Ann Thorac Surg 2004;77:1079-1080
© 2004 The Society of Thoracic Surgeons
Case report
A large lipoma of the ascending aorta
Piroze M. Davierwala, MDa,
Tirone E. David, MDa*,
Jaglish Butany, MDa
a Division of Cardiovascular Surgery and Department of Pathology, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
Accepted for publication April 9, 2003.
* Address reprint requests to Dr David, Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St, Room EN 13-219, Toronto, ON M5G 2C4, Canada
e-mail: tirone.david{at}uhn.on.ca
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Abstract
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Ascending aortic tumors are extremely rare. We describe a patient with a large lipoma of the ascending aorta, which was discovered after opening the pericardium for a surgical procedure for mitral regurgitation due to prolapse.
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Introduction
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Primary tumors of the aortic wall are rare, and preoperative or antemortem diagnosis is uncommon. There are a number of case reports of primary aortic wall tumors, and in all but 2 cases, they were located in the descending thoracic or abdominal aorta [1–8]. We present an unusual case of a large lipoma arising from the adventitia of the ascending aorta in a patient who underwent an operation for mitral regurgitation.
A 44-year-old man with mildly symptomatic mitral regurgitation due to prolapse was referred for mitral valve repair. Transthoracic echocardiography (TTE) revealed mitral regurgitation due to a flail posterior leaflet. The left atrium was dilated at 48 mm. A chest roentgenogram was unremarkable. Angiography disclosed normal coronary arteries. The patient was taken to the operating room, and transesophageal echocardiography (TEE) was performed, confirming the findings of TTE. No other abnormalities were detected. As the pericardial sac was opened, a large pedunculated tumor located in the ascending aorta was seen (Fig 1). It appeared to be attached only to the adventitia of the midportion of the anterior wall of the ascending aorta. It was thought to be either a lipoma or a neurofibroma. The patient was placed on cardiopulmonary bypass, and the tumor was excised with the adventitia of the aorta. There was no attachment to the media of the aorta. The pedicle of the tumor was 15 mm wide. The mitral valve was repaired. There was no mitral regurgitation on postoperative TEE, and the mitral valve area was approximately 3 cm2 in size. The left ventricular function remained unchanged. The postoperative course was uncomplicated, and the patient was discharged on warfarin sodium and instructed to maintain an international normalized ratio of 2.0 to 3.0 during the first 3 postoperative months. He remained well, and TTE done 6 months postoperatively showed no changes in the repaired mitral valve, and the left ventricle was normal in size and function. The left atrium diameter decreased to 40 mm.
Pathologically, the tumor was deep yellow, fatty, well circumscribed, and oval in shape with dimensions of 5.2 x 3.5 cm and thickness of 2.4 cm. The outer surface was relatively smooth, and the other surface, which was slightly depressed, was the adventitial one. The entire specimen had the same fatty consistency and texture. No solid areas were seen in its core or on its surface. Microscopically, the entire mass was made up of mature fat cells suggestive of lipoma.
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Comment
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Browdowski [1] described the first case of an aortic tumor in 1873. In reviewing the literature, we found a total of 90 patients reported, but there are only 2 reported cases of a tumor arising from the ascending aorta. One was a spindle-cell sarcoma [2] and the other a malignant fibrous histiocytoma [3]. Both patients were treated surgically and were alive at the time of the reports. All the other aortic tumors reported were located in the descending thoracic or abdominal aorta, and most were malignant. Sarcomas were the most common type of tumors. Fibrosarcomas, angiosarcomas, leiomyosarcomas, rhabdomyosarcomas, chondrosarcomas, and other histologic types have been found in the thoracic and abdominal aorta. There have been a small number of cases of sarcomas that developed after the replacement of the descending thoracic or abdominal aorta with vascular prosthetic grafts [4]. Implanting plastic materials in the subcutaneous tissue of rats can produce sarcomas [5], but the carcinogenic effect of vascular prosthetic grafts in humans remains unknown. The diagnosis and treatment of malignant aortic tumors is difficult, and the outcomes are usually poor.
There have been a few reports of benign tumors (myxoma, fibromyxoma, and leiomyoma) in the descending thoracic and abdominal aorta [6–8]. No benign tumor has been described in the ascending aorta. Although our patient had a relatively large tumor, it was probably not large enough to cause the compression of vital structures within the pericardium and cause symptoms attributable to it. However, we were surprised that intraoperative TEE could not detect the large mass attached to the ascending aorta.
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References
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- Browdowski W. Primares Sarkom der Aorta thoracica mit Verbreitung des Neugebildes in der unteren Korperhalfte. Jahresbuch Leistung Gesellsch Med 1873;8:243-246.
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- Guvendik L., Ross J.K., Marshall R.J. Primary aortic malignant fibrous histiocytoma: a successfully treated case by surgical excision. Ann Thorac Surg 1986;42:578-580.[Abstract/Free Full Text]
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- Oppenheimer B.S., Oppenheimer E.T., Stroup A.P., Willhite M., Danishefsky I. The latent period in carcinogenesis by plastics in rats and its relation to the presarcomatous stage. Cancer 1958;11:204-212.[Medline]
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- Kimbrell O., Kaasa L. Primary intraluminal aortic myxoma with involvement of several vertebrae. JAMA 1973;226:459-460.[Medline]
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O. Chataigner, S. Mussot, E. Fadel, and P. G. Dartevelle
Two cases of intra-pericardial tumors arising from the ascending aorta in adults
Eur J Cardiothorac Surg,
July 1, 2007;
32(1):
174 - 175.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
