207

Fatty Tumors of the Thorax

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Demonstrated by CT

The radiographic signs previously described for fatty tumors of the thorax although
Gaston Mendez, Jr. ,
helpful are nonspecific. In the past, the diagnosis of benign fatty tumors of the chest in
Michael B. Isikoft,1
asymptomatic patients required surgical intervention. This report illustrates the gamut
Sharon K. Isikoff,2
of fat-containing tumors of the thorax encountered over a recent 1 year period. CT
and Walther N. Sinner1 proved to be helpful in the diagnosis and management on these cases. When the CT
numbers of the fatty lesion was around -55 EMI units, intervention was felt to be
unnecessary. However, when the CT number of the mass ranged from - I 0 to - 20 EMI
units, intervention was felt to be necessary since a malignancy could not be excluded
on the basis of the CT findings alone.

Fatty tumors of the thorax are uncommon. In addition to fatty infiltration of the
mediastinum, paraspinal lipomas, transmural thoracic lipomas, and parenchymal
lipoblastomas have all been reported. Although unusual, liposarcomas may also
occur in the thorax. Many of the radiographic signs that have been described
[1], although helpful, are often nonspecific. In the past, the diagnosis of a benign
tumor of the chest or mediastinum in an asymptomatic patient required surgical
intervention [2]. Recent reports stress the importance of CT in the diagnosis of
fatty tumors of the chest [3-6]. This report illustrates the gamut of fat-containing
tumors of the thorax encountered at Jackson Memorial Medical Center during
the last year.

Materials and Methods

In one year 385 patients with suspected thoracic pathology were studied by CT. The
scans were performed on a G.E. CT/T total body scanner with a scanning time of 4.8 sec
and a slice thickness of 1 cm. Scans were performed at 1 .5 cm intervals; in most patients,
Received December 1 9, 1 978; accepted after 1 4-1 8 slices were sufficient to cover the area of interest. The studies were monitored by
revision April 24, 1979. a radiologist and the pictures were recorded by a multiformat camera. Intravenous contrast
This work was supported in part by BSR grant material was not used. Ten patients were found to have thoracic tumors with at least some
H-841 3R. fatty components. Age range of the patients was 8-74 years. Six patients were male and
1 Department of Radiology, university of Miami four were female.
School of Medicine, Jackson Memorial Medical
Center, P.O. Box 016960, Miami, FL 33101. Ad-
dress reprint requests to G. Mendez, Jr.
Representative Case Reports
2 Department of Pathology. University of Miami
School of Medicine, Jackson Memorial Medical Case 1
Center, Miami, FL 33101.
S. G. , a 74-year-old white man, had shortness of breath over the previous 2 months.
AJR 133:207-21 2, August 1979
0361 -8o3x/79/1332-o2o7 $00.00 Chest radiography revealed a large lobulated posterior mediastinal mass (figs. 1 A and 1 B).
© American Roentgen Ray Society CT scan at that time confirmed the presence of a posterior mediastinal mass (figs. 1 C and
 .
.208.
MEN .i Ai...
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#{149}

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‘iii: i:fs;- 1 ii’/ supeiorIy on’right and inferiorly behind heart lncu
-. - , - . I pleural’thickening at right base. B, Lateral film
... -. .! displacing trachea (arrow) Lobulation of mass.E

- c CT scan through chest at level of heart Lar”

‘I heart (H) anteriorly and aorta laterally to left
pl#{234}url thickening on right (cur” 1’
,men.ILarge,’retrocrural rr’
Note’xtension along -‘

. .,, ‘*4 differentiated liposarcc

 AJR:133, August 1979 CT OF FATTY THORACIC TUMORS 209
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Fig. 2.-Case 2. A, Posteroanterior film after ingestion of barium. Anterior mediastinal mass obliterates profile of right cardiac border (arrows). B, CT scan.
lnhomogeneous mass with mixed pattern (arrows) adjacent to right cardiac border. H = heart. At surgery this was benign teratoma.

1 D). The density of the mass measured -20 EMI units. The trachea mass was adjacent to the ascending aorta but distinctly separate
and heart were displaced anteriorly. The great vessels were inse- from it. The overall density of the mass measured about - 1 5 EMI
parable from the tumor. However, the patient did not have a superior units indicating that at least part of this mass was fatty. A biopsy at
vena cava syndrome. At surgery a well differentiated liposarcoma mediastinoscopy proved it to be a thymolipoma.
was found (fig. 1 E).
Case 5

Case 2 L. W., a 23-year-old white man, had been on treatment with

steroids for chronic idiopathic thrombocytopenic purpura. Follow-
R. W., an 8-year-old white boy, had chest radiography because up chest radiography revealed widening of the anterior mediastinum
of a questionable cardiac murmur. A right anterior mediastinal mass (fig. 5A). Because of the steroid treatment, a CT scan was per-
was found (fig. 2A). CT scan confirmed the presence of an anterior formed; it revealed diffuse infiltration of the mediastinum by fat (fig.
mediastinal mass with CT numbers
1 5 EMI units (fig. of - 1 0 to -
5B). Density was -55 EMI units. No further studies were required.
2B). An exact histologic diagnosis could not be made. At surgery
an 8 x 5 x 4 cm mass was removed. The mass contained cystic
areas with mixed fatty elements. The histology was a benign tera- Results
toma.
Ten patients with suspected mediastinal and thoracic
tumors on routine chest films were evaluated with CT. In all
Case 3 cases, the mass exhibited low CT numbers ranging from
R. D. , a 72-year-old white woman from Nicaragua, had a chief -10 to -55 EMI units (table 1). In six of these patients, CT
complaint of shortness of breath. An oblique chest film revealed a demonstrated the benign nature of the fatty tumors. Four
lobulated mass contiguous with the left hemidiaphragm (fig. 3A). patients were found to have mediastinal lipomatosis, two
CT scan demonstrated a 3 x 4 cm mass in the area of the left due to obesity and two due to steroid medication. These
hemidiaphragm (fig. 3B). The density of the mass was -55 EMI cases demonstrated diffuse infiltration of the mediastinum
units, consistent with fat. On further cuts the mass could be seen with fat (-55 EMI units). In two patients, the fatty masses
extending into the abdomen. Because of the benign appearance of
represented eventration of abdominal fat through the dia-
the mass on CT, no surgery was performed. This mass most likely
phragm. In one patient, with a paravertebral mass on the
represented a localized eventration of the diaphragm containing
chest film, CT demonstrated paravertebral and retrocrural
abdominal fat.
fat. Three patients had masses with CT numbers less than
water density (0 EMI units), but greater than pure fat (-55
Case 4 EMI units). In these cases, the benignancy of the lesions
M. R., a 66-year-old black woman, was admitted with a diagnosis could not be established by CT. Two of these masses were
of hypertension. Admission chest radiography revealed a right in the anterior mediastinum. Pathologically, one was a ter-
anterior mediastinal mass (fig. 4A). No symptomatology referable atoma and the other a thymolipoma. The last case in that
to the chest could be obtained. CT scan showed a well defined density range had a posterior mediastinal mass which
8 x 6 cm anterior mediastinal mass (fig. 4B). The homogeneous proved to be a well differentiated liposarcoma.
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Fig. 4.-Case 4. A, Posteroanterior film. Right anterior mediastinal mass (arrows). B, CT scan at level of aortic arch. Low density mass (arrows) contiguous
with but separate from, aorta (A). Superior vena cava (c) displaced posteriorly. At surgery this was thymolipoma.
 AJR:133, August 1979 CT OF FATTY THORACIC TUMORS 21 1
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Fig. 5.-Case 5. A, Widening of mediastinum especially on left (arrows) without loss of aortic profile. B, CT scan through aortic arch (A). Increase in fat
content of anterior mediastinum (arrows). C = superior vena cava, T = trachea.

sion or displacement. The fat deposition may be seen in

TABLE 1: Correlation of CT Find ings with Need for Surgery other areas such as the extrapleural space [4], the paraver-
Surgical tebral space [5], the cardiophrenic angle [8], and the retro-
CT Final intervention
Diagnosis/No. Diagnosis Felt
crural space [9]. Mediastinal lipomatosis may be associated
Necessary with steroid-induced Cushing’s syndrome [1 0]. With exog-
Benign mediastinal lipomatosis: enous steroids, the radiographic abnormalities may return
-55 Same; obesity No to normal after discontinuation of therapy. There is one case
-55 Same; obesity No report in which mediastinal lipomatosis was associated with
-55 Same; steroids No ectopic ACTH production from a carcinoma of the lung
-55 Same; steroids No
Eventration diaphragm: [1 1 ]. However, simple obesity can also be associated with
-55 Same No mediastinal lipomatosis due to the physiologic deposition of
-55 Same No fat.
Paravertebral fat: Even though the diagnosis of mediastinal lipomatosis can
-55 Same No
be inferred from the radiographic findings on a plain chest
Mediastinal mass (rule out
malignancy): film, it is often difficult to prove. Since most fatty tumors are
Anterior: benign and usually asymptomatic, surgical intervention is
- 10 . Teratoma
Thymolipoma
Yes often unnecessary if the diagnosis can be conclusively
- 15 Yes
established. Computed tomography has the advantage of
Posterior:
-20 . . Liposarcoma Yes providing information about the absorption coefficient of
tissue displayed on a cross-sectional format. Fat can be
identified on CT by its low attenuation coefficient of -50 to
-60 EMI units.
Juxtadiaphragmatic and juxtacardiac masses may also
Discussion
pose a diagnostic dilemma as seen in two cases from our
Increase in the width of the mediastinal shadow may be series. Both patients had a localized eventration of the
produced by many conditions such as tumor, lymph node diaphragm containing abdominal fat. Because of the CT
enlargement, substernal thyroid tissue, a dilated esophagus, findings, both were treated conservatively. In two of our
vascular ectasia, and neurogenic and fatty tumors. Fat is cases, anterior mediastinal tumors with low CT numbers
normally present to a variable degree especially in the around - 1 0 to - 1 5 EMI units were identified. These cases
anterior mediastinum [7]. Benign lipomatosis results in a turned out to be a benign teratoma and thymolipoma, both
symmetrical widening without evidence of organ compres- containing a significant amount of fat histologically. In these
 212 MENDEZ ET AL. AJR:133, August 1979

cases, CT was helpful in delineating the extent of the tumor. REFERENCES

However, a definitive diagnosis of the nature of the mass 1 . Koerner JH, Sun DIC: Mediastinal lipomatosis secondary to
was impossible and surgery was required. steroid therapy. AJR 98 : 461 -464, 1966
Our last case was a primary liposarcoma of the posterior 2. Price JE, Rigler LG: Widening of the mediastinum resulting
mediastinum. Liposarcomas of the mediastinum are ex- from fat accumulation. Radiology 96 : 497-500, 1970
3. Cohen WN, Seidelmann FE, Bryan PJ: Computed tomography
tremely rare tumors (about 50 cases in the literature). Even
of localized adipose deposits presenting as tumor masses. AJR
Downloaded from ajronline.org by 103.165.236.99 on 02/25/24 from IP address 103.165.236.99. Copyright ARRS. For personal use only; all rights reserved

though more common in the posterior mediastinum, they

128:1007-1011, 1977
have been reported in the anterior mediastinum, middle
4. Faer MJ, Burman RE, Beck CL: Transmural thoracic lipoma:
mediastinum, and thoracic inlet [1 2]. The multicentric de- demonstration by computed tomography. AJR 130:161-163,
velopment of liposarcoma in different areas of the body has 1978
been documented [1 3]. Because of this multicentric origin, 5. Bein ME, Mancuso AA, Mink JH, Hansen GC: Computed to-
caution should be taken in establishing a diagnosis of meta- mography in the evaluation of mediastinal lipomatosis. J Com-
static liposarcoma. put Tomogr 2 : 379-384, 1978
Of all liposarcomas, 1 5% occur with a superior vena cava 6. Rubin E: Case of the winter season. Semin Roentgenol 13:5-
syndrome. The symptoms, as in our case 1 result from ,
6, 1978
7. Heitzman ER, Goldwin RL, Proto AV: Radiologic analysis of the
compression of adjacent structures secondary to the large
mediastinum utilizing computed tomography. Radio! C!in North
size that these tumors may attain. Pathologically, liposar-
Am 15:309-329, 1977
comas vary from well encapsulated low grade malignancies
8. Cohen SL: The right pericardial fat pad. Radiology 60: 391-
to unencapsulated highly aggressive neoplasms which tend 393, 1953
to directly invade contiguous intrathoracic structures and 9. Jost RG, Sagel 55, Stanley RJ, Levitt AG: Computed tomog-
rapidly cause death [1 2, 14]. raphy of the thorax. Radiology 1 26: 1 25-1 36, 1978
The CT number may prove to be a helpful guide to the 1 0. Teates CD: Steroid induced mediastinal lipomatosis. Radiology
composition of fatty tumors. Even a well differentiated lipo- 96:501-502, 1970
sarcoma, such as in case 1 had a CT number , greater than 11. Drasin GF, Lynch T, Temes GP: Ectopic ACTH production and
normal fat (-20 EMI units versus -55 EMI units for normal mediastinal lipomatosis. Radiology 1 27 : 61 0, 1978
1 2. Schweitzer DL, Aguam AS: Primary liposarcoma of the me-
fat). Poorly differentiated tumors, which pathologically tend
diastinum. Report of a case and review of the literature. J
to be more cellular [15] with less fat per cell, are likely to
Thorac Cardiovasc Surg 74:83-97, 1977
have CT numbers approaching that of other solid tumors
1 3. Georgiades DE, Alcalasis CB, Karabela VG: Multicentric well-
(+15 to +25 EMI units).
differentiated liposarcomas. Cancer 24 : 1 091 -1 097, 1969
14. Razzuk MA, Urschel HC, Race GJ, Kingsley WB, Pauson DL:
ACKNOWLEDGMENTS Liposarcoma of the mediastinum. J Thorac Surg 61:819-826,
We thank Dorene A. Ferris and Cynthia 0. Bellinger for assistance 1971
in manuscript preparation, and Chris Fletcher for photographic 15. Robbins SL: Patho!ogy, 3d ed, Philadelphia, Saunders, 1968,
work. p 124