Copyright
©The Author(s) 2017.
World J Gastroenterol. Aug 14, 2017; 23(30): 5619-5633
Published online Aug 14, 2017. doi: 10.3748/wjg.v23.i30.5619
Published online Aug 14, 2017. doi: 10.3748/wjg.v23.i30.5619
Table 1 Comprehensive review of the 32 giant gastric lipomas reported since 1980
Ref. | Age, sex, clinical presentation, PMH, signs and lab abnormalities | Diagnostic work-up | Treatment, pathology | Outcome and follow-up |
Upper GI bleeding | ||||
Current case report 1 | 63 y. o. M with previous medical history of hypertension and hyperlipidemia presented with melena and dyspnea on exertion for 3 d and epigastric pain, early satiety and 10-kg weight loss during the last 6 mo. BP = 144/77 mm/Hg, pulse = 87/min. Hgb = 6.2 g/dL | EGD: 13-cm-wide, submucosal, yellowish, gastric mass in antrum covered by smooth mucosa except for focal ulcerationAbdominal CT: well-circumscribed, uniform 13.4 cm × 8.4 cm × 8.2 cm mass, with attenuation characteristic for fat | Laparotomy: Resected by subtotal gastrectomy extended by partial bulbar duodenectomy with Billroth II reconstructionPathology: Homogeneous, submucosal, soft, 14.5 cm × 8.7 cm × 7.5 cm mass. Lipoma with spindle cell variant by CD34 positivity by immunohistochemistry | Did well postoperatively with no complications. Asymptomatic at 8 wk of follow-up |
Current case report 2 | 78 y. o. F presented with melena for 3 d, associated with weakness and orthostatic dizziness. BP = 124/67 mmHg, pulse = 68/min. Rectal exam-melena. Hgb = 7.1 g/dL | Abdominal CT: submucosal, 9.5 cm × 6.0 cm × 4.5 cm, antral mass. EGD: large, focally ulcerated, antral gastric mass, exhibiting a positive cushion sign | Laparotomy: large, 9.0 cm × 6.0 cm × 4.5 cm, submucosal mass excised by distal gastrectomy. Pathology: lipoma | Patient discharged 5 d postoperatively with no further bleeding |
Ramdass et al[1], 2013 | 37 y. o. F with epigastric pain, melena, vomiting and weakness for 4 d. Pallor and epigastric tenderness. Hgb = 5.9 g/dL. Transfused 6 units packed erythrocytes | EGD: submucosal mass with 1 cm central ulcer in gastric body | Gastric body. Laparotomy: 4 cm × 3.5 cm × 3.2 cm mass at junction of body and antrum removed surgicallyPathology: lipoma | Did well postoperatively with uneventful recovery |
Almohsin et al[2], 2015 | 61 y. o. M presented with hematemesis, melena, epigastric pain, and fatigue | EGD: Gastric mass with an ulcer. Endoscopic biopsies: benign tissue. EUS: large, hyperechoic, antral, submucosal lesion. Abdominal CT: 8.5 cm × 5 cm submucosal, well-encapsulated antral lesion with density of fat with ulcerated overlying mucosa | Laparotomy: enucleation of lesion and overlying mucosa. Pathology: lipoma | Remained well at 9 mo follow-up |
Beck et al[3] ,1997 | 13 y, o. M with hematemesis, melena and abdominal pain for 2 d. Occasional nausea and vomiting for several years. Benign abdomenHgb = 10.5 g/dL | Abdominal radiograph: polypoid mass. EGD: 8 cm × 3 cm × 4 cm soft and compressible, polypoid mass with basal ulceration on anterolateral wall of antrum. Endoscopic mucosal biopsy: normal antral tissue. Abdominal CT: smooth, uniform intraluminal mass with low attenuation in submucosal layer | Endoscopic polypectomy: Unsuccessful due to thick polyp stalk and patient pain during attempted polypectomySurgery: Excision of polypPathology: lipoma | Uneventful postoperative course. Patient asymptomatic |
Bijlani et al[4], 1993 | 70 y. o. M presented with acute hematemesis. Physical examination revealed pallor. Hgb = 7.0 g/dL | EGD: Protruding mass in antrum. Could not traverse endoscope beyond mass. Endoscopic biopsies: normalUGI series: space-occupying lesion in antrumAbdominal USD: normal | Laparotomy: soft, yellowish mass in antrum stretching the serosa. Mass enucleated via serosal approachPathology: lipoma | Uneventful post-operative recovery. Asymptomatic at 6 mo of follow-up |
Bloch et al[5], 1974 | 55 y, o. F with 1 episode of melenaNausea, epigastric fullness, and belching for 7 mo. Physical exam reveals grapefruit-sized epigastric massN.A | Supine abdominal radiograph: Well-demarcated, large epigastric massUGI series: huge, sharply demarcated, mass in distal two-thirds of stomach with 2 cm × 3 cm ulcer at apex of mass | Distal two-thirds of stomach on anterior wall. Laparotomy: huge, grapefruit size submucosal lipoma arising from anterior wall with shallow central ulcerSurgical resection: not documented | N.A |
Chu et al[6], 1983 | 61 y. o. F with previous medical history of gastric ulcer and hiatal hernia diagnosed 2 yr earlier presented with melena and weakness for several days. Rectal exam: fecal occult blood. Hgb = 6.0 g/dL. Transfused 3 units of packed erythrocytes | UGI series: sliding hiatal hernia, and golf-ball-sized mass protruding from lesser curve in antrum. Mass moved in and out of pylorusEGD: well-circumscribed, submucosal, 5 cm × 3 cm-mass protruding along lesser curve in antrum. Positive cushion sign | Laparotomy: 5 cm × 4 cm × 3 cm mass in pre-pylorus. Underwent resection of mass with adjacent lesser curvature, and pyloroplastyPathology: lipoma | Uneventful postoperative course and asymptomatic at 1 yr |
Kibria et al[7], 2009 | 44 y. o. F with hematemesis and melena for 1 d. Hgb = 8.6 g/dL | EGD: Soft, broad-based, 5 cm × 3 cm mass on greater curvature of stomach. Two ulcers on mass. Positive cushion sign. Abdominal CT: 4.5 cm × 3.0 cm gastric mass with attenuation of fat projecting into lumen. Doppler-assisted EUS: submucosal mass of mixed echogenicity | Greater curvature of stomachSurgical resection, 4.8 cm × 3.2 cm, mature adipocytes with ulceration and necrosis of overlying mucosa | Uneventful recovery. Unremarkable EGD at 6 mo of follow-up |
Kumar et al[8], 2015 | 72 y. o. previously healthy M presented with presyncope associated with diaphoresis and pallor. Rectal exam revealed melena. Hgb = 9.9 g/dL | Abdominal CT: 4.3-cm-wide polypoid mass in antrum consistent with gastric lipoma. EGD: large, submucosal mass in gastric antrum with central ulcer with overlying clot. Ulcer injected with dilute epinephrine | Laparotomy: Gastrostomy with wide excision of antral lesion along anterior wall. Pathology: lipoma | Good postoperative recovery and discharged 3 d after surgery |
López Cano et al[9], 1991 | 76 y. o. M with recent NSAID use, and hypertension presented with acute melena. Hgb = 6.8 g/dL | EGD: posterior wall of antrum 3.5-cm-wide lesion with overlying smooth mucosa. Central ulceration. Endoscopic biopsy: gastritis. Abdominal ultrasound with water-filled stomach: 4-cm-wide, echogenic submucosal mass | Partial gastrectomyPathology: lipoma | No postoperative complications |
Myint et al[10], 1996 | 54 y. o. F presented with hematemesis and melena for 1 wk. BP = 70/50 mmHg. Benign abdominal exam. Hgb = 4.0 g/dL. | EGD: 4 cm × 3 cm ulcerated submucosal mass in antrumEndoscopic biopsies: nondiagnostic. Abdominal CT: gastric mass with attenuation value of lipoma | Laparotomy: 6 cm × 6 cm mass in posterior wall of gastric antrum with central ulceration. Pathology: lipoma | Patient alive with no evident disease 6 mo after surgery |
Ortiz de Solórzapo Aurusa et al[11], 1997 | 60 y. o. F. PMH: vitiligo, acute pancreatitis, duodenal ulcer presented with melena, postprandial pain, nausea, vomiting and early satiety. Pallor. Rectal exam: melena. Hgb = 12.8 g/dL | EGD: antral deformity. No active bleeding. Gastric volvulus? Abdominal USD: 5.8 cm × 3.4 cm pedunculated antral mass intussuscepting into duodenum. Abdominal CT: 4 cm × 3 cm × 3-cm-wide, well-defined, submucosal mass | Surgery; Underwent partial gastrectomy for antral mass intussuscepting into duodenum. Pathology: lipoma | Did well for 6 mo of follow-up |
Paksoy et al[12], 2003 | 71 y. o. M with acute hematemesis and melena. BP = 110/70 mmHg, Pulse = 100/minHematocrit = 27% | EGD: 4 cm-wide mass with superficial ulcer on posterior gastric wall. Endoscopic biopsies: “benign” lesionAbdominal CT: 4 cm lesion of lipid density in inferioposterior wall of stomach | Inferioposterior wall of stomachSurgery: laparoscopic transgastric resection of 4 cm intramural lipomaPathology: intramural lipoma | Discharged 6 d postoperatively without complications |
Pérez Cabañas et al[13], 1990 | 73 y. o. M presented with melena and hematemesis for 2 d. Recent NSAID use. PMH: hypertension. Physical exam: pallor, rectal exam-melena. Hgb = 8.6 g/dL. Transfused 5 units of packed erythrocytes | EGD: gastric mass on posterior wall and greater curve with superficial overlying ulcer, small hiatal hernia. Abdominal ultrasound: normal stomach. UGI series: large filling defect, from submucosal lesion | Surgery: Wedge resection for 5 cm × 4 cm submucosal massPathology: ulcerated lipoma | Did well after surgery |
Priyadarshi et al[14], 2015 | 46 y. o. M with melena for 1 yr. Palpable, soft epigastric lump. Mild epigastric tendernessHgb = 5 mg/dL; coagulation parameters and chemistry WNL | EGD: large mass arising from posterior wall antrum with superficial ulceration. Unable to traverse pylorus due to obstruction. Abdominal CT: huge mass with lobulated surface projecting into gastric lumen with density consistent with fat. Tumor extended into pylorus and caused gastric outlet obstruction | Posterior wall of gastric antrumLaparotomy: Billroth I partial gastrectomy; 14 cm × 11 cm × 5 cm sessile broad based submucosal lipoma; path = mature adipocytes | No reported complications |
Rao et al[15], 2013 | 60 y. o. M presented with melena, fatigue and pallor. Hgb = 7.2 g/dL | EGD: large, smooth, submucosal bulge along lesser curvature of stomach. Contrast enhanced abdominal CT: Well-defined, encapsulated, submucosal mass with attenuation of fat along lesser curvature of stomach | Laparotomy: large submucosal tumor excised via anterior gastrotomyPathology: 15 cm × 12 cm submucosal tumor with a focal ulcer. Microscopy demonstrates submucosal lipoma | Presently asymptomatic |
Regge et al[16], 1999 | 52 y. o. M presented with hematemesis and melena. Hgb = 5.5 g/dL | EGD: 3.5-cm-wide, round, pale-pink formation on anterior gastric antrum with oozing superficial ulcer. Hemostasis achieved with dilute epinephrine injection. Abdominal USD: 4-cm-wide hyperechoic antral lesion with distinct margins. Abdominal CT with IV contrast: 4-cm-wide, well-circumscribed, antral lesion with density of fat. Abdominal MRI: Confirmed fat-tissue signal in mass by hyperintensity on T1-weighted images and marked signal reduction on sequences performed with fat suppression | Laparotomy: Antrectomy and gastrojejunal anastomosis via a Roux-en-Y loop. Pathology: lipoma | N.A |
Sadio et al[17], 2010 | 44 y. o. M with medical history of hypertension, obesity, and sleep-apnea, presented with fatigue and intermittent melena for 1 mo. Physical exam revealed pallor. Hgb = 7.8 g/dL | EGD: 4-cm-wide, yellowish, submucosal mass in gastric fundus with central overlying ulceration. EUS: hyperechoic submucosal mass. Abdominal CT: homogeneous, well-circumscribed mass in fundus with density of fat | Surgery: partial gastric resectionPathology: submucosal lipoma | Did well and discharged 10 d postoperatively |
Singh et al[18], 1987 | 40 y. o. M with melena, pyrexia, chills, and weakness. BP = 100/70 mmHg, pulse = 106/min, temp = 39 °C, abdomen-soft, nontender, no palpable mass. Hgb = 4.0 g/dL | EGD: huge polypoid tumor in gastric body along greater curve. Multiple small superficial ulcers in antrumEGD biopsies: Mildly inflamed, mature adipose tissueUGI series: large gastric tumor | Gastric body along greater curveLaparotomy: smooth mass in gastric body and antrum. Multiple small ulcerations. Underwent subtotal gastrectomy and gastrojejunostomy. Pathology: 18 cm × 10 cm × 10 cm encapsulated lipoma | Discharged 2 wk postoperatively. Asymptomatic for 1 yr. |
Youssef et al[19], 1999 | 54 y. o. nonalcoholic F presented with melena and dizzinessPhysical exam: stable vital signs, abdominal tenderness without peritoneal signs. Hgb = 9.2 g/dL | EGD: submucosal protrusion with mucosal erosion along greater curvature in body and antrumAbdominal USD: homogeneous, hyperechoic mass in submucosa of posterior gastric wall. Abdominal CT: homogeneous, 5.1 cm × 3.7 cm lesion with density of fat in posterior gastric wall | Laparotomy: with full-thickness resection of lesionPathology: 5.2 cm × 3.8 cm × 3.2 cm submucosal lipoma | Uneventful recovery |
Abdominal pain | ||||
Alberti et al[20], 1999 | 11 y. o. F with periumbilical and RLQ abdominal pain for 3 yr. Outpatient UGI series revealed multiple filling defects in gastric antrum and body. Normal physical examination. Abdomen was soft with no palpable mass. No fecal occult bloodNormal routine blood studies. Normal iron studies | EGD: multiple, large, soft, masses protruding into gastric body and antrum with normal overlying mucosa. Gastric biopsies: normal mucosa. Abdominal USD: multiple, homogeneous, well-encapsulated, submucosal masses with attenuation characteristic of fat. Abdominal MRI: solid, hyperintense formations with signal characteristic of fat in gastric body and antrum. Percutaneous transgastric ultrasound guided biopsy: features of lipoma with mild inflammatory infiltrate | Gastric body and antrum. No treatment because became asymptomatic | “Pain progressively relieved”Follow-up MRI of abdomen: no change |
Hamdane et al[21], 2012 | 51 y. o. M with epigastric painN.A | EGD: soft, large, ulcerated, submucosal mass in antrumEndoscopic biopsies: nonspecific inflammation of gastric mucosa. Abdominal CT: Round, well-circumscribed, low-attenuation, 9-cm-wide, gastric mass | Surgery: total gastrectomy. Pathology: 9 cm × 7.5 cm × 5 cm., mature adipocyte proliferation with variation of cell size in a fibro-myxoid background. Immunohistochemistry: positive to anti-HGMA2, but not S-100, or CD34, No MDM2 or CDK4 amplification, consistent with lipoma | Uneventful recovery. No symptoms at 1 yr follow-up |
Neto et al[22], 2012 | 63 y. o. M history of dyslipidemia, and hypertension with upper abdominal pain. Physical exam reveals a palpable, moveable upper abdominal massNormal routine laboratory tests | Abdominal USD: large echoic mass compatible with an expansive lesion in gastric antrum. EGD: large bulging mass in posterior gastric wall with three ulcerated areasEndoscopic biopsies: necrotic mucosaAbdominal CT: well-defined, homogeneous, oval mass located within the posterior gastric wall that compressed descending duodenum and had the density of fat | Posterior gastric wall. Laparotomy with a subtotal gastrectomy and D1 lymphade-nectomy with Roux-en-Y reconstruction: 12 cm × 8 cm × 6 cm, lipoma with mature, well differentiated adipocytes surrounded by a fibrous capsule with 3 ulcerative lesions of 0.5 cm, 1 cm, and 1.4 cm | Uneventful recovery with discharge 7 d postoperatively |
Ramaraj et al[23], 2012 | 52 y. o. M with dyspepsia, anorexia, and early satiety for 6 mo. Gastric ulcer 5 yr earlier. Iron deficiency anemia: Hg = 11.5 g/dL, ferritin = 5 ng/mL | Colonoscopy: within normal limits. EGD: Extrinsic indentation in distal stomach with smooth overlying mucosa. Endoscopic biopsy: normal mucosaCT abdomen: 15 cm × 14 cm fatty tumor in distal stomach | AntrumSubtotal gastrectomy: Submucosal antral lipoma with central ulceration | No postoperative complications. Asymptomatic at 4 wk of follow-up |
Zak et al[24], 2006 | 58 y. o. M with intermittent upper abdominal discomfort, early satiety, smoking, hyperlipidemia, obesity, PTSD, and depression. Has iron deficiency anemia | EGD: 10 cm × 6 cm smoothly lobulated, submucosal mass in gastric antrum along greater curvature. Chronic inflammation and intestinal metaplasia of gastric mucosa. EUS: hypoechoic submucosal mass surrounded by a hyperechoic layer in posterior wall of stomach, consistent with encapsulated lipoma. Abdominal CT: homogeneous, round, sharply-defined, encapsulated, submucosal lesion with characteristic density of fat | Gastric antrum along the greater curvatureLaparotomy: resection only of the encapsulated massPathology: 10 cm × 6 cm lipoma | Uneventful recovery with discharge on day 7. Follow-up abdominal CT 2 mo later revealed no abnormalities |
Predominantly nausea and vomiting or obstructive symptoms | ||||
Aslan et al[25], 2015 | 77 y. o. M with nausea and vomiting,and dyspepsia. Complete blood count and comprehensive metabolic panel: WNL | EGD: submucosal mass with normal overlying mucosa extending into antrum along lesser curve | Endoscopic submucosal resection of 9-cm-long lipoma with an intact capsule | Discharged after 3 d. Resolution of symptoms at 6 mo of follow-up. Repeat endoscopy did not reveal a mass |
Lin et al[26], 1992 | 77 y. o. F with nausea, vomiting, abdominal pain for 3 wk and 7-kg-weight-loss. Dehydrated and generalized mild abdominal tenderness. Rectal exam: fecal occult blood | UGI series: large polypoid gastric mass intussuscepting into duodenum. Abdominal USD: suspected intussusception. EGD: inadequate examination. Differential of gastric torsion vs intussusception | Laparotomy: large necrotic polypoid intussuscepting mass arising in stomach. Polyp resected at its base. Pathology: large polypoid lipoma | Ultimately recovered and was discharged |
Mouës et al[27], 2002 | 72 y. o. M with anorexia, early satiety, nausea, and involuntary weight loss. No overt GI bleeding. Left lung lobectomy for bronchial lung cancer 10 yr earlier. Hemoglobin = 4.7 g/dL | EGD: gastric mucosal hypertrophy extending into duodenum. Abdominal USD: hyperechoic mass in small intestine, consistent with lipoma, with likely intussusception. CT abdomen: low attenuation intraluminal tumor compatible with small intestinal lipoma | Laparotomy: large pedunculated tumor intussuscepting into jejunum. Mass reduced back into stomach. Gastrostomy revealed 10 cm × 5 cm superficially ulcerated gastric lipoma. Mass excised. Pathology: mature adipose tissue | Uneventful recovery |
Nasa et al[28], 2016 | 56 y. o. F with dyspepsia and occasional vomiting for 1 yr. Mild epigastric tenderness | EGD: smooth 5-cm-wide antral bulge with overlying normal mucosa. Positive cushion sign. Endoscopic biopsy: chronic active gastritis from Helicobacter pylori. EUS: homogeneous, hyperechoic, mass arising from layer 3 of gastric wall, compatible with lipoma. Abdominal CT: homogeneous, 6-cm-wide, oval mass in antropyloric region, with density of fat | Antrum and pylorus along lesser curveLaparotomy: Excision of 6 cm wide, encapsulated tumor along lesser curve of stomach | Did well and discharged. Asymptomatic at 6 mo |
Treska et al[29], 1998 | 61 y. o. M with intermittent vomiting for several days. History of gastric ulcer N.A | UGI series: spherical, smooth, 4.0 cm × 4.5 cm defect in gastric antrum. EGD: protruding, yellowish tumor in prepylorus. Two ulcers above tumor. Abdominal ultrasound: 7 cm × 6 cm × 5 cm echogenic defect in wall of gastric antrum. Abdominal CT: prepyloric intramural lipoma | Gastric antrum. Laparotomy: 7.0 cm × 6.0 cm tumor in prepylorus. Tumor resection of lipoma with performance of Billroth II | Discharge 12 d postoperatively. No GI symptoms 8 mo after surgery |
Lipoma discovered incidentally in work-up for other condition | ||||
Al Shammari et al[30], 2016 | 41 y. o. M presented for morbid obesity with a BMI of 43.9 kg/m2 and history of obstructive sleep apnea. Normal routine blood tests | Abdominal ultrasound: liver span of 18.8 cm.EGD: rounded 3 cm × 3 cm mass in antrum with normal overlying mucosa. Positive cushion sign. Abdominal CT: 3.5 cm × 3.0 cm lesion in stomach suspicious for lipoma | Antrum. Laparoscopy: Intragastric submucosal mass excised from inside stomach after gastrostomy. Sleeve gastrectomy then performed for morbid obesity. Pathology: 4 cm × 3 cm × 2 cm lipoma | Discharged 4 d postoperatively. Asymptomatic at 2 wk of follow-up |
Hyun et al[31], 2002 | 22 y. o. M who underwent abdominal CT as preoperative evaluation of retroperitoneum before orchiectomy for testicular cancer. N.A | Abdominal CT: large gastric mass with attenuation of fat projecting into gastric lumen. EGD: large, soft, sessile mass on greater curve of stomach with overlying pink mucosa. Positive cushion sign. Endoscopic biopsies: normal mucosa. EUS: Submucosal mass with less echogenicity than expected for lipoma | Surgical resection: 12 cm × 9 cm × 2.5 cm mobile mass resected. Pathology: Submucosal gastric lipoma | Doing well at 2 mo follow-up |
López - Zamudio et al[32], 2015 | 59 y. o. M who underwent abdominal CT performed during episode of acute alcoholic pancreatitis revealed probable pyloroduodenal intussusception of a tumor with attenuation suggestive of fat. Hgb = 9.3 g/dL | EGD: 8 cm long polypoid mass impeding flow near pylorus. EGD biopsy: gastritis and incomplete intestinal metaplasia. Repeat EGD: greater curve posterior wall large pedunculated polyp with central ulcerationRepeat EGD biopsies: chronic gastritis, focal ulceration intestinal metaplasia and Helicobacter pylori infection. EUS: 5.6 cm × 4.9 cm mass in gastric antrum in muscular layer | Surgery: 5 cm × 5 cm tumor in anterior wall of gastric antrum. Underwent antroduodenectomy with gastroduodenal anastomosis and Roux-en-Y | No postoperative surgical complications. Asymptomatic at 18 mo of follow-up |
Table 2 Risks factors for upper gastrointestinal bleeding among 32 patients with giant gastric lipomas
Parameter | mean ± SD of parameter in patients with bleeding | mean ± SD of parameter in patients without bleeding | Patients with bleeding: n with ulcer/total n (% with parameter) | Patients without bleeding: n with parameter/total n (% with parameter) | P value | OR | 95%CI | Statistical test |
Continuous variables | ||||||||
Patient age | 54.9 ± 15.5 yr | 53.8 ± 19.6 yr | - | - | 0.87 | NA | NA | Student’s t test |
Lipoma size | 7.1 cm ± 4.4 cm | 9.3 cm ± 3.1 cm | - | - | 0.16 | NA | NA | Student’s t test |
Dichotomous variables | ||||||||
Male sex | - | - | 12/19 (63.2) | 10/13 (76.9) | 0.47 | 0.51 | 0.08-3.17 | χ2 test |
Ulcer overlying lipoma | - | - | 16/19 (84.2) | 4/13 (30.8) | 0.004 | 12.0 | 1.72-101.9 | Fisher’s exact test |
Table 3 Distinctive features of giant gastric lipomas
Test/technique/parameter | Distinctive characteristic | Pathophysiology | Ref. |
Age | Average age = 54.5 ± 17.0 years old | Current Report | |
Gender ratio | Male-to-Female ratio approximately 2:1 | Unknown (sexual hormones?) | Current Report |
Lipoma size | Average maximal dimension = 7.9 cm × 4.1 cm | Current Report | |
Most common clinical presentation | 19 of 32 presented with acute UGI bleeding | Postulated from ulcer at tip of lipoma caused by rubbing/trauma of tip against gastric wall contralateral to base of lipoma | Current Report |
EGD | Smooth bulge covered by normal mucosa | Submucosal (or occasionally subserosal) location. No tumor invading mucosa due to benignity | Neto et al[22], 2012, Thompson et al[36], 2003 |
Most commonly located in gastric antrum | Thompson et al[36], 2003, Menon et al[40], 2014 | ||
Yellowish hue | Yellow color of adipose tissue in submucosa transmitted to mucosal surface | Menon et al[40], 2014, Chen et al[41], 2014 | |
Broad base | Rarely pedunculated | Singh et al[18], 1987 | |
Cushion or pillow sign: easily deforms like a cushion with mild pressure applied against it by an endoscopic probe (closed biopsy forceps). | Lipoma consists of soft, compressible tissue. | De Beer et al[37], 1975, Hwang et al[38], 2005 | |
Tenting sign: Mucosa easily retracts after it is grasped and gently pulled with a forceps | Mucosa separates from submucosa when gently pulled via forceps because lipoma has fibrous capsule and does not infiltrate into adjacent tissue | Priyadarshi et al[14], 2015 | |
Naked fat sign: repeated biopsies at same site reveals yellow fatty tissue | Multiple biopsies at same site (using well technique) exposes submucosal lipomatous tissue | Chen et al[41], 2014, Patrick et al[42], 2007 | |
Moderately frequent focal central ulceration of mucosa | Likely secondary to giant lipoma abutting and rubbing against contralateral gastric wall. Ischemia may also contribute to ulceration. | Kumar, et al[8], 2015, Thompson et al[36], 2003 | |
Highly useful diagnostic test for lipomas | Typically strongly suggestive of diagnosis | Demonstrates anatomy of mass. Shows if ulcerated or intussuscepting mass. Characteristic findings: yellow hue, smooth overlying mucosa, relatively homogeneous, round margins. Exhibits pillow, tenting or naked fat signs. | Current Report |
Endoscopic biopsies | Standard endoscopic biopsies usually reveal only normal mucosa and insensitive for pathologic diagnosis. | Standard endoscopic biopsies typically sample superficial mucosa and miss deeper submucosal lipoma. | Current Report, Neto et al[22], 2012 |
Techniques to increase yield of endoscopic biopsies; use jumbo forceps for endoscopic biopsies; or well technique (repeated endoscopic biopsies at same mucosal site). | Repeated biopsies at same site permits sampling of deeper (submucosal) tissue | Wang et al[47], 2015 | |
Abdominal CT | Submucosal mass | Typically submucosal, occasionally subserosal, and never mucosal. | Beck et al[3], 1997 |
Well-circumscribed with well-defined edges | Characteristically has a firm fibrous capsule with no invasion through capsule due to benignity | Thompson et al[36], 2003 | |
Typically solitary | Multiple gastric lipomas are very rare | Park et al[48], 1999, Skinner, et al[49], 1983 | |
Homogeneous | Composed of homogeneous lipocytes | Park et al[48], 1999, Alkhatib et al[50], 2012 | |
Densitometry of -80 to -120 HU (Hounsfield units). | Characteristic of adipose tissue | Alberti et al[20], 1999 | |
Highly useful as diagnostic test for gastric lipomas | Demonstrates characteristic findings in about 95% of cases. | Characteristic findings: well-circumscribed, submucosal, homogeneous mass with an attenuation characteristic of fat. | Current Report |
EUS | In third layer of gastric wall | Typically submucosal (rarely subserosal) | Chen et al[43], 2011 |
Hyperechoic (bright) | Alkhatib et al[50], 2012, Eckardt et al[51], 2012 | ||
EUS-guided needle biopsy or endoscopic mucosal resection | EUS guidance used to obtain diagnostic deep (submucosal) biopsies | Deep biopsies permit sampling of submucosal lipomas | Alkhatib et al[50], 2012, Karaca et al[52], 2010 |
Transcutaneous abdominal ultrasound | Not very useful for gastric lipomas. | Supplaned by abdominal CT or EUS for evaluating suspected gastric lipomas | Current Report |
Upper gastrointestinal series | Mostly obsolete test | CT is a superior alternative | Current Report |
Histopathology | Diagnostic features | Rounded, plump cells with abundant clear, homogeneous cytoplasm containing fat, eccentric nuclei, mature adipocytes with no lipoblasts, scant stroma, rare inflammatory cells. | Current Report |
Imunohistochemistry | Reveals no MDM2 or CDK4 gene amplification. | Distinguishes lipoma from liposarcoma. | Shimada et al[45], 2006, Boltze et al[46], 2001 |
Immunohistochemistry | Lipoma stains positively for CD4 | Indicates spindle-cell lipoma variant | Lau et al[39], 2015 |
- Citation: Cappell MS, Stevens CE, Amin M. Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies. World J Gastroenterol 2017; 23(30): 5619-5633
- URL: https://www.wjgnet.com/1007-9327/full/v23/i30/5619.htm
- DOI: https://dx.doi.org/10.3748/wjg.v23.i30.5619