A Case Report: The Third-largest Case in the Literature of a Vulvar Lipoma.

Lipoma is the most common soft-tissue tumor of mesenchymal tissue origin although very rarely found in the vulva. The present study aims to present a very rare and big lipoma. In this case, the patient was 70 years old and was admitted to our clinic with the complaint of soft vulvar mass, 17 cm × 14 cm × 10 cm in size. The mass appeared about 7 years ago and was growing for the past 2 years and extended to the labium majus from the left inguinal region. The author performed a vulvar reconstruction with total excision of the mass. Pathological examination revealed a lipoma. Vulvar lipoma should be considered in the differential diagnosis of vulvar masses, although lipomatous masses are rarely seen in vulva. Copyright:

INTRODUCTION

Lipomas are the most common mesenchymal tumors and usually have a thin fibrous capsule. Although most lipomas are a few centimeters, vulvar lipomas may be in very large sizes. On examination, a mass-oval mass that is not painful can be detected. Lipomas rarely turn into malignancy. This study aims to present the details of a large vulvar lipoma, which is rare and may sometimes be misdiagnosed.

CASE REPORT

In this case, the patient was 75 years old and had six normal deliveries. The author has patient consent for this study. Her medical history revealed hysterectomy due to myxomatosis. There was no history of trauma or chronic disease. The patient was admitted to the clinic in 2018. She had a feeling of swelling (no complaints of pain and limitation of movement) for 7 years, but it had been grown in the past 2 years. Before her admission to our clinic, she was misdiagnosed with an inguinal hernia in her preliminary examination. On the evaluation, a 17 cm vulvar mass with soft consistency extending from the left inguinal region to the labium majus was observed with no intra-abdominal extension.

In the pelvic magnetic resonance imaging (MRI) imaging, a mass with approximately 170 mm × 100 mm size and necrotic components covering completely the left labium were seen. The postoperative measurements of the mass were 17 cm × 14 cm × 10 cm. No intraabdominal or pelvic invasion was detected. Although the final diagnosis was after pathology interpretation; the MRI imaging was useful to reveal the lipomatous consistency of these tumors and to predict the pathologic diagnosis.

The patient underwent dissection in the dorsolithotomy position under spinal anesthesia [Figure 1a], and a 17 cm soft-tissue mass was excised by the sharp and blunt dissection [Figure 1b and c], and the skin was closed with a 3.0 vicryl suture. Vulvar reconstruction was performed as a simple closure, no additional surgery [Figure 1d].

Figure 1

The soft-tissue mass (17 cm) was excised by the sharp and blunt dissection. (a) Linear dissection, (b,c) Sharp and blunt dissection. (d) Simple closure

Tumor excision and vulva reconstruction were performed. The patient was discharged home on the 2nd postoperative day. Pathological examination of the mass revealed a lipoma [Figure 2a]. Microscopic examination revealed a lesion composed mature adipocytes surrounded by a thin fibrous capsule. Follow-up visits were conducted in the postoperative 1st and 8th month.

Figure 2

The excised mass (lipoma) and pelvic magnetic resonance imaging. (a) The mass (Lipoma) excised completely, (b) Pelvic MRI imaging

DISCUSSION

Lipogenic tumors of the vulva include lipomas and liposarcomas. Although lipomas are the most common tumors of soft tissue, their occurrence in the vulva is rare.[1] Recognition of this benign vulvar swelling is important to differentiate it from cystic swellings and malignant neoplasms in the vulva.[2] Although the vulva found at all ages, they are more common seen in 40–60 years.[3] If they are not removed, their size is likely to increase considerably. Vulvar lipomas are very rare. Thus, very few cases have been reported in the literature.[4]

The most common pathologies involved in the clinical differential diagnosis of vulvar lipomas are Bartholin's gland cyst and Nuck canal cyst.[35] However, they may be confused with liposarcomas in pathological diagnosis. Examination and imaging methods can be used for the diagnosis. The appearance of homogeneous exogenous mass on ultrasonography supports the diagnosis of lipoma.[56]

There are very few reports on large lipomas in the vulva. In 2017, Szanecki et al.[7] reported two cases of benign tumors: one (18 cm) case located on the outer surface of the vulva, and the second (23 cm) case extended beyond the vagina. In 2018, Reda and Gomaa[8] presented a case of vulvar lipoma 15 cm in size. In 1999, Kehagias et al.[1] published a 52-year-old female patient with pedicled vulvar lipoma 17 cm in size. In 2007, Sherer et al.[9] reported a case of vulvar lipoma 15 cm in size.

Our case was one of the largest vulvar lipomas ever published in the literature, after the largest lipoma measuring 23 cm and 6.6 kg reported by Szanecki et al.[7] Several isolated spindle/pleomorphic lipomas, such as angiolipomas in the vulva, have been described. The importance of these lesions is due to their histological differences despite similar clinical manifestations. All these tumors are smaller than the tumors seen in our case. Liposarcomas of the vulva, which has been presented in a few cases so far, are rare malignant subcutaneous neoplasms. The most common type of well-differentiated lipoma is observed. Comprehensive tumor sampling is recommended to differentiate lipomas from liposarcomas.[10] Although some cases have been determined in the literature, it was determined to be one of the largest vulvar lipomas therein.

As a conclusion, vulvar lipoma should be considered in the several diagnoses of vulvar masses, although lipomas are rarely seen in the vulva. Given that lipomas can be confused as are in malignant and Bartholin's gland cysts. It is important that the conditions of these patients are well evaluated; the surgical excision is performed at an early stage and histopathologically separated from liposarcomas. The author thinks that MRI imaging is important for the proper diagnosis [Figure 2b].

Ethical approval

The study was approved by Health Sciences University Derince Training and research Hospital, approval protocol number: 2019-0221 obtained on June 24, 2019.

Declaration of patient consent

The author certifies that he have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.