Giant disfiguring occipital lipoma: successful surgical management of a late-presenting case in a resource-limited setting in Somaliland

Abstract

Background:

Giant lipomas – defined as lipomas exceeding 10 cm – are rare and clinically significant because they can mimic malignant soft tissue tumors such as liposarcomas. Diagnostic uncertainty, particularly when these lesions arise in unusual locations, underscores the importance of comprehensive evaluation and timely management.

Case Presentation:

We report the case of a 60-year-old woman who presented with a giant occipital lipoma that had been slowly enlarging for over 20 years, with marked progression in the preceding 5 years. The mass caused significant morbidity, including cosmetic disfigurement, chronic headaches, sleep disturbances, and psychosocial distress. Imaging with ultrasound and computed tomography confirmed a large, well-encapsulated fatty mass without intracranial extension, and fine-needle aspiration cytology established a diagnosis of benign lipoma. The patient underwent successful surgical excision under general anesthesia. The tumor was removed in its entirety, and her postoperative course was uneventful, with marked improvement in quality of life.

Discussion:

This case highlights the challenges of managing giant lipomas in resource-limited settings, where delays in surgical intervention can allow benign conditions to grow to massive, disfiguring sizes. Timely diagnosis and surgery are essential to prevent morbidity, improve outcomes, and restore quality of life.

Conclusion:

Giant lipomas, though rare, should be considered in the differential diagnosis of large soft tissue tumors of the head and neck. This case illustrates the importance of early recognition, thorough evaluation, and prompt surgical management, even in low-resource settings such as Somalia, to prevent complications and improve patient well-being.

Introduction

Lipomas are the most common benign mesenchymal tumors in adults, composed of mature adipocytes and capable of arising in any location where adipose tissue is present. They occur in an estimated 1%–2% of the population and most frequently develop in the subcutaneous tissues of the proximal extremities, back, neck, and buttocks. Clinically, they are typically painless, well-circumscribed, and slow-growing, making them among the most frequently encountered soft-tissue lesions in everyday practice^[1,2^].

HIGHLIGHTS

• Giant occipital lipomas, though benign, can cause severe morbidity and cosmetic disfigurement if diagnosis and treatment are delayed.

• Successful surgical management of giant, complex head and neck tumors is achievable even in resource-limited settings with careful planning.

• Timely surgical excision is the definitive treatment, leading to a dramatic improvement in symptoms and patient quality of life.

• Surgical excision remains the gold standard for treatment and provides immediate improvement in quality of life.

Lipomas are generally small, ranging from less than an inch to a few inches in diameter. However, when a lipoma grows larger than 10 cm (about 4 in), it is referred to as a giant lipoma. Only about 1% of lipomas are considered “giant.” Although they are usually benign, in the case of a giant lipoma, it is essential to rule out malignancy before embarking on surgical treatment^[3^]. Crucially, it is essential to understand that while benign lipomas have a virtually zero risk of turning into cancer (malignant transformation), the real clinical danger lies in misdiagnosis.

Benign conditions such as epidermal cysts, nodular fasciitis, erythema nodosum, subcutaneous fat necrosis, vasculitic nodules, rheumatic nodules, hematomas, and infections can often resemble lipomas. These conditions are generally non-malignant and are sometimes caused by inflammatory, traumatic, or autoimmune processes^[4^]. However, the clinical classification becomes even more challenging for physicians when dealing with giant lipomas, especially intramuscular ones, as they may mimic malignant tumors like liposarcomas, metastatic carcinomas, or malignant histiocytoma^[4^]. This diagnostic uncertainty underscores the importance of increasing awareness among clinicians. For this reason, we are contributing to the literature by adding case reports to help physicians more accurately recognize and differentiate giant lipomas. In this context, we present our current case.

Methods

The case report meets the SCARE criteria^[5^].

Case presentation

A 60-year-old female presented to the Surgical Outpatient Department of Hargeisa Group Hospital with a chief complaint of a progressively enlarging posterior scalp mass.

History of presenting illness

The patient reported a 20-year history of a slowly progressive occipitonuchal mass, with marked acceleration in growth during the preceding 5 years. She described the lesion as comparable in size to a “second head,” significantly impairing her ability to lie in a supine position and causing chronic headaches, cosmetic concern, and substantial psychosocial distress, including anxiety and social withdrawal.

She denied any history of trauma, infection, constitutional symptoms, or similar lesions elsewhere on the body.

Physical examination

On general examination, the patient appeared well, with a normal body habitus and no pallor or jaundice. Vital signs were within normal physiological limits.

Local examination of the posterior scalp demonstrated a massive, bilobed, soft-tissue mass occupying the occipitonuchal region. The larger component measured approximately the size of a large watermelon, while the adjacent satellite lesion was roughly lemon sized. The mass was non-tender, spherical, and soft to firm in consistency, and opaque on transillumination. It appeared encapsulated, mobile at the periphery, but firmly fixed to the underlying occipital bone at its base. The overlying skin was intact and hair-bearing, with prominent dilated superficial veins (Fig. 1). No other masses were identified on examination of different anatomical regions.

Figure 1.

Giant occipital lipoma in the head of the patient, preoperatively.

Diagnostic workup

Routine laboratory investigations were performed to evaluate the patient’s baseline status before surgical intervention. All hematological and biochemical parameters were within normal reference ranges (Table 1).

Table 1.

Test	Result	Normal range
Hemoglobin (Hb)	14.2 g/dL	Male: 13.5–17.5 g/dL/ Female: 12–16 g/dL
White blood cell count	6.4 × 109/L	4–11 × 109/L
Platelets	270 × 109/L	150–450 × 109/L
Creatinine	0.9 mg/dL	0.6–1.3 mg/dL
Blood urea nitrogen	13 mg/dL	7–20 mg/dL
AST	24 U/L	0–40 U/L
ALT	28 U/L	0–40 U/L
Alkaline phosphatase	72 U/L	40–129 U/L
Total bilirubin	0.8 mg/dL	0.2–1.2 mg/dL
Albumin	4.2 g/dL	3.5–5.5 g/dL

Radiological evaluation included ultrasonography, which identified a well circumscribed, encapsulated, hyperechoic lesion consistent with adipose tissue. A contrast-enhanced computed tomography (CT) scan of the head confirmed a large, homogeneous, fat-density mass with thin fibrous septations (Supplemental Digital Content Figure S2, available at: http://links.lww.com/IJSCR/A31), without evidence of intracranial extension or occipital bone erosion.

Fine-needle aspiration cytology (FNAC) demonstrated mature adipocytes without atypia, consistent with a benign lipoma.

Surgical intervention

A decision was made to proceed with excision of the mass. Informed consent was obtained.

Under general anesthesia, the patient was positioned prone with the head rotated to the left. A transverse elliptical incision was made around the mass’s pedicle using a scalpel, and electrocautery was utilized to achieve adequate hemostasis. Intraoperatively, the lesion was found to be a deep, subfascial lipoma firmly adherent to the periosteum of the occipital bone near the nuchal line – sharp and blunt dissection allowed for complete removal of the mass (Supplemental Digital Content Figure S1, available at: http://links.lww.com/IJSCR/A31). The tumor was found to be a well-encapsulated fatty specimen (Fig. 2). The total operative time was 3 hours, and the estimated blood loss was 120 mL. Due to the ample surgical dead space and the vascular nature of the lesion, a closed-suction drain was placed. The wound was closed in anatomic layers.

Figure 2.

Excised giant occipital lipoma from the patient’s head.

Post-operative course

The patient’s post-operative recovery was uneventful. The drain was removed on postoperative day 3 after achieving minimal output, and she was discharged home on oral antibiotics. At her first follow-up visit, 6 days after discharge, she reported complete relief of headaches and restored comfortable sleep. She expressed high satisfaction with the cosmetic and functional outcomes (Supplemental Digital Content Figure S3, available at: http://links.lww.com/IJSCR/A31).

This represents the largest occipital lipoma surgically managed at Hargeisa Group Hospital to date.

Discussions

Lipomatous tumors can arise in various anatomical regions, including the head and neck, where they may present diagnostic challenges. When encountered in this location, they should be included in the differential diagnosis for soft-tissue masses, particularly to distinguish benign lesions from malignant counterparts, such as liposarcomas. Accurate evaluation requires a meticulous clinical history, thorough physical examination, and appropriate imaging and cytological assessment to ensure correct diagnosis and management^[6^].

The typical presentation of a head and neck lipoma is a slow-growing, painless, subcutaneous swelling most frequently found in the posterior neck. These tumors show a distinct male predominance and typically develop in individuals during their fifth and sixth decades of life. On physical examination, a lipoma characteristically feels like a non-painful, round, mobile mass with a distinctively soft, “doughy” consistency^[7^]. While most lipomas are superficial, they can, on rare occasions, present in deeper locations like the larynx or pharynx, which can cause diagnostic confusion with other, more common conditions in those areas^[7^].

Physical examination of a head and neck mass is an essential first step, but it is often insufficient for a definitive diagnosis, making imaging a crucial next step. Sonography (ultrasound) is a key diagnostic tool that reveals the characteristic appearance of lipomas in this region. A sonographic examination will typically show a lipoma as a well-defined, compressible, elliptical mass oriented parallel to the skin^[8^]. The most distinctive sonographic feature is its internal architecture, with multiple fine, bright (echogenic) lines running parallel to the skin surface. These masses are usually brighter (hyperechoic) than the surrounding muscle and show no evidence of internal blood flow. By identifying this specific set of features, sonography provides a confident diagnosis and can effectively differentiate a benign lipoma from other types of neck masses^[8^]. However, when the diagnosis is uncertain or the mass has atypical features, advanced imaging, such as a CT scan, may be required for further evaluation.

CT plays a definitive role in diagnosing lipomas and is widely regarded as the most appropriate imaging modality for confirming their presence. Its diagnostic strength lies in its ability to characterize tissues according to radiodensity using Hounsfield Unit (HU) measurements. Because lipomas are composed of mature adipose tissue, they exhibit a distinctly low attenuation, typically ranging from −65 to −125 HU, a value considered virtually pathognomonic for fat^[8^]. This numerical signature allows clinicians to confidently identify lipomatous lesions in the majority of cases without the need for invasive confirmation, such as biopsy.

CT imaging additionally delineates the size, internal morphology, and anatomical relationships of the mass with high precision. These features are critical for preoperative planning, particularly when lesions are large or located near vital neurovascular or visceral structures^[8^]. The ability of CT to differentiate lipomas from other soft-tissue masses, therefore, significantly reduces diagnostic uncertainty and ensures appropriate surgical decision-making.

Further supporting this, a case report by Ozen et al demonstrated the essential diagnostic value of CT in evaluating colonic lipomas. In this report, the CT scan identified an intraluminal mass measuring 40 × 53 × 55 mm, with a fat-density value of −42 HU, consistent with a lipoma. The lesion exhibited classic imaging characteristics such as a homogeneous internal structure, sharp margins, and an ovoid contour^[9^]. However, the presence of internal “dense septal appearances” introduced a diagnostic limitation, as such features may mimic those seen in well-differentiated liposarcomas (WDLS). Thus, despite CT’s high specificity for fat-containing lesions, the possibility of malignancy could not be entirely excluded based on imaging alone^[9^].

While CT is frequently utilized as the first-line imaging modality for evaluating soft-tissue tumors, magnetic resonance imaging (MRI) remains the reference standard for definitive characterization of lipomatous lesions. According to Coran et al, MRI plays a pivotal role in distinguishing benign lipomas from malignant counterparts, such as atypical lipomatous tumors (ALT) or WDLS^[10^]. Specific radiological features – namely septa thicker than 2 mm, intralesional nodules, and signal inhomogeneity on fluid-sensitive sequences – have been identified as statistically significant indicators of malignancy. Remarkably, Coran et al reported a 100% negative predictive value for MRI, indicating that tumors exhibiting homogeneous fatty signals with thin or absent septa can be confidently diagnosed as benign, potentially obviating the need for invasive procedures^[10^]. Moreover, in lesions with complex characteristics, MRI facilitates targeted biopsies of areas prone to dedifferentiation, thereby reducing the risk of diagnostic underestimation^[10^].

In the present case, MRI was not performed due to the high cost, although it would have been ideal for establishing a definitive diagnosis at an earlier stage. Nonetheless, CT imaging and FNAC provided sufficient information to guide safe surgical management.

While many lipomas are diagnosed on clinical grounds, excisional biopsy and subsequent histopathological analysis remain the gold standard for definitive diagnosis, providing crucial information, particularly for deep-seated or atypically presenting head and neck lesions. Diagnosis of ALT/WDLS is usually established on routine histopathology, but small or suboptimal biopsies may require molecular confirmation. MDM2 gene amplification, detected by FISH or immunohistochemistry, can help differentiate ALT/WDL from benign mimics or low-grade dedifferentiated liposarcoma. While FISH is highly sensitive, immunohistochemistry is more cost-effective, and molecular testing should be reserved for equivocal cases to avoid unnecessary expense. In this case, although molecular testing was not performed, imaging and cytology provided sufficient information to guide surgical management safely^[11,12^].

The case presented here exemplifies the value of a thorough diagnostic workup. For this patient, a comprehensive evaluation involving ultrasonography, CT, and ultimately, histopathology was performed – an approach not routinely employed in our clinical setting for such lesions. The clinical imperative driving this investigation was the mass’s size, which necessitated excluding the possibility of liposarcoma. The final diagnosis confirmed a benign lipoma, reinforcing the principle that size alone is not a definitive predictor of malignancy. This case adds to the body of evidence that even giant lipomas can be entirely benign entities.

The massive size of this lipoma can be attributed to the prolonged delay in receiving surgical intervention. This delay reflects the challenges of accessing timely and specialized care in low-resource healthcare systems. In such settings, the limited availability of surgical services and trained specialists often leads to the postponement of elective procedures. Delaying necessary surgery is clinically significant, as it allows even benign conditions to progress unchecked, increasing operative complexity, raising the risk of postoperative complications, and worsening overall patient outcomes. It also contributes to prolonged physical and psychosocial morbidity, as patients endure escalating discomfort, functional limitations, and diminished quality of life.

In this particular case, multiple socioeconomic and systemic factors influenced the delayed presentation. The patient resided in a rural area of the Togdheer region in Somaliland, where healthcare facilities, diagnostic tools, and experienced surgeons capable of managing complex soft-tissue tumors are scarce. Limited financial resources and poor health literacy further constrained healthcare-seeking behavior. Additionally, the initially asymptomatic nature of the mass – aside from cosmetic disfigurement and increasing heaviness – reduced the perceived need for medical attention. Fear of a possible malignant diagnosis also contributed to hesitancy in seeking timely evaluation. Collectively, these interrelated determinants underscore how disparities in healthcare access can culminate in advanced disease presentation and significant patient suffering.

Conclusion

This case demonstrates the successful diagnosis of a giant benign lipoma of the head and neck through a comprehensive, multimodal approach. Although advanced imaging techniques such as CT can provide a highly confident diagnosis of lipoma based on characteristic tissue attenuation, the lesion’s significant size created a clinical imperative to exclude liposarcoma definitively. Although not always standard practice, the decision to proceed with excisional biopsy and histopathological analysis served as the ultimate gold standard, confirming the mass’s benign nature. This case reinforces a crucial clinical principle: for giant or atypically located soft tissue masses, histopathological verification remains invaluable for providing diagnostic certainty and ensuring appropriate patient management.

Ethical approval

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for this case report was obtained from the Amoud University (AU) Research Ethics Committee (REC; reference number: 706-AU-REC-2025).

Consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images, including the preoperative clinical photograph. A copy of the written consent form is available for review by the Editor-in-Chief of this journal upon request.

Sources of funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

A.A.N.H.: Was the primary surgeon, was involved in the perioperative management of the patient, and drafted the initial manuscript. H.M.A.: Assisted in the surgical procedure, contributed to postoperative patient care, and reviewed the literature. B.C.I.: Assisted in the surgical procedure, contributed to the discussion section, and helped edit the manuscript. A.I.S.: Was involved in the diagnostic workup, data collection, and preparation of the case presentation. M.S.H.: Conceived and supervised the study, critically revised the manuscript for important intellectual content, and approved the final version for submission. All authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no competing interests.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Dr. Abdirahman A. N. Hori.

Provenance and peer review

Commissioned; externally peer-reviewed. This case report was peer-reviewed by two independent reviewers in a double-blind process.

Data availability statement

All data generated or analyzed during this study are included within this published article. Further inquiries can be directed to the corresponding author upon reasonable request.