Giant angiolipoma of the back complicated with ulceration and sepsis: unusual presentation of a rare benign tumour

Abstract

A 63-year-old woman presented to the emergency unit with a huge (40 × 35 × 10 cm) oval-shaped pedunculated growth in the back with superficial ulceration in its lower aspect, associated with signs of sepsis. After adequate resuscitation, the patient was transferred to the operation theatre where the tumour was completely excised and the resultant wound was closed in primary manner using polypropylene sutures with suction drains inserted in the wound bed. The patient was discharged home after two days and was followed-up for two months. No wound complications were recorded on follow-up.

Angiolipoma is a benign variant of lipoma that, despite what has been reported in the literature, may affect any age and any region of the body. Complications of angiolipoma may include ulceration, sepsis, gangrene and possible systemic inflammatory response syndrome which may pose a threat to the patient’s life, hence should be managed promptly after adequate patient preparation.

Introduction

Angiolipoma is rare pathologic variant of lipoma.¹ The clinical and pathological characteristics of angiolipoma are shown in Table 1.^2–5 Although angiolipomas usually do not exceed 5 cm in size, they can reach massive size according to a few reports in the literature.^2,6 We present the management of a giant, complicated angiolipoma in the back of an elderly female.

Table 1.

The classical characteristics of angiolipoma.

Characteristic	Value
Other names	Lipoma cavernosum, telangiectatic lipoma, or vascular lipoma
Incidence	5–17% of all lipomas
Common sites	Arm, forearm, neck, and trunk
Usual size	Less than 4 cm
Pathological types	Infiltrating and non-infiltrating
Pathological features	As regular lipomas but with more prominent vascularity
Presumed aetiologies	Drugs as steroids and indinavir sulfate
Type of patient	Common in men 20–30 years of age
Clinical presentation	Painful, multiple, small subcutaneous lesions
Associated conditions	Familial multiple angiolipomatosis
Diagnostic modalities	computed tomography, magnetic resonance imaging, biopsy

Case history

A 63-year-old woman presented to the emergency unit with a huge (40 × 35 × 10 cm) pedunculated growth in her back with superficial ulceration in its lower aspect (Fig 1). On assessment of the patient, tachycardia, tachypnoea, high temperature, leucocytosis (total leucocyte count 16.000), hypoalbuminaemia (serum albumin 2.5 mg/dl), and hyperglycaemia (random blood glucose 250 mg/dl) were noted.

Figure 1.

Giant angiolipoma of the back with ulceration and inflammation of the lower part.

Upon resuscitation of the patient, the procedure was performed under general anaesthesia. An elliptical incision was made around the pedicle of the mass and was deepened through the fascia, reaching down to the muscles. Using electrocautery, dissection continued and several large blood vessels were identified and ligated with polyglactin 2/0 sutures. The mass was then completely excised and careful haemostasis was achieved. The wound was closed primarily after insertion of two suction drains in its bed (Fig 2).

Figure 2.

Primary closure of the wound after complete excision of angiolipoma.

On gross examination, the tumour was firm in consistency, yellowish in colour and weighed 9 kg. Microscopic examination revealed benign tumoral proliferation consisting of lobules of mature fat cell with variable-sized and variable-shaped blood vessels on a myxoid background, confirming the diagnosis of angiolipoma (Fig 3).

Figure 3.

Microscopic image of angiolipoma excised showing mature lipocytes with multiple, variable-sized blood vessels.

The patient was discharged home after 48 hours and was followed at the outpatient clinic for two months postoperatively. Stitches and drains were removed and no postoperative wound complications were recorded. A written informed consent was obtained from the patient to publish her case.

Discussion

The patient of this report represents an exception of the classical presentation of angiolipoma. While angiolipomas usually affect young and middle-aged men and do not tend to exceed 4 cm in size, our patient was an elderly woman with a giant angiolipoma. The angiolipoma was complicated with acute sepsis secondary to ulceration and gangrene of its lower part. This emergent presentation should draw our attention that even benign lesions such as angiolipoma may turn into life threatening conditions if complicated with acute sepsis.

Conclusion

Although subcutaneous angiolipomas do not usually exceed 5 cm in size, giant variants may occur. Complications of angiolipoma may include ulceration, sepsis, and gangrene which threaten the patient’s life, hence should be managed promptly.