Breast-Size Paired Bumps on the Back of an Old Man

This article was originally presented as an independent educational activity under the direction of CME LLC. The ability to receive CME credits has expired. The article is now presented here for your reference. CME LLC is no longer responsible for the presentation of the article.

HISTORY

A 93-year-old man with known Alzheimer dementia has his admission physical examination on transfer to a geropsychiatric hospital unit due to behavioral difficulties. A language barrier and his stoicism minimize communication, but his devoted wife translates and recounts that he is not in any physical discomfort. Has sometimes needed oxygen treatment in the past.

PHYSICAL EXAMINATION

Somewhat overweight man who appears a few years younger than stated age, affable but usually silent although he understands more English than he lets on. Breath sounds normal. Range of motion of upper limbs mildly reduced to a degree typical for age. Two hemispheric bumps on back feel utterly soft. Neither is fixed to overlying skin nor to chest wall. Small vertically aligned area of firmer tissue abuts medial margin of left-sided mass. No bruit audible over either. Bumps are distinct from scapulae, which move normally.

What's Your Diagnosis? (Answer on next page)

Answer: Giant Lipomas

These immense masses, covered by intact and normal overlying skin, are readily diagnosable at bedside as lipomas. On palpation, they had the texture of a bag of water because the neutral fat of which they are composed is semi-liquid at body temperature. One did not even look hard for a pore as a possible indicator of an epidermal inclusion cyst (sebaceous cyst, wen), because the texture was so characteristic of lipoma.

The masses also felt exactly like normal breasts of women who are decades past menopause and have not received exogenous estrogen. In such patients atrophy of lobular, ductal, and stromal elements results over many years in breast tissue that is predominantly, almost exclusively, made up of adipocytes. The visual resemblance to pendulous breasts-which one might regard as ridiculous given the gender of the patient and the locale on the back of the thorax rather than the front, not to mention the absence of nipple-areolar complexes and the diagonal rather than horizontal comparative orientation-actually carried meaning: It reminded us to look for sweat retention and intertriginous mycotic dermatitis on the undersides and in the skin fold beneath. Our patient had neither.

An incidental finding is the enlargement of what looks like the left olecranon bursa; in fact this area was multilobulated and firm, and there was a mate to it anteriorly. We diagnosed old gouty tophi and excluded both xanthomas and olecranon bursitis based on locale and characteristics.

COULD THOSE HUGE THINGS BE SARCOMAS?

Even before reading that most liposarcomas arise from deep locations, not from subcutaneous lipomas,^1-4 we had low suspicion of cancer. We interpreted the firmer areas, especially because of their location at the (internally indistinct) edge of the lesions, as adjacent trapezius or paraspinal muscles that were somewhat compressed by their large benign neighboring structure. The normality of the skin was consistent with an innocent nature but not confirmatory. While bruits are neither sensitive nor specific markers of cancer, let alone liposarcoma, we were also pleased to find this particular search for trouble came up negative.

The epidemiology offers help: liposarcoma is not a lesion often seen in extreme old age. We took more skeptically the wife’s reassurance that the lesions had not changed for years. Many patients so assert either because they are unaware of slow growth, or to deflect attention and so escape procedures, or even-through magical thinking-the threatening prospect of a malignant diagnosis.

WHAT MAKES THEM GIANT LIPOMAS?

An extensive literature describes giant lipomas in a host of subcutaneous locales^5-9 and internally. No consensus exists on what size defines this variant. The smallest tumor we have seen so labeled had a maximal dimension of 10 cm. So both of this patient’s masses far exceed the threshold. Others in numerous reports are still bigger.⁸

Perhaps this subtype is well known because even if, say, only 1% of any histological type of soft-tissue neoplasm attains such size, so many lipomas arise that even a tiny subset eventually constitutes a well-known entity. We have seen no convincing reports that locale, genetics with the known frequent rearrangements of chromosome ^12,1-4 or demographics distinguish giant lipomas from smaller ones. Counterintuitively, we find no evidence that large size predisposes to being malignant, ie a sarcoma.

THE MISTAKE OF NON-EXPOSURE

Internal server error