My Strangest Case: The Patient Whose Shirts Stopped Fitting

Dana Goldenberg, BA; Darrin V. Bann, MD, PhD

Disclosures

July 16, 2020

Discussion

This case proved to be a bit of a mystery to us. Common diagnoses for large, lateral neck masses include lymphadenopathy (benign or malignant), lymphangioma, branchial cleft cyst, and benign or malignant thyroid masses.[1] The location of this patient's mass in the retropharyngeal space ruled out many of these more commonly occurring neck masses. Lesions of the retropharyngeal and prevertebral spaces include[2]:

Considering the location of the mass and the patient's MRI results, our strongest suspicion was that his neck swelling was caused by a retropharyngeal tumor — most likely a large lipoma or liposarcoma — given his unusual presentation.

The retropharyngeal space extends from the skull base to the upper mediastinum. Diseases of this space are uncommon but can result in significant morbidity. As in this patient, the lesions are inaccessible to clinical inspection, and diagnosis often hinges on cross-sectional imaging.

Liposarcomas are a rare, malignant cancer of the fatty tissue that can occur anywhere in the body. They are most commonly found in the abdomen, thigh, and behind the knee. Liposarcomas of the thyroid are extremely rare, with only approximately 12 cases reported in the English literature.[3] Aside from the rarity of this disease, accurate diagnosis is difficult because of its nonspecific and varied clinical presentation. All patients with liposarcoma of the thyroid have a rapidly growing tumor in the neck, but other symptoms may include dysphagia, respiratory distress (including dyspnea and shortness of breath), alterations in the voice (eg, hoarseness), globus sensation, weight loss, coughing, and deafness in one or both ears.[3] Although our patient had only one of the above symptoms, none are actually required for a diagnosis of liposarcoma.

Like liposarcomas, lipomas are also composed of fat tissue. However, they are characterized as benign, soft-tissue masses.[1,4] They tend to be asymptomatic and occur in the head and neck region in 13% of patients. A lipoma can appear as either a sporadic, solitary lesion or as multiple lesions. Lipomas tend to be slow-growing and 2-10 cm in dimension.[4] If a lipoma is larger than 10 cm in size or weighs more than 1000 g, it is classified as giant; only then does a lipoma tend to be symptomatic and require treatment.[1,4]

Of note, the literature reflects that lipomas can appear with upper limb paresthesia, which was seen in this patient.[3] Although lipoma seemed to most accurately fit our patient's symptoms and presentation, liposarcoma could not be ruled out. Based on the MRI findings, our primary considerations were a neurogenic tumor, lipoma, or liposarcoma.

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