Lipoma of the fossa femoralis mimicking a femoral hernia. Report of 2 cases

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ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

Case

Series

Lipoma

of

the

fossa

femoralis

mimicking

a

femoral

hernia.

Report

of

2 cases

G. Amato

a,∗

_,

_G.

_Romano

b

_,

_A.

_Agrusa

b

_,

_V.

_Rodolico

c

_,

_L.

_Gordini

d

_,

_P.G.

_Calò

d

a_Postgraduate_School_of_General_Surgery,_University_of_Cagliari,_Monserrato,_Cagliari,_Italy b_Department_of_General_Surgery_and_Urgency,_University_of_Palermo,_Italy

c_Department_of_Pathologic_Anatomy_and_Histology,_University_of_Palermo,_Italy d_Department_of_Surgical_Sciences,_University_of_Cagliari,_Monserrato,_Cagliari,_Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14May2018

Receivedinrevisedform8July2018 Accepted10July2018

Availableonline19July2018 Keywords:

Lipoma Femoralmass Femoralhernia Differentialdiagnosis Chroniccompressivedamages Ultrasound

a

b

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INTRODUCTION:Lipomaofthefemoralfossaisuncommon.Oftenasymptomatic,femorallipomamay growthwithinthecircumscribedspaceofthefemoralfossacausingpainanddiscomfort.Aworsening paincausedbyalipomatousmassinthefemoralareaisaclinicalfeaturethatcanmisleadthediagnosis, resemblingthemorecommonconditionoffemoralhernia.

METHODS:Twocasesofsymptomaticlipomasofthefemoralfossamimickinganincarceratedfemoral herniaarepresented.Inboth,Caucasianfemale,patientsclinicalexaminationandultrasoundofthe femoralregionrevealedapainfulneoplasmsuspectedforincarceratedfemoralhernia.

RESULTS:Intraoperatively,amassofencapsulatedfatarisingfromthebottomofthefossafemoralis wasfound.Novisceralprotrusionthroughthefemoralringcouldbedocumented.Theneoplasmswere removedintoto.Histologyoftheexcisedspecimensevidencedthediagnosisoffemorallipomassuffering bychroniccompressivedamages.Inamidtermpostoperativefollowup,bothpatientswere symptom-free.

DISCUSION:Acorrectpreoperativediagnosisoffemorallipomaischallenging,evenfollowinganaccurate diagnosticpathway.Thecaseshighlightedherewithseemtoconﬁrmthatlipomaofthefemoralfossacan bemistakenwithafemoralhernia.

CONCLUSIONS:Theclinicalandhistologicalfeaturesevidencedcouldresulthelpfulinthedifferentiation ofalipomatousmassofthefemoralfossafromagenuinefemoralhernia.

1. Introduction

Groinpaincouldbeachallengingdiagnosticdilemmaforthe anatomicalcomplexityoftheregionandcouldarisefrommultiple underlyingpathologicalprocesses.

Thegroinmaybeaffectedbyawiderangeofpathologic enti-ties;thereforetheclinician,theradiologistandthesurgeonneed tomastertheanatomy,thepathologyforacorrectmanagementof thiscomplexregion[1].

Lipomaisabenignneoplasmconstitutedbymatureadipocytes [2].Itrepresentsoneofthemostcommonmesenchymaltumors andoccursinaround10%ofthepopulationinparticularbetween theﬁfthandtheseventhdecadewithoutgenderpredilection[3].

∗ Correspondingauthorat:ViaRapisardi66,I-90144,Palermo,Italy. E-mailaddresses:amatomed@gmail.com(G.Amato),giorgio.romano@unipa.it (G.Romano),agrusa.antonino@unipa.it(A.Agrusa),vitorodolico@gmail.com (V.Rodolico),lucagordini@aol.com(L.Gordini),pgcalo@tiscali.it(P.G.Calò).

Frequentlyasymptomatic,lipomamayshowaspeciﬁc mislead-ingsymptomshidingacorrectpreoperativediagnosis.Generally, itsexcisionisrequiredforcosmeticreasons,fortheexclusionof malignancy,andforcompressiononadjacentorgansorstructures [4,5]. Furtherindicationsfor excisioninclude size(greaterthan 5cm),subfasciallocation,rapidgrowth,clinicalfeaturessuchas pain,ﬁrmness,orirregularity[6].

Althoughlipomaoftheinguinalcanalisnotrare,itslocalization inthefossafemoralisisuncommonandmayleadtoerroneous interpretationsbeingsometimesclinicallyindistinguishablefrom agroinhernia[7,8].

Womenpresentalifetimeoccurrenceofgroinherniabetween 3and6%[9].Femoralherniaisaboutfourtimesmorecommonin women,inparticular,agedover50yearsandrepresents approxi-mately5–10%ofallgroinherniasinadults[10,11].

Thehighriskofcomplicationssuchasstrangulationandbowel resection discourages a watchful waiting strategy, supporting surgeryasthetreatmentofchoice[12].

https://doi.org/10.1016/j.ijscr.2018.07.009

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Fig.1.a)Ultrasoundimageofthefemoralareashowingamasswithundefinedcontoursurroundedbyfluidsuspectedforincarceratedfemoralhernia.b)Lipomaofthe fossafemoralisbeforeremoval.c)Histologicalcaptureofthespecimen:lobulesofmatureadipocyteswithminimalvariationinsizeandshape;slightectasiaofthevascular structures;scatteredinflammatorycells(HE×20).

Anincorrectdiagnosismayleadtoawrongtreatmentorthe developmentofintraoperativecomplications[8].

Lipomaofthefossafemoralisisapoorlyrecognizedentitythat maymimicafemoralhernia.Twocasesworthofnoteare high-lightedherewith.

2. Materialandmethods

ThestudywasregisteredatResearchRegistry.Theresearchwork hasbeenreportedinlinewiththePROCESScriteria[13].

2.1. Presentationofcases

2.1.1. Case1

A63yearsoldCaucasianfemalepresentedwithseverepainin correspondenceoftherightfossafemoralis.Thepainwasperceived asspontaneousandexacerbatedwithmovements.No comorbidi-tieswerepresent. Clinicallyasmallswelling wasfound.Digital examinationof thefemoralregion conﬁrmedthepainful bulge withapositive coughimpulse.Ultrasoundrevealedamass sur-roundedby ﬂuidleading toadiagnosisof incarceratedfemoral hernia(Fig.1a)and,consequently,toanemergentsurgicalrevision ofthe fossafemoralis.Intraoperatively, a 2×4cm mass consti-tutedencapsulatedbybrightyellowfatarisingfromthebottom ofthefossawasfoundwithoutanyvisceralprotrusionthrough thefemoralring(Fig.1b).Anintotoexcisionoftheneoplasmwas carriedout,thenthewoundsutured.

Thespecimenwasfixedin10%bufferedformalin,dehydrated in ethanol and paraffin-embedded according to standard tech-nique;4–5␮msectionswerecutandstainingwithHematoxylin& Eosin(H&E)andimmunostainingwasperformed[14]. Histopatho-logicalexamination of surgicalspecimenshowedmesenchymal tissueconstituted bylobulesofmatureadipocytespresenting a slightvariationinsizeandshapeandminimalfibroussepta inter-posed.Nonecrosisormitosiswerewitnessed.Onlyfewlipoblasts

andscatteredinﬂammatorycells,mainlylymphocytesandplasma cells,werealsoobserved(Fig.1c).Vascularandlymphatic struc-turesshowedslightectasiaand,occasionally,signsofcongestion supportingthehypothesisofischemicsufferingdueto compres-sion.Immunohistochemistryshowedpositivityforvimentinand S100proteinandnegativityforMDM2(Fig.1d),p16andCD34, excludingatypicallipomatoustumororwell-differentiated liposar-coma.Histologicalandimmunohistochemicalfeaturessupported thediagnosisoflipoma.

Atshort-termfollow-up,nomorepainwasreported,andeven 15monthsafterthesurgicalprocedure,thepatientisstillpain-free.

2.1.2. Case2

A62-year-oldCaucasianfemalereportedsuddenpainfulness intherightfemoralregion.Thepainwasworseningandthe dis-comfortinherrighttightaffectedthewalking.Thepatienthada leftSpigelianherniarepairbutnohistoryofcomorbidities.Clinical examinationcouldnotrevealtheoriginofthepain. Ultrasonogra-phyoftherightfemoralregionshowedasmallmassinthefemoral fossasurroundedbyaslightexudativecontourraisingthesuspicion ofincarceratedfemoralhernia(Fig.2a).Thesurgicalexplorationof thefossafemoralisrevealedthepresenceofasmall(1,5×3cm) encapsulatedneoformation constitutedbybrightyellowfatand coveredbyathinﬁlmofexudate(Fig.2b).Thetumorwasintoto excised.Noevidenceoffemoralherniawasfound.

Thehistologicalandimmunohistochemicalanalysiswere con-ductedinasimilarmannerofthepreviouscasewithcomparable findings. Histopathological examination of surgical specimen showed mesenchymal tissue constituted by lobules of mature adipocytes.Edemaandchronicinflammatoryinfiltratewerefound. Vascular structures showeda discreet ectasia, probably due to compression.Ischemicinjurieswereobservedassomeadipocytes presentedfocaldisruptionofthecytoplasmicmembranes(Fig.2c). Theimmunohistochemicalpatternshowedsimilarresultsofthe previouscase,withpositivityforvimentinandS100proteinand

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Fig.2. a)Ultrasoundimageofthefemoralareashowingamasscontouredbyafilmofexudatesuspectedforfemoralhernia.b)Lipomaofthefossafemoralisarisingbelow theCooper’sligament.Thesurfaceofthemassseemstobecoveredbyathinfilmofexudatethatgivestothemassatranslucentaspectthatcontrastswiththenormal appearanceofthesurroundingsubcutaneousfat.c)Histologyofthespecimen:ischemicinjuryofsomeadipocytesshowingfocalfragmentationofcytoplasmicmembranes associatedwithdiscreetectasiaofthevascularstructures,edemaandchronicinflammatoryinfiltrate(HE×20).

negativityforMDM2,p16andCD34.Onthebasisofthese ﬁnd-ings,diagnosisoflipomawasconﬁrmed.Oneyearafterthesurgical removalofthelipoma,thepatientispain-free.

3. Discussion

Thehighvarietyofpathologicconditionsthatmayaffectthe groincanbeclassiﬁedintoﬁvemajorgroups:

• congenitalabnormalities(hernias,cysts,undescendedtestis,and retractiletestes);

• noncongenitalinguinalandfemoralhernias;

• vascular conditions (haematomas and false aneurysm, true aneurysm,varicoceles,varicesofthelargesaphenousvein,and post-traumaticarteriovenousﬁstulas);

• infectious or inﬂammatory processes (inﬂammation of the iliopectineal bursa, synovial osteochondromatosis and abscesses);

• neoplasms(benignandmalignantlesions)[1,15,16].

The aforementioned pathologic conditions are sometimes asymptomaticandoftenclinicallyindistinguishabletotheextent thattheymakeacorrectpreoperativediagnosisarealchallenge. This polymorphic presentation puzzles the clinician facingthe groinpathology.

Lipoma is a common benign neoplasm that may be either superficial or deep [17]. It is usually asymptomatic unless it compressesadjacentstructuresororgans.Its“benign”behaviour becomesfickleandinsidiouswhenlocalizedincriticalareassuch asinguinalcanal,femoraltriangleorpoplitealregion[3,16].Inthese anatomicalminefields, lipomacanmimic hernias,causevenous insufficiencyandmaymisleadtheclinicianfromacorrectdiagnosis [4,5,8,18].

Usually,adetailedknowledgeofanatomycombinedwith clini-calacumencouldleadtoastraightforwardpreoperativediagnosis ofagroincomplaintwithoutanydiagnosticimaging.

Aclinicallyevidentgroinherniaisusuallyconﬁrmedon clini-calgrounds,butsometimesphysicalexaminationalonecanmiss herniasespeciallyifsmall,multipleandinobesepatientsandbe inaccurateindifferentiatinggroinswellings[18,19].

However,when patienthistory is unclearoruneventful and physicalexaminationisobscuredbyobesity,previoussurgery, radi-ationortrauma,imagingiscrucialintheassessmentofthecorrect diagnosisand,consequently,intheestablishmentoftheoptimal management[20,21].

Imaginghasfourgoals: findingtheexact localization of the lesion,findingevidenceforunderlyingcausativedisease, differen-tiatingsolidfromfluid-containingcysticlesions,performingUSor CT-guidedaspirationincaseoffluid-containinglesions[20].

Ultrasonographyasaninitialdiagnosticimagingmodalityfor groin herniasis widelyavailable,non-invasive, repeatable, use-fulindiagnosingotherconditions,cost-effective,well-acceptedby patients,andshowsahighsensitivityandpositivepredictivevalue indoubtfulcases[20–23].

However,whileultrasonographyinthediagnosisofgroin her-niasshowshighaccuracy,ithasbeendemonstratedtohavelow accuracyinthediagnosisofsofttissue lipomas(sensitivity52%, speciﬁcity86%)[24].

The operator dependence of clinical examination and ultra-sonographyindetectingandinterpretingthepathologicconditions ofthegroinshouldbetakenintoaccount.Sonographicﬁndings aretypicallyinterpretedinconjunctionwithclinicaljudgement, andsometimesit ispreciselythis interactionthatmaybiasthe radiologist’sopinion.

ItmaybenecessarytoexpandthediagnosticmethodswithCT orMRIwhetherthediagnosisisunclearorunreliableonclinicaland sonographicgrounds,thusfurtherdiagnosticinvestigationssuchas

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ComputerTomographyandMagneticResonancearerequiredfor groinpainorgroinswellingofunknownoriginoranydiagnostic doubts[1,22,25].

Ultrasonography plays a fundamental role in the diagnostic pathwayofgroinpathologicconditions,butinsomecases,itcannot betheconclusivediagnostictool[18].

Notwithstanding notable enhancement of diagnostic tools investigatingthegroinregion,sometimesisintheoperating the-atrethatthelastsceneofthediagnosticplaycanberevealed[25]. The surgeon must be aware that misdiagnosis may lead to wrongtreatmentstrategy;thereforemeticulousandcareful sur-gicalexplorationismandatorytoreachthecorrectdiagnosisand avoidcomplicationsonthetable[18,26].

Reachingacomprehensivepreoperativeevaluationis a chal-lenge for the clinician and diagnostic imaging may assist in pursuingthisaimbutoftenthesurgeonispivotalinthediagnostic pathway[17].

Thetwocasesoflipomaofthefemoralareawithits intrigu-ingclinicalfeaturespresentedherewithundoubtedlyrepresented achallengeforourdiagnosticefforts.Itwasnoteasy preopera-tivelydiagnosesuchinfrequentpathologicalentity.Theonlyway todefinitelyresolvetheclinicaldilemmawastheintraoperative inspection.Actually,assuringtherightdiagnosisandexcludingthe presenceofanincarceratedfemoralprotrusionwasthefirstscope ofthesurgicalprocedure.Thisincludedthecarefuldissectionof thefemoralfossatoexcludetheoccurrenceofasmallhernia aris-ingfromthefemoralring.Oncetherightdiagnosiswaswelldefined theremovalofthemasscouldbesafelycarriedout.

4. Conclusions

Thetwo casesreportedabove seemto furtherconfirm that, despiteanaccuratepreoperativediagnosticpathway,the occur-renceofalipomaexpandingwithinthefemoralfossacanleadtoa misinterpretationofthediagnosticfindings.Amongsymptomsthat characterizethiscondition,afundamentalandmisleadingroleis playedbythepainlocalizedinthefemoralareathatmay irradi-atecraniallytowardstheabdominalwallandcaudallytothetight. Localpainanddiscomfortappeartobestrictlyconnectedwiththe enlargementofthelipomawithinthenarrowspaceofthefemoral trianglesufferingfromcompressivedamage.Thehistological fea-turesseemtoconfirmthattheinjuryaffectingthelipomatousmass isduetochroniccompression.Theoccurrenceoffemoralpain,often worsening,isthemostimportantfactorthatleadstothe misinter-pretationoftheclinicalstatusinfavorofthemorecommonvisceral protrusionthroughthefemoralring.Althoughapreoperative diag-nosisoffemorallipomaishardtoachieve,itshouldbekeptinmind incaseofuncertaindiagnosticevidenceconnectedwithpaininthe femoralarea.

Conﬂictofintereststatement

Allauthorshavenoconﬂictofinterest.

Funding

Nograntsorotherkindofﬁnancialsupporthasbeenreceived forrealizingthearticle.

Ethicalapproval

Beingaretrospectivestudy,theinvestigationisexemptedfrom approvalbyEthicsCommittee.

Consent

Writteninformedconsentwasobtainedfromthepatientsfor publicationofthis casereportandanyaccompanyingimages.A copyofthewrittenconsentisavailableforreviewbythe Editor-in-Chiefofthisjournal.

Authorcontribution

GiuseppeAmato:madesubstantialcontributionstostudy con-ceptionanddesignaswellasinterpretationofdata.

GiorgioRomano:madesubstantialcontributionstoacquisition andanalysisofdata.

AntoninoAgrusa:madesubstantialcontributionsto interpreta-tionofdata.

VitoRodolico:madesubstantialcontributionstoanalysisand interpretationofdata.

LucaGordini:hasbeeninvolvedindraftingthemanuscriptand revisingitcriticallyforimportantintellectualcontent.

PiergiorgioCalò:made substantialcontributionsto interpre-tation ofdata and gave theﬁnal approval of theversion tobe published.

ResearchRegistrationNumber

researchregistry3754.

Guarantor

GiuseppeAmato.

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