement of the nonadipose components [14]. Due to its pedunculated nature and feasibility of complete excision, a mass biopsy was not performed for our patient. Surgical excision remains the gold standard for treatment. In our case, resection was facilitated by the pedunculated nature and performed without reconstruction. Complete excision of giant lipomas usually carries a favorable prognosis with minimal risk of recurrence [3,6]. However, a few cases of malignant transformation into liposarcoma after primary lipoma excision have been reported, mainly in men over 60 years [15,16].

This case highlights an exceptionally rare giant pedunculated chest wall lipoma measuring 34 cm, with more than four decades of progression, successfully managed through complete en bloc resection after multidisciplinary planning. The surgical approach achieved wide safety margins without the need for complex reconstruction, and the patient remained recurrence-free after one year of follow-up. The report enriches the limited literature on giant chest wall lipomas, offering insights into diagnosis and management. However, its single-case nature limits generalizability, preoperative histological confirmation was not obtained, and MRI was not performed to further characterize soft tissue involvement. Additionally, although adequate for benign lesions, follow-up may be insufficient to detect extremely late recurrences.

4. Conclusion

Giant chest wall lipomas are rarely reported. This case is exceptional due to its pedunculated appearance resembling an additional limb, and a slow evolution over more than 40 years. Complete surgical resection ensures a favorable prognosis.

Author contribution

Zied Chaari: conception and writing.

Aymen Ben Ayed: conception and writing.

Hanen Bouattour: Collecting data and figures.

Ahmed Ben Ayed: Collecting data and figures.

Abdessalem Hentati: Supervision and final decision.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval for this study was provided.

Guarantor

Doctor Zied CHAARI.

Research registration number

Not applicable.

Declaration of Generative AI and AI-assisted technologies in the writing process

No generative artificial intelligence or AI-assisted tools were used in any part of the research process or manuscript preparation.

Funding

No sources of funding.

Conflict of interest statement

No conflict of interest to declare for all authors.