Carpal tunnel syndrome caused by a giant lipoma of the hand: A case report

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InternationalJournalofSurgeryCaseReports80(2021)105647

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Carpal

tunnel

syndrome

caused

by

a

giant

lipoma

of

the

hand:

A

case

report

Belle

Tellier

(MD)

a

_,

_Mariam

_Gabrian

_(MD)

b,∗

_,

_Jean-Bart

_Jaquet

_(MD

_PhD)

a

a_Plastic,_{Reconstructive}_and_Hand_Surgery_Department,_Maasstad_Hospital,_Rotterdam,_The_Netherlands b_Department_of_General_Surgery,_Erasmus_Medical_Center,_Rotterdam,_The_Netherlands

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r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received21January2021

Receivedinrevisedform10February2021 Accepted11February2021

Availableonline15February2021 Keywords: Giant Lipoma Handsurgery Carpaltunnel Casereport

a

b

s

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INTRODUCTIONANDIMPORTANCE:Lipomasarecommonbenigntumourswhichoccurinupto2%ofthe

population.Theyareclassiﬁedasgiantwhenlargerthan5cm.Althoughtheyareusuallyasymptomatic,

giantlipomasofthehandmaycausecompressionoftheunderlyingtissues.

CASEPRESENTATION:A62-year-oldCaucasianmalepresentedtothePlasticandReconstructiveSurgery

outpatientclinicwithnumbnessandpaininhislefthand.Thenumbnessinhisﬁngerspointedto

com-pressionofthemediannerve,aswellastheulnarnerve.Hepresentedwitharapidlyprogressiveswelling

inhisleftpalm.AnMRIscanofthehandwasmade,whichshowedalipomaofapproximately8,5cm

indiameter.Theswellingwassurgicallyremovedandsentforhistopathologicalanalysis,which

con-ﬁrmedthediagnosisofbenigngiantlipomaofthehand.Twoweekspostoperatively,painandnumbness

signiﬁcantlydecreased.

CLINICALDISCUSSION:Neuralinjuryincarpaltunnelsyndromeisrelatedtothedurationanddegreeof

compression.Agiantlipomaisconsideredmalignantuntilprovenotherwisesincevariantswithhigh

potentialformetastasizingexist.Distinguishingbetweenabenigntumourandamalignantlipomais

essential,sinceamoreradicaltreatmentplanmightberequired.

CONCLUSION:Giantlipomasofthehandareararecauseofcarpaltunnelsyndromeandamalignant

variantshouldalwaysbesuspected.ApreoperativeMRIscanshouldbeperformed.Rapidenblocexcision

isnecessaryincaseofcompressionoftheunderlyingtissues.

accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

1. Introductionandimportance

A lipoma is a common subcutaneous mesenchymal benign tumour,whichoccursin2%ofthepopulation.Localizationindistal extremitiesisuncommon,occurringinlessthan1%ofcases[1,2]. Itisclassiﬁedasgiantifitexceeds5,0cm[1–4].Agiantlipoma inthehandisusuallyasymptomatic.In25%ofcasesitcancause compressionofsurroundingtissues[1,2].

Directcompressionofthemedianorulnarnervecanresultin symptoms suchas paraesthesia,painand lossofstrength [1,2]. Incase ofmediannerveneuropathies,whichaccountfor90%of entrapmentneuropathies, paraesthesiaisseenin theﬁrstthree digitsandradialhalfofthefourthdigit;night-timepainanda pos-itiveﬂicksignareothercommonlyseensymptoms[5].Riskfactors associatedwithcarpaltunnelsyndrome(CTS)arevibration expo-sureandwristposition.Patientswithdiabetes,obesity,alcoholism, thyroiddiseaseandrheumatoidarthritishaveanincreased likeli-hoodofdevelopingCTS[6].Whenagrowingmassexertspressure onanerve,thebloodnervebarrierisaffectedresultinginperineural

∗ Correspondingauthor.

E-mailaddress:m.mubarak-gabrian@erasmusmc.nl(M.Gabrian).

edemaandﬁbrosis.Incasesofchroniccompression,demyelination followedbydegenerationoccur.Caseswithalowdegreeofneural injuryaremorelikelytoshowremyelinationandintimerecover function[6].AlthoughitisanatypicalcauseofCTS,somecasesof mediannerveentrapmenttriggeredbyagiantlipomahavebeen reported[1,4].

Whilemostlipomasarebenign,arapidlygrowingandpainful massismorelikelytobemalignant[1].Agiantlipomais consid-eredmalignantuntilprovenotherwise[7],sincevariantswithhigh potentialformetastasizingexist[8,9].Magneticresonance imag-ing(MRI)isrecommendedtodeterminethepresenceofmalignant characteristics.Furthermore,italsoallowsdetailedvisualizationof themassinrelationtootherviablestructures[1,4,8].Thistypeof examinationhasa94%diagnosisrateindetectingmassesinthe handandwrist[4]. Biopsyofthemassshouldbeconsideredin caseofmalignantfeaturespreoperatively[2].Only histopathologi-calexaminationcanconﬁrmadeﬁnitivediagnosisofabenigngiant lipoma[3].

2. Casepresentation

TheworkhasbeenreportedinlinewiththeSCARE2020criteria [10].A62-year-oldmalepresentedtothePlasticand Reconstruc-https://doi.org/10.1016/j.ijscr.2021.105647

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B.Tellier,M.GabrianandJ.-B.Jaquet InternationalJournalofSurgeryCaseReports80(2021)105647

Fig.1.MRI-scanofthehanddepictingthefattytissuetumour.Themasswaslocalizedventrallyfromtheﬂexortendons,measuring4,8×1,8cminthetransverseplane.In

thesagittalplane,themaximumdiameterwas8,6cm.

Fig.2. Totalexcisionofthegiantlipomaofthehand,measuring4,8×1,8×8,6cm.ThecarpaltunnelandGuyon’scanalwerereleasedtorelievepressureonthemedian

andulnarnerves.

tiveSurgeryoutpatientclinicwithagrowingmassinhisleftpalm, whichsuddenlyappeared18yearsagoandhadnotincreasedin sizebefore.However,itrecentlystartedtogrow,causing progres-sivesymptomsofpainandlossofsensoryandmotorfunctionof boththemedianandulnarnerve.Clinically,themasswaslocalized inthehandpalm,ulnarfromthethenareminenceandmeasured approximately4_×4cm.Norelevantdiseasesormedicationuse werereported.Thepatientdidnothaveahistoryofsmokingor drug/alcoholabuse.

Anultrasoundshowedtwomassesofsimilardensityand archi-tecture.Theulnarandradialswellingmeasured27×14mmand35 ×15mm,respectively.AnMRIscanwasperformedwhichshowed alipomaof4,8×1,8×8,6cmvolartotheﬂexortendons(Fig.1).The tumourspreadouttothecarpaltunnelandGuyon’scanal.A

hypo-intenseﬁbrousbandwasseen,whichcouldexplaintheillusionof twoseparatemassesonultrasound.Someoedemawaspresent,but therewasnosuspicionofamalignanttumour.

Duetotheprogressionofsymptoms,rapidexcisionofthemass wasrecommended.Thecarpaltunnelwasopenedthroughanl -shapedskinincisioninthepalmarcrease.Secondly,themedian nervewasidentiﬁedandprotectedafterdissectionofthesuperﬁcial componentofthelipoma.Subsequently,weproceededtodissect thedeeppalmarspaceandthecomponentlocatedinGuyon’scanal. ThebranchoftheulnarnerveinGuyon’scanalwasspared.

The lipoma wasremoved completely (Fig.2) with no post-operativecomplications.Pathologicalexaminationconﬁrmedthe diagnosisofabenigngiantlipoma.Aftertheoperation,thepatient wasadvised to elevate thehand for theﬁrst week toprevent

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B.Tellier,M.GabrianandJ.-B.Jaquet InternationalJournalofSurgeryCaseReports80(2021)105647

swelling.Furthermore,apressurebandagewasused,whichwas removed after 12 days. Two weeks postoperatively, pain and numbnesssigniﬁcantlydecreased.Threemonthslater,thepatient experiencedafullrecoveryoffunctionofthehand.

3. Clinicaldiscussion

Neuralinjuryisrelatedtothedurationanddegreeof compres-sion[6].Agiantlipomaexertingpressureonthemediannerveand causing compressioncaneventuallyleadtonervedegeneration. Recoveryoffunctionislesslikelyincasesofchroniccompression. Therefore,earlyremovalofthemassiscritical.

A giant lipoma is considered malignant until proven other-wise[7],sincevariantswithhighpotentialformetastasizingexist [8,9]. Therefore, incases suchas this,distinguishingbetweena benignlipomaandaliposarcomaisessential,asmoreradical treat-mentmightberequired.Liposarcomasaccountforapproximately 20%ofallsofttissuesarcomas[11].Presenceinchildren isvery rareandthesetumoursseldomarisefrompreexistinglipomasor subcutaneousfat[3].Thewell-differentiatedliposarcoma(WDLS) is the largest subgroup, accounting for 40% of the cases. [8,9] WDLSandatypicallipomatoustumours(ALT)arelocally aggres-sivewithnopotentialofmetastasizing.ALTarisesmorefrequently inextremities,andthusismorelikelyincaseofamalignantgiant lipomaofthehand.Itisoftenintramuscularanddoesnottypically invadebone.WDLSandALTshareidenticalhistologicalfeatures [9].

Other more aggressive, but less common, forms with high potential for metastasizing (17–30%) are the dedifferentiated liposarcoma(DDLS);themyxoidroundcellliposarcoma(MRCL); and pleiomorphic liposarcoma (PMLS). These types have high recurrenceratesrangingfrom34%to45%.Interestingly,theDDLS canarisedenovoorbepresentinrecurrenceofWDLS.DDLSismore oftenfoundintheretroperitoneum[3,9].Fortheselesions,excision withawidemarginandadjuvantradiotherapyaredesired. Com-pleteresectiondiminishestheriskofrecurrence[9].ForMRCLand PMLSresectionofmusclegroupsisoftennecessary.Aliposarcoma in theextremitywithoutdistantmetastasesrequireslimb spar-ingsurgerycombinedwithadditionaltherapyinmostcases[11]. Incaseoflimbsparingsurgery,adjuvantradiotherapyhasshown improvement oflocalcontrol.However,it hasnoexpected sur-vivalbeneﬁtintheALT/WDLSgroupsincetheydonotmetastasize [9].

4. Conclusion

Incaseofagiantlipomaofthehand,apreoperativeMRIscan ishighlyrecommended,consideringtheriskofmalignant poten-tial.Furthermore,detailedvisualizationofthemassinrelationto otherviablestructuresisanasset[1,4,8].Webelieverapidenbloc excisionofagiantlipomaisnecessaryincaseofcompression.For everypatient,anindividualizedtrajectoryisneededwithdiligent planning.Furthermore,webelievegoodpostoperativeresultscan beachieved,withoutpermanentdamagetotheviablestructures involved.

Declarationofcompetinginterest Nothingtodeclare.

Funding

Nothingtodeclare. Ethicalapproval

Noethicalapprovalwasnecessary. Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

Allauthorscontributedtotheconceptionanddesign.Jean-Bart Jaquetand Mariam Gabrian performedthesurgery. Allauthors contributedtodrafting,criticalrevision,andﬁnalapprovalofthe article.

Registrationofresearchstudies NotApplicable.

Guarantor

Jean-BartJaquet,BelleTellierandMariamGabrianareall guar-antorsforthereport.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed. References

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