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Ann Thorac Surg 2009;87:316-318. doi:10.1016/j.athoracsur.2008.06.038
© 2009 The Society of Thoracic Surgeons
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Case Reports

Parosteal Lipoma of the Rib

Se-Min Jang, MDa, Woong Na, MDa, Young Jin Jun, MDa, Won Sang Chung, MDb, Seung Sam Paik, MDa,*

a Department of Pathology, College of Medicine, Hanyang University, Seoul, Korea
b Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hanyang University, Seoul, Korea

Accepted for publication June 16, 2008.

* Address correspondence to Dr Paik, Department of Pathology, College of Medicine, Hanyang University, 17 Haengdang-dong, Seongdong-gu, Seoul, 133-792, Korea (Email: sspaik{at}hanyang.ac.kr).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Parosteal lipoma is a rare benign tumor that is composed mainly of benign mature lipocytes, and it has an intimate association with the underlying periosteum of affected bone. Parosteal lipoma involving the rib is quite rare. We believe that only four cases have been previously reported in the English literature. Here we describe an exceedingly rare case of parosteal lipoma that developed in the right seventh rib, which presented in a 50-year-old man having a previous history of trauma at this site.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Parosteal lipoma is an uncommon benign neoplasm consisting of mature adipose tissue which has an intimate association with the periosteum of bone [1]. Parosteal lipoma is the preferred terminology rather than periosteal lipoma because the periosteum does not contain fat cells [2]. The commonly involved sites are the femur, proximal radius, humerus, tibia, clavicle, and pelvis [3–5]. The rib as an involving site is quite uncommon. We believe that there are only four previously reported cases of parosteal lipoma of the rib [4–7]. Here we report an extremely rare case of parosteal lipoma of the rib.

A 50-year-old man was referred to our hospital with a 2-month history of right pleuritic pain accompanied by acute respiratory symptoms, such as cough, sputum and fever, beginning five days earlier. He had a history of blunt trauma to the right lateral chest wall approximately 5 years ago. On physical examination, decreased lung sound was noted in the right mid and lower lung fields.

Computed tomographic scan and chest roentgenogram revealed an incidentally detected, relatively well-demarcated mass exhibiting marked exophytic pattern of calcification from the underlying seventh rib in the right chest wall (Fig 1). The surface of involved rib presented obvious ossific protuberances into the mass. Pneumonic consolidation of right lower lobe posterior basal segment and pleural effusion of the right hemithorax were noted. The radiologic impression was a chondrosarcoma or osteosarcoma of the rib with pneumonia and parapneumonic effusion.


Figure 1
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  		Fig 1. Chest computed tomographic scan showed a well-demarcated mass of fat attenuation, which was attached to the lateral aspect of right seventh rib. The rib revealed cortical thickening and ossific protuberances.

 
En block resection of the mass with right seventh rib was performed. The mass was well circumscribed and easily isolated from adjacent soft tissue. However, the base of the tumor adhered strongly to the underlying seventh rib. The mass measured 8 x 6 x 2.5 cm in dimensions, and was well encapsulated by a thin, fibrous membrane. A piece of rib was strongly attached to the broad, flat base of the mass. The mass showed a round lobulating and typical lipomatous appearance (Fig 2). On section, the cut surface of the mass revealed bright yellowish, homogenous, and soft adipose tissue intermingled with hard bony tissue exhibiting branch-like, exophytic growth pattern from the underlying rib.


Figure 2
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  		Fig 2. The resected tumor showed a round, yellowish mass with a thin fibrous capsule, which was strongly attached to the rib.

 
Microscopically, the lesion was encapsulated by a thin fibrous capsule and was mainly composed of mature adipose tissue. The periosteum of rib showed slender, long protuberances toward the inside of the mass in the attached region. Multi-foci of metaplastic bone were seen in the mass (Fig 3). The adipocytes did not show atypia or pleomorphism. Other evidence of malignancy including mitosis, necrosis, or atypical stromal component was not present. The final diagnosis was a parosteal lipoma of the rib.


Figure 3
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  		Fig 3. The tumor was composed mainly of mature adipocytes. The metaplastic bony excrescences were observed in the tumor. (Hematoxylin & Eosin stain; x100.)

 
After the surgical resection of the mass, the patient showed no postoperative complications, including local recurrence during the follow-up period of 4 months.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Parosteal lipomas are relatively rare and usually asymptomatic benign lesions composed mainly of mature adipose tissue [4]. The incidence of parosteal lipoma is 0.3% of all lipomas [4, 5]. Although the possibility of mixed origin due to foci of metaplastic cartilage undergoing chondral ossification within adipose tissue and traumatic origin has been suggested [6, 7], the cause of parosteal lipoma is still unknown. In our case, the patient had a previous history of trauma in the tumor site.

Age distribution of patients with common parosteal lipoma ranges from 40 to 60 years old. Patients with parosteal lipoma of the rib range in age from 57 to 60 years old [4–6]. Most patients complain a history of a slow-growing, large, painless, and nontender mass. Sometimes motor and sensory disturbances from adjacent nerve compression may occur [8, 9]. In our case, the patient was 50 years old and did not complain of the neurologic symptom.

The radiologic features of parosteal lipoma are characterized by osseous reactive changes, such as bowing of bone or erosion of bony cortex secondary to the adjacent lipomatous tumor. The findings of a computed tomographic scan for parosteal lipoma include a variable degree of surface bone productive changes, ranging from subtle to conspicuous thickening of cortex and various sized ossifying processes or excrescent bone spicules [4, 5].

On gross and microscopic examinations, the parosteal lipomas have strongly adhered to the underlying periosteum of bone and well-demarcated greasy, yellowish, soft masses encapsulated by thin fibrous membrane. These tumors consist of mature adipose tissue identical to the other lipomas of soft tissue. Foci of osseous metaplasia, cartilage, and osseous excrescences or thickening of cortex extending from and attaching the lesion to the surface of bone are commonly observed [10].

The primary treatment of parosteal lipoma is complete surgical excision. If nerve entrapment accompanies, the tumor will be eliminated as soon as possible before irreversible atrophic change of muscle. The parosteal lipomas strongly adhere to the underlying periosteum of affected bone. Therefore, partial resection of involved bone may be required. Local recurrence is uncommon and malignant transformation has not been documented yet [5].

In brief, we have described an extremely rare case of parosteal lipoma of the rib. Although the incidence is extremely rare, parosteal lipoma should be considered in the radiologic and pathologic differential diagnosis.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Murphey MD, Johnson DL, Bhatia PS, Neff JR, Rosenthal HG, Walker CW. Parosteal lipoma: MR imaging characteristics AJR Am Roentgenol 1994;162:105-110.[Abstract/Free Full Text]
  2. Fleming RJ, Alpert M, Garcia A. Parosteal lipoma AJR Am Roentgenol 1962;87:1075-1084.
  3. Bui-Mansfield LT, Myers CP, Chew FS. Parosteal lipoma of the fibula AJR Am Roentgenol 2000;174:1698.[Free Full Text]
  4. Imbriaco M, Ignarra R, De Rosa N, Lambiase G, Romano M, Ragozzino A. Parosteal lipoma of the rib: CT findings and pathologic correlation Clin Imaging 2003;27:435-437.[Medline]
  5. Kim HK, Choi YH, Cho YH, Sohn YS, Kim HJ. Intercostal neuralgia caused by a parosteal lipoma of the rib Ann Thorac Surg 2006;81:1901-1903.[Abstract/Free Full Text]
  6. Fiorentino L, Rossi G, Ruggiero C, et al. Parosteal rib lipoma: description of a case Pathologica 2001;93:668-671.[Medline]
  7. Latifi M, Madhar M, Belkhiat R, Hamdaoui A, Essadki B, Fikry T. Ossifying parosteal lipoma of the rib: a case report Rev Chir Orthop Reparatrice Appar Mot 2003;89:357-360.[Medline]
  8. Fitzgerald A, Anderson W, Hooper G. Posterior interosseous nerve palsy due to parosteal lipoma J Hand Surg 2002;27:535-537.[Abstract/Free Full Text]
  9. Kim JY, Jung SL, Pak YH, Kang YK. Parosteal lipoma with hyperostosis Eur Radiol 1999;9:1810-1812.[Medline]
  10. Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, Kransdorf MJ. From the archives of the AFIP. Benign musculoskeletal lipomatous lesions. RadioGraphics 2004;24:1433-1466.[Abstract/Free Full Text]



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This Article
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