Successful management of pleural lipoma by video-assisted thoracoscopic surgery.

Pleural lipoma is an extremely rare clinical entity. Symptomatic pleural lipoma is rarer. We report a case of symptomatic pleural lipoma which was successfully managed by video-assisted thoracoscopic surgery (VATS). A brief review of relevant literature has been included in the article.

INTRODUCTION

Lipomas are benign soft tissue tumors arising from mature adipocytes. Although they can be encountered almost anywhere in the body, their occurrence within the thoracic cavity in relation to the pleura is very rare. Most reported cases of pleural lipoma are of asymptomatic lipomas, which are accidentally discovered. We report a case of symptomatic pleural lipoma, which was successfully treated by video-assisted thoracoscopic surgery (VATS).

CASE REPORT

A 45-year-old man presented to us with dry cough and mild chest discomfort since 1 year. His chest examination was unremarkable. Plain X-ray of the chest showed an abnormal spherical shadow in the upper portion of the right lung. A CT scan of the thorax revealed a 9 × 6 cm2 sized well-circumscribed lesion with fat attenuation in the upper lobe of the right lung suggestive of pleural lipoma [Figure 1]. All other haematological and biochemical investigations were within normal limits. The lesion was removed by VATS [Figure 2]. Histopathological examination of the retrieved specimen revealed that the lesion was composed of well-differentiated mature adipocytes, which is suggestive of a lipoma.

Figure 1

CT scan of the thorax showing a well-circumscribed lesion with homogenous fat attenuation in the upper lobe of the right lung

Figure 2

Intraoperative photograph showing pleural lipoma being excised

DISCUSSION

Lipomas are benign soft tissue neoplasms composed of mature adipocytes. Although lipomas are ubiquitous, they are rarely encountered in the thoracic cavity. Intrathoracic lipomas are classified as,[1]

Endobronchial lipoma: arising from the sub-cutaneous fat of the tracheobronchial tree.

Parenchymal lipoma: located peripherally within the lung parenchyma.

Pleural lipoma: originating from the submesothelial parietal pleura which may extend into subpleural, pleural or extrapleural spaces.[2]

Mediastinal lipoma.

Cardiac lipoma.

These slow growing neoplasms are mostly asymptomatic. Rarely they may attain a sufficient size to produce symptoms such as non-productive cough, heaviness in the chest and dyspnoea. An asymptomatic pleural lipoma may be accidentally discovered by a plain radiograph. A CT scan may be required to demonstrate the pleural origin and fatty composition.[3] In the CT scan, pleural lipomas demonstrate a homogenous fat attenuation with values of –50 to–150 HU. A heterogenous attenuation should suggest the possibility of a liposarcoma.[4]

In spite of the benign nature of the pleural lipoma, surgical treatment is recommended by most authors[56] as it is very difficult to differentiate lipoma from a well-differentiated liposarcoma preoperatively. However, if the lesion is symptomatic as in our patient, surgery is the only option which offers cure. When surgery for a benign lesion-like lipoma is being contemplated, it is of paramount importance that the procedure causes least discomfort, morbidity and interference with the quality of life. VATS satisfies all these criteria and hence can be considered as the most appropriate procedure for such lesions. It avoids thoracotomy and significantly reduces the procedure related morbidity thereby assuring early return to normal activity. A literature search yields very few reports of treatment of intrathoracic lipomas by VATS.[7-9] To the best of our knowledge, this is the first reported case of an intrathoracic lipoma successfully treated by VATS in the English literature.

To conclude, a pleural lipoma though rare should be included in the list of differential diagnosis for a homogenous pleural mass and VATS is the most appropriate treatment option for such benign intrathoracic lesions.