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• W1985880734 abstract "Lipoma of the diaphragm is an extremely rare entity. A 67-year-old asymptomatic man who had a tumor located in the posterior region of the left hemi-diaphragm is presented. The tumor was removed through a left mini-thoracotomy. The diaphragm was reconstructed primarily by using nonabsorbable suture material. The final pathologic examination revealed a mature lipoma. The patient remains without evidence of recurrence 60 months after the operation. Lipoma of the diaphragm is an extremely rare entity. A 67-year-old asymptomatic man who had a tumor located in the posterior region of the left hemi-diaphragm is presented. The tumor was removed through a left mini-thoracotomy. The diaphragm was reconstructed primarily by using nonabsorbable suture material. The final pathologic examination revealed a mature lipoma. The patient remains without evidence of recurrence 60 months after the operation. Primary tumors of the diaphragm are rarely seen, especially benign ones, which are very uncommon [1Gierada D.S. Slone R.M. Fleishman M.J. Imaging evaluation of the diaphragm.Chest Surg Clin N Am. 1998; 8: 237-280PubMed Google Scholar]. Diaphragmatic lipoma is a very rare entity and it is located predominantly on the left side (ratio, 2 to 1) and posterolateral area of the diaphragm [2Weksler B. Ginsberg R.J. Tumors of the diaphragm.Chest Surg Clin N Am. 1998; 8: 441-447PubMed Google Scholar], although lipoma is the most common benign tumor of the diaphragm [1Gierada D.S. Slone R.M. Fleishman M.J. Imaging evaluation of the diaphragm.Chest Surg Clin N Am. 1998; 8: 237-280PubMed Google Scholar]. Benign tumors, including lipomas and cystic masses (such as bronchogenic, mesothelial, and teratoid cysts) are most frequently reported diaphragmatic tumors. The diaphragm is commonly involved with malignant pleural or peritoneal disease [2Weksler B. Ginsberg R.J. Tumors of the diaphragm.Chest Surg Clin N Am. 1998; 8: 441-447PubMed Google Scholar]. Most malignant tumors are sarcomas of fibrous or muscular origin [1Gierada D.S. Slone R.M. Fleishman M.J. Imaging evaluation of the diaphragm.Chest Surg Clin N Am. 1998; 8: 237-280PubMed Google Scholar]. Surgical exploration is recommended because the possibility of liposarcoma can not be excluded [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar]. A 67-year-old man was admitted for back pain. His physical examination was normal other than moderate high blood pressure. Auscultatory findings of the chest were normal. No abnormality was found in his complete blood count, biochemical studies, and tumor markers. Erytrocyte sedimentation rate was 15 mm/1 h. Arterial blood gases on air were PaO2 = 65.5 mm Hg, PaCO2 = 47 mm Hg, pH = 7.417, base excess = 6.5, bicarbonates = 30.6, and saturation = 95%. A spirogram showed almost normal data with forced vital capacity = 2.83 L (84.7%), forced expiratory volume in 1 second = 2.06 L (63.1%), and forced expiratory volume in 1 second/forced vital capacity = 72.7%. A chest roentgenogram revealed a 5 × 6 cm mass obscuring the posterior contour of the diaphragm in the lateral view (Fig 1). The appearance of the mass on computed tomographic scan (CT) examination was 5 × 5 cm in size, fat in density (−90 Hounsfield unit), which was located in the base of the left lung adjacent to the pleura (Fig 2).Fig 2Computed tomographic scan view of the chest with arrows indicating lipoma.View Large Image Figure ViewerDownload (PPT) The patient underwent a left posterior mini-thoracotomy. In surgery the mass was found in the posterior localization of the diaphragm, and it was totally free of lung tissue. It was yellowish pink in color, covered by diaphragmatic pleura, and it originated from muscle tissue of the diaphragm (Fig 3). The mass was resected in total, and the remaining defect on the pleural surface of the diaphragm was repaired by direct suturing with 2-0 nonabsorbable suture material. Light microscopy showed a lipoma consisting of mature adipose tissue, and no evidence of malignancy existed. The patient made an uneventful recovery and was discharged home 6 days postoperatively. To date (5 years after the operation), the patient remains in good condition without evidence of recurrence on diagnostic imaging. Primary tumors of the diaphragm are rare and commonly present in the fourth and fifth decades of life. There have been less than 200 cases described in the English literature between 1868 and 2005 [4Cada M. Gerstle J.T. Traubici J. Ngan B.Y. Capra M.L. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm.J Pediatr Surg. 2006; 41: 1722-1726Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. Grancher described a primary diaphragmatic tumor, which was a benign fibroma in 1868 [2Weksler B. Ginsberg R.J. Tumors of the diaphragm.Chest Surg Clin N Am. 1998; 8: 441-447PubMed Google Scholar]. Clark described a diaphragmatic lipoma in 1886 [4Cada M. Gerstle J.T. Traubici J. Ngan B.Y. Capra M.L. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm.J Pediatr Surg. 2006; 41: 1722-1726Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. In a 71-patient series with primary diaphragmatic neoplasms, only 9 patients had lipomas [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar]. Lipomas, mesothelial cysts, neurofibroma, and angiofibroma are common benign tumors [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar, 5Cheon J.S. You Y.K. Kim J.G. Lee D.H. Park K. Ahn C.J. Diaphragmatic lipoma in a 4-year-old girl: a case report.J Pediatr Surg. 2006; 41: e37-e39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar], and lipomas make up 35% of them. Furthermore, lipomas are rarely seen in the thoracic cavity [6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 7Shimizu J. Hashimoto T. Imai T. Kawahara E. Primary lipoma of the diaphragm.Respiration. 1996; 63: 397-399Crossref PubMed Scopus (4) Google Scholar]. These two rarely seen features, being primary diaphragmatic lipoma grown into the thoracic cavity are present in the patient reported in this article. On the other hand, primary malignant neoplastic lesions are mostly mesenchymal origins of the diaphragm. Rhabdomyosarcoma is the most common malignant tumor of the diaphragm [4Cada M. Gerstle J.T. Traubici J. Ngan B.Y. Capra M.L. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm.J Pediatr Surg. 2006; 41: 1722-1726Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. The diaphragm is commonly involved with malignant pleural or peritoneal disease [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar]. Tumors of the diaphragm are not associated with any characteristic symptom [7Shimizu J. Hashimoto T. Imai T. Kawahara E. Primary lipoma of the diaphragm.Respiration. 1996; 63: 397-399Crossref PubMed Scopus (4) Google Scholar]. The presentation of the patient with a diaphragmatic tumor is variable depending on age at presentation, size of mass, involvement of adjacent organs, or metastatic disease, and tumor histology. “Chest-associated” symptoms are more common than “abdomen-associated” symptoms at presentation. Clinical presentation was reported by authors to be a combination of chest, shoulder, and back pain, shortness of breath, cough, hemoptysis and respiratory failure, and rupture of the diaphragm [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar, 4Cada M. Gerstle J.T. Traubici J. Ngan B.Y. Capra M.L. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm.J Pediatr Surg. 2006; 41: 1722-1726Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 5Cheon J.S. You Y.K. Kim J.G. Lee D.H. Park K. Ahn C.J. Diaphragmatic lipoma in a 4-year-old girl: a case report.J Pediatr Surg. 2006; 41: e37-e39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. However, most diaphragmatic lipomas are incidentally found [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar, 5Cheon J.S. You Y.K. Kim J.G. Lee D.H. Park K. Ahn C.J. Diaphragmatic lipoma in a 4-year-old girl: a case report.J Pediatr Surg. 2006; 41: e37-e39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. There was slight elevation in the preoperative blood PCO2 level of the patient presented in this case report, without any shortness of breath. However we have no clear evidence whether CO2 retention has any relation with reduced diaphragmatic function if there is any in the present patient. Radiologic evaluation is extremely important that 0 and −100 Hounsfield unit are defined as CT number for water and air, respectively. Fatty tissue corresponds −80 to −135 Hounsfield unit. Negative CT numbers are observed only in air and fatty tissue [6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 8Gaerte S.C. Meyer C.A. Winer-Muram H.T. Tarver R.D. Conces Jr, D.J. Fat-containing lesions of the chest.Radiographics. 2002; 22: S61-S78Crossref PubMed Google Scholar]. Due to the high specificity of CT scan in identifying homogenous fat-containing structure, the diagnosis of lipoma was established with certainity [6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. Diaphragmatic lipoma is located predominantly on the left side (ratio, 2 to 1) and posterolateral area of the diaphragm [2Weksler B. Ginsberg R.J. Tumors of the diaphragm.Chest Surg Clin N Am. 1998; 8: 441-447PubMed Google Scholar]. Lobulations, localized eventration slip or hypertrophic diaphragmatic crus may simulate tumors of the diaphragm, and this should be kept in mind during evaluation [1Gierada D.S. Slone R.M. Fleishman M.J. Imaging evaluation of the diaphragm.Chest Surg Clin N Am. 1998; 8: 237-280PubMed Google Scholar, 6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 8Gaerte S.C. Meyer C.A. Winer-Muram H.T. Tarver R.D. Conces Jr, D.J. Fat-containing lesions of the chest.Radiographics. 2002; 22: S61-S78Crossref PubMed Google Scholar]. In this regard, diaphragmatic hernia or eventration containing omentum should be taken into consideration as a possibility in differential diagnosis. Occasionally the left kidney is located in a high position and locally elevates the diaphragm, mimicking a neoplasm [6Castillo M. Shirkhoda A. Computed tomography of diaphragmatic lipoma.J Comput Tomogr. 1985; 9: 167-170Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. The management of asymptomatic diagnostic lipomas has not been established. Some authors recommend a radiologic follow-up of asymptomatic noninfiltrating diaphragmatic lipomas, whereas others insist on surgery because of the risk of developing a diaphragmatic liposarcoma [2Weksler B. Ginsberg R.J. Tumors of the diaphragm.Chest Surg Clin N Am. 1998; 8: 441-447PubMed Google Scholar, 3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar, 5Cheon J.S. You Y.K. Kim J.G. Lee D.H. Park K. Ahn C.J. Diaphragmatic lipoma in a 4-year-old girl: a case report.J Pediatr Surg. 2006; 41: e37-e39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Although malignant changes in a lipoma are exceedingly rare, some of these are pleomorphic lipomas and others are well-differentiated liposarcomas in which the malignant characteristics were missing when the tumor was first examined [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar, 5Cheon J.S. You Y.K. Kim J.G. Lee D.H. Park K. Ahn C.J. Diaphragmatic lipoma in a 4-year-old girl: a case report.J Pediatr Surg. 2006; 41: e37-e39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Differentiation between diaphragmatic lipoma and a malignant tumor (such as liposarcomas) often relies on the assumption that malignancy would often be associated with a pleural effusion [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar]. However it has been suggested that histologic examination of a completely resected specimen is a much safer way to secure final diagnosis. Therefore we have decided that surgical resection rather than conservative management by close observation alone is a safer way of treatment for the outcome of the patient presented in this report [3Papachristos I. Lautides G. Papaefthimiou O. Andrianopoulos E.G. Gigantic primary lipoma of the diaphragm presenting with respiratory failure.Eur J Cardiothorac Surg. 1998; 13: 609-611Crossref PubMed Scopus (11) Google Scholar]. To ensure complete surgical resection a diaphragmatic tumor, a portion of the hemidiaphragm usually has to be sacrificed, which may necessitate repair with a muscular flap or exogenous material such as polytetrafluoroethylene (or Gore-Tex [W.L. Gore & Assoc, Flagstaff, AZ]) [4Cada M. Gerstle J.T. Traubici J. Ngan B.Y. Capra M.L. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm.J Pediatr Surg. 2006; 41: 1722-1726Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. In surgery we were able to reconstruct the diaphragm by simple suturing without using a patch material. In conclusion, a patient is presented with lipoma, which originated in the left hemidiaphragm, detected as an abnormal pulmonary shadow on chest roentgenogram. We recommend surgical exploration because the possibility of liposarcoma can not be excluded. Treatment of the patient was surgical excision of the tumor and primary closure of the defect on the diaphragm. To date, 5 years after the operation, our patient has been in good condition, without evidence of recurrence on diagnostic imaging." @default.
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• W1985880734 title "Lipoma of the Diaphragm: A Rare Presentation" @default.
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