Case Presentation
A 46 years old man from remote and difficult to reach part of the
country, came to our center with complaints of huge neck mass in the
right side, almost occupying the whole of the right neck from level
2,3,4 and 5. He gave a history of swelling, which was gradually
progressive and painless for more than 18 years. Due to financial
reasons and remote parts of the country, the patient presented very late
after the onset of disease. Late presentation to the hospital is a
common problem in developing countries. But recently, for the past 2
years, the size of the swelling has increased progressively than before.
With the fear of cancer, the patient somehow managed to turn up in the
hospital. There was no history of xerostomia, dysphagia, shortness of
breath, facial deviation, change in sensation, fever, no intraoral
discharge, loss of weight or change in appetite, and no known
comorbidity.
On examination, the mass was well defined, multilobulated with a size of
approximately 15 x 11 cm at the right side of neck, superiorly up to the
level of ear lobule, inferiorly 4 cm above the clavicle, medially up to
midline and posterolaterally occupying half of posterior triangle
(Figure 1). The overlying skin was free, with no pain or tenderness on
palpation, and the mass was firm in consistency, mobile, and,
multilobulated with a well-defined border. There was no change in skin
color, no sinuses, and no scar. Based on history and examination, a
provisional diagnosis of soft tissue mass probably salivary gland origin
was made. Fine needle aspiration cytology was done, which could not
provide a definite opinion and just gave a suggestion of fat origin.
CT scan was done, which reported as a huge lobulated mass measuring 15 x
10 x 6.5 cm in the right side of the neck and face. Radiologically the
mass contained enhancing solid areas on the periphery, which was
supplied by large vessels and had fat components medially. No
calcification or cystic areas noted and no significant lymph nodes. The
lesion was abutting the parotid and submandibular gland. The CT reported
lesion to be suggestive of the fat-containing soft-tissue tumor as
angiolipoma with a differential of liposarcoma. (Figure 2)
The vertical incision was given on the right side over the swelling. The
subplatysmal flap was elevated. The capsule of the mass was dissection
from all around the margin superiorly and inferiorly. The dissection was
carried on securing the hemostasis. There were no findings suggestive of
malignancy such as adhesions, friability of tissues, or invasion of
surrounding tissues. Medially the tissue was abutting the lower pole of
the superficial lobe of the parotid gland. The mass of excised in toto
and sent for histopathological examination. The drain was kept, and the
surgical site was sutured. (Figure 3 and 4)
Gross examination revealed a single piece of tissue comprising of two
nodular tissue attached in the center by fibrofatty tissue measuring
together 15x9.8x5cm. The outer surface was nodular, brownish with
congested vessels which were capsulated with pericapsular fat. Cut
surface showed homogeneous brownish (mahogany brown) lobulated areas
admixed with fatty tissue.
Microscopic examination showed multiple lobules of tumor separated by
thin fibrovascular septa with a fibrous capsule. The lobules composed of
prominent oncocytes arranged in tubules, admixed with fatty tissue
composed of mature adipocytes in varying proportions. Foci of squamous
and sebaceous differentiation, chronic inflammatory cells, and stromal
edema were evident as well. No features of malignancy noted. The final
diagnosis of oncocytic adenolipoma of parotid gland origin was made.