AB Horcajadas

AH Stein Jr

GL Cribb

M Kalisman

MD Murphey

MG Brand

MM Al Qattan

PE Higgs

RD Leffert

S Ersozlu

V De Giorgi

SpringerPlus

English

Luis Ramirez-Montaño

Ricardo Pacheco Lopez

Nicolas Sastre Ortiz

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a SpringerOpen JournalRamirez-Montaño et al. SpringerPlus 2013, 2:164http://www.springerplus.com/content/2/1/164CASE STUDY Open AccessGiant lipoma of the third finger of the handLuis Ramirez-Montaño*, Ricardo Pacheco Lopez and Nicolas Sastre OrtizAbstractWe report a case of a 50-year old female presenting with a giant tumor on the volar aspect of the third finger ofthe left hand, a thorough clinical and paraclinical evaluation followed by surgical resection resulted in a benignlipoma with an uneventful postoperative course. We present this case due to its rare location and repercussion inthe decision making process when other more common similar pathologies with varying prognosis are conceived.IntroductionExcluding cutaneous malignancy, 95% of tumors of thehand are of benign origin. Non-neoplastic ganglions areprobably the most common on hand and wrist. Afterthese tumors, inclusion cysts, warts, giant cell tumors,granulomas and hemangiomas follow in frequency. Li-pomas are benign mesenchymal neoplasms occurring inareas of abundant adipose tissue. They are not very com-mon in the hand, when present, they predominate in thethenar and hypothenar regions (Al Qattan et al. 2005).Those involving the fingers are very rare, with an inci-dence of 1% (De Giorgi et al. 2005). The clinical spec-trum varies depending on its location, presenting as apainless slow growing mass, that affects the mobility ofthe finger due to its size, they may also cause neurologicchanges in the peripheral nerves of the hand (Leffert1972). Stein reported the first lipoma of the finger in1959 (Stein 1959), afterwards, 14 similar cases wereidentified in the literature (Ersozlu et al. 2007). We pre-sent a case of a giant lipoma in the third finger of thedominant hand, with no prior traumatic history of theproximal and middle phalanx.Case reportA 50-year-old otherwise healthy female arrived at ourPlastic Surgery Department, with a one year history of apainless slow growing tumor on the volar aspect of thethird finger of the left hand (Figure 1) that progressed toa limited interphalangeal joint movement promptingmedical assistance.The presenting lesion was a 50 × 20 mm subcutaneousmass in the proximal and middle phalanx, with a firm* Correspondence: luisrm82@gmail.comPlastic and Reconstructive Surgery, General Hospital of Mexico, Eje 2A Sur(Dr. Balmis) 148 Doctores, Cuauhtémoc, México City 0672, Mexico© 2013 Ramirez-Montaño et al.; licensee SpringCommons Attribution License (http://creativecoreproduction in any medium, provided the origconsistency but mobile over the underlying structures;she had discrete erythema and bluish skin color withoutpalpable pulse, thrill or bruit. She presented limitedmovement in flexion of the interphalangeal joint andfingertip paresthesia. There was no local hyperthermiaor manifestations of systemic disease.The Roentgenogram showed a soft tissue swellingof low density over the middle phalanx, with no bonealteration.An ultrasound scan showed a well circumscribed iso-echoic well defined ovoid mass, with a thin capsule andscarce septations, without alteration of the surroundingtissues (Figure 2).It was decided to perform an excisional biopsy with azealous and careful dissection, with clear identificationof the neurovascular structures and tendons, the tumorwas nourished by two pedicles that emerged from ulnarand radial digital bundle branches (Figure 3).Pathology result reported as a lipoma that measured53×25 mm with no neural component or malignanttransformation (Figure 4).She had an uneventful postoperative course, followedby complete movement and function of the finger. Thereported fingertip paresthesia disappeared.There was no evidence of recurrence of the tumorduring the 12 months of postoperative follow-up withexcellent range of motion and sensivity (Figure 5).DiscussionLipomas account for approximately 16% of soft tissuemesenchymal tumors. They usually develop as a well-circumscribed, encapsulated mass with a doughy feelthat is freely mobile underneath the skin. Accordingto the 2002 World Health Organization’s committeefor the Classification of Soft Tissue Tumors, they areer. This is an Open Access article distributed under the terms of the Creativemmons.org/licenses/by/2.0), which permits unrestricted use, distribution, andinal work is properly cited.Figure 1 Preoperative appearance of the patient showing athird left hand finger volar tumor.Figure 3 Appearance of the tumor during the operation.Ramirez-Montaño et al. SpringerPlus 2013, 2:164 Page 2 of 4http://www.springerplus.com/content/2/1/164categorized into 9 entities, including lipoma, lipoma-tosis, lipomatosis of nerve, lipoblastoma, angiolipoma,myolipoma of soft tissue, chondroid lipoma, spindlecell/pleomorphic lipoma and hibernoma. Benign lipoma-tous lesions affecting bone include intraosseous lipoma,parosteal lipoma and liposclerosing myxofibrous tumor.Benign lipomatous lesions may also affect joints and ten-don sheaths, in a focal, or more commonly, a diffuse pat-tern. They are rarely encountered in the hand and withvery less frequency in the digits. Its etiology is unknown,but multiple causative factors have been proposed whichFigure 2 Preoperative ultrasound scan of the tumor showed awell circumscribed isoechoic well defined mass.Figure 4 Macroscopic appearance of the tumor with53×25 mm dimensions.Figure 5 Appearance of the hand after excisional biopsy. Complete range of motion.Ramirez-Montaño et al. SpringerPlus 2013, 2:164 Page 3 of 4http://www.springerplus.com/content/2/1/164include genetic, traumatic and metabolic triggers. Theyappear mostly in the fifth and sixth decade. Presentingsuperficially or arising from the subfascial deep plane, inrare cases they can originate from juxta-articular regionsor adjacent to the periostium as a parosteal lipoma orerode into the bone. Previous studies have defined a giantlipoma of the upper extremity as a mass larger than 5 cm(Cribb et al. 2005).Lipoma in the hand typically presents with painlessswelling and usually attains a large size by the timepatients seek medical attention. Clinically, it has beendescribed with grasping difficulties, decreased digitalflexion and deviation of the fingers (Brand & Gelberman1988). They can cause pain and distal sensory alterationswith motor weakness. Accuracy of clinical evaluationreaches up to 85% in the superficial type (Kalisman &Dolich 1982).Imaging studies are diagnostic in 71% of the cases,(Murphey et al. 2004) computed tomography and mag-netic resonance have proved to be the gold standard(Horcajadas et al. 2003). In developing countries otherless costly radiographic modalities are used in the pre-operative evaluation, such as plain radiographs, wherelipomas appear as an area of characteristic radiolucencyreferred to as a “water-clear density.” Ultrasound exami-nation demonstrates a homogeneous and circumscribedhyperechoic or isoechoic area.Surgical resection is the treatment of choice, it requiresextensive dissection and mobilization of the neurovascularstructures to accomplish success. Physician-patient rela-tionship is key for the understanding of potential loss offunction and other sequela. The main indication for theirremoval is the disturbance caused in hand functionalityand cosmetic appearance (Higgs et al. 1993). The re-currence of this benign tumor is considered uncommonand reappearance is usually caused by technical surgicalmishaps.In this case, the patient sought for medical attentionwhen movement limitation appeared with no othersystemic association. It is clear that other neoplastic le-sions and non-neoplastic lesions appear with clinical cha-racteristics similar to those of a lipoma and should beconsidered as a differential diagnosis. When evaluating atumor in the upper extremities the main concern is to ruleout malignancy, which changes decision making and prog-nosis dramatically. Although lipoma is considered a rareentity in the hand, the surgeon should be aware of theirexistence due to its benign nature and favorable outcomebefore making radical decisions; as in this case, in whichcomplete tumor resection lead to cure of the pathologywith excellent cosmetic and function result.In conclusion, lipomas of the digits are rare but benigntumors with a very limited risk of malignant transfor-mation, they are associated with an excellent prognosisafter successful excision; however, the preoperative eval-uation requires a careful diagnostic workup due to itsshared similarities to other pathologies.ConsentWritten informed consent was obtained from patient forpublication of this report and any accompanying images.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsLRM, RPL and NSO carried out diagnostic, clinical evaluation and surgery.All authors read and approved the final manuscript.Received: 11 January 2013 Accepted: 13 April 2013Published: 16 April 2013ReferencesAl Qattan MM, Al Lazzam AM, Al Thunayan A et al (2005) Classification of benignfatty tumours in the upper limb. Hand Surg 10(1):43–59Brand MG, Gelberman RH (1988) Lipoma of the flexor digitorum superficialiscausing triggering at the carpal canal and median nerve compression.J Hand Surg Am 13(3):342–344Cribb GL, Cool WP, Ford DJ, Mangham DC (2005) Giant lipomatous tumours ofthe hand and forearm. J Hand Surg Br 30(5):509–512De Giorgi V, Salvini C, Sestini S, Alfaioli B, Carli P (2005) Lipoma of the finger:a case report and differential diagnosis. Clin Exp Dermatol 39(4):439–440Ramirez-Montaño et al. SpringerPlus 2013, 2:164 Page 4 of 4http://www.springerplus.com/content/2/1/164Ersozlu S, Ozgur AF, Tandogan RH (2007) Lipoma of the index finger. Dermatol Surg33(3):382–384Higgs PE, Young VL, Schuster R, Weeks PM (1993) Giant lipomas of the hand andforearm. South Med J 86(8):887–890Horcajadas AB, Lafuente JL, de la Cruz BR et al (2003) Ultrasound and MRfindings in tumor and tumor-like lesions of the fingers. Eur Radiol 13:672–685Kalisman M, Dolich BH (1982) Infiltrating lipoma of the proper digital nerves.J Hand Surg Am 7(4):401–403Leffert RD (1972) Lipomas of the upper extremity. J Bone Joint Surg Am54(6):1262–1266Murphey MD, Caroll JF, Flemming DJ et al (2004) Benign musculoskeletallipomatous lesions. Radiographics 24:1433–1466Stein AH Jr (1959) Benign neoplastic and nonneoplastic destructive lesions in thelong bones of the hand. Surg Gynecol Obstet 109(2):189–197doi:10.1186/2193-1801-2-164Cite this article as: Ramirez-Montaño et al.: Giant lipoma of the thirdfinger of the hand. SpringerPlus 2013 2:164.Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.com

Giant lipoma of the third finger of the hand

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Giant lipoma of the third finger of the hand

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