Author Information
Tiwari N*, Chaudhari HK**
(* Assistant Professor, ** Associate Professor, Department of Gynecology and Obstetrics, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
A paravulvar lipoma is a very rare tumor. It can be mistaken for a vulvar lipoma. We present a case of a large paravulvar lipoma in a young woman.
Introduction
Lipomas are widely disseminated benign tumors of soft tissues. Their etiology is unknown. Trauma seems to be one of the causes.[1,2] It is common over the neck, upper back, shoulders, abdomen, buttocks, and proximal portions of the limb [3]. It rarely present in vulva [4,5]. In this paper, we report the case of a paravulvar lipoma that was diagnosed in a 20 year-old woman. Our patient was young without any history of trauma. We discuss the clinical features and management options of this pathology with the histopathological evaluation of all excised lesions. A review of the literature is also presented.
Case Report
A 20 year-old woman presented with a painless and slow-growing soft movable swelling of private parts. She reported a sudden uncomfortable feeling in the perineum. The mass had grown gradually over one year. There was no significant family history. She had no history of change in color or any discharge from the mass, the main reason to seek medical attention was the cosmetic disfigurement. Her previous menstrual and obstetrical history was unremarkable. A physical examination done by unit head revealed a single soft and pasty mass in her right paravulvar region (figure 1 ). The mass could be moved freely under her skin. The dimensions of the mass measured was 10 cm X 8 cm. There was no visible palpable cough impulse or inguinal lymphadenopathy. Her physical pelvic examination was normal. Ultrasonography was performed which demonstrated a homogenous and hyperintense mass with a well-defined contour in our patient’s right labium majus of vulva in the subcutaneous plane. All her laboratory tests were normal. In lithotomy position and under general anesthesia a longitudinal incision along the most prominent area of the right labium majus was taken. The fatty lump was identified and mobilized. The mass including 1- cm width of redundant skin on the incision line was excised carefully (figure 2). There was no difficulty in surgery because the mass was well-encapsulated. After securing hemostasis, the skin was closed with interrupted sutures of No. 3-0 monofilament polyamide (figure 3). The postoperative course was uneventful and the patient left hospital on the fourth postoperative day. The excised specimen measured 10 × 8 × 3.8 cm (figure 4) and it was surrounded by a fibrous capsule. Serial histological sections showed lobulated yellow tissue and homogeneous mature adipocytes without any hemorrhage or necrosis. The histopathologic diagnosis of a lipoma was confirmed.
Figure 1. Image showing the vulva mass. local examination.
Figure 2. Intraoperative image showing excision of the paravulvar mass.
Figure 3. Image showing closure of skin incision with non-absorbable sutures.
Figure 4. Image showing excised specimen.
Discussion
The most common areas for lipomas are the upper back, neck, shoulder and abdomen. Lipomas are usually seen between 40 and 60 years of age.[1,2] They are the most common benign tumor in soft tissues. Solitary lipomas are more common in women. Multiple lipomas are more common in men. Variants seen include spindle cell lipomas, pleomorphic lipomas, angiolipomas and adenolipomas. It is derived from mesenchymal cells.[4] Congenital childhood lipomas are mostly inherited and rare.[5]
Lipomas usually present as single or multiple, not causing pain, gradually increasing in size and mobile swelling. The tumor shows ill-defined, or pedunculated aspects that are not adherent to the overlying skin. These pecularities provide correct diagnosis in most cases by clinical examination.[7,8,9,10,11] However, various differential diagnosis are liposarcomas, cystic swellings of Bartholin’s gland and Nuck’s canal, and inguinal hernia, especially in children.[3,4,6] Other rare tumors such as aggressive angiomyxoma,[12] benign lipoblastoma-like tumors,[13] granular cell tumors and,[14]liposarcoma,[15,16] must be differentiated from a simple lipoma. In our case it was a large swelling. Diagnosis was difficult. It was arising from genitocrural fold and grown downwards. Its origin was not vulvar but paravulvar.
In developing countries, ultrasound is recommended instead of expensive imaging investigation because of its availability and cost-effectiveness.[3] Vulvar lipoma ultrasound demonstrates a non-specific homogenous echogenic mass with lobular structures consistent with fat deposition.[3,9,10] Computed tomography and MRI are useful for evaluating tumor extensions and anatomical connections with surrounding structures.[4,9,10] MRI is a supportive tool to differentiate vulvar lipomas from liposarcoma.[3,6,11] Therefore, soft lipomatous lesions with thin septa that are not enhanced on MRI could be diagnosed as lipoma.[6,17]
Conservative treatment for a lipoma includes steroid injection and liposuction and is done commonly. However, complete surgical excision is the treatment of choice for vulvar lipomas.[3] Surgery also allows for excluding malignant nature by performing a histological study.[3,4] Typically, a histological study shows a thin peripheral capsule surrounding a lobular proliferation of adipocyte.[6] Recurrence is possible; short-term recurrence should draw the attention of clinicians to possible malignant nature of the tumor.
Lipomas usually present as single or multiple, not causing pain, gradually increasing in size and mobile swelling. The tumor shows ill-defined, or pedunculated aspects that are not adherent to the overlying skin. These pecularities provide correct diagnosis in most cases by clinical examination.[7,8,9,10,11] However, various differential diagnosis are liposarcomas, cystic swellings of Bartholin’s gland and Nuck’s canal, and inguinal hernia, especially in children.[3,4,6] Other rare tumors such as aggressive angiomyxoma,[12] benign lipoblastoma-like tumors,[13] granular cell tumors and,[14]liposarcoma,[15,16] must be differentiated from a simple lipoma. In our case it was a large swelling. Diagnosis was difficult. It was arising from genitocrural fold and grown downwards. Its origin was not vulvar but paravulvar.
In developing countries, ultrasound is recommended instead of expensive imaging investigation because of its availability and cost-effectiveness.[3] Vulvar lipoma ultrasound demonstrates a non-specific homogenous echogenic mass with lobular structures consistent with fat deposition.[3,9,10] Computed tomography and MRI are useful for evaluating tumor extensions and anatomical connections with surrounding structures.[4,9,10] MRI is a supportive tool to differentiate vulvar lipomas from liposarcoma.[3,6,11] Therefore, soft lipomatous lesions with thin septa that are not enhanced on MRI could be diagnosed as lipoma.[6,17]
Conservative treatment for a lipoma includes steroid injection and liposuction and is done commonly. However, complete surgical excision is the treatment of choice for vulvar lipomas.[3] Surgery also allows for excluding malignant nature by performing a histological study.[3,4] Typically, a histological study shows a thin peripheral capsule surrounding a lobular proliferation of adipocyte.[6] Recurrence is possible; short-term recurrence should draw the attention of clinicians to possible malignant nature of the tumor.
Conclusion
Paravulvar lipomas share very similar clinical and imaging profiles with liposarcomas. Recently, CT and MRI have been used with some success to differentiate the two.[18] To exclude the possibility of malignant tumors, biopsy should be performed by surgical excision. The final diagnosis should be based on histopathological evaluation. This case report will help students to distinguish a vulvar swelling from paravulvar swelling.
References
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- Copcu E. Sport-induced lipoma. Int J Sports Med. 2004; 25:182–5
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- Ohguri T, Aoki T, Hisaoka M, Watanabe H, Nakamura K, Hashimoto H, et al. Differential diagnosis of benign peripheral lipoma from well-differentiated liposarcoma on MR imaging: is comparison of margins and internal characteristics useful? Am J Roentgenol. 2003, 180: 1689-94.
- Mandai K, Moriwaki S, Motoi M. Aggressive angiomyxoma of the vulva. Report of a case. Acta Pathol Jpn 1990; 40: 927-934.
- Atallah D, Rouzier R, Chamoun ML. Benign lipoblastomalike tumor of the vulva: report of a case affecting a young patient. J Reprod Med 2007; 52: 223-224.
- Raju G, Naraynsingh V. Granular cell tumours of the vulva. Aust N Z J Obstet Gynaecol 1987; 27: 349-352.
- Nucci M, Fletcher C. Liposarcoma (atypical lipomatous tumors) of the vulva: a clinicopathologic study of six cases. Int J Gynecol Pathol 1998; 17: 17-23.
- Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, Kransdorf MJ. Benign musculoskeletal lipomatous lesions. Radiographics. 2004, 24: 1433-1466.
Citation
Tiwari N, Chaudhari HK. Paravulvar Lipoma Masquerading As Vulvar Lipoma. JPGO 2018. Volume 5 No.12. Available from: https://www.jpgo.org/2018/12/paravulvar-lipoma-masquerading-as.html