SPINE Volume 39, Number 11, pp 919-920 ©2014, Lippincott Williams & Wilkins
IMAGING CORNER
Unknown Case Part 2 Brahim Eljebbouri, MD, Mohcine Salami, MD, Jawad Laaguili, MD, and Brahim ElMostarchid, MD
PARTI
PART II
A 54-year-old otherwise healthy male presented with a posterior cervical growing tumor (Eigure lA). Although there was no pain associated with the tumor, it had been growing at a regular pace and the patient had been experiencing symptoms for 1 year. Clinical examination revealed a mobile soft mass. We found no cervical, supraclavicular, or axillary node. A magnetic resonance image (MRI) of the neck showed a 150-mm long, well-defined tumor. The axial Tl image with fat suppression (Eigure lBl) and the sagittal T2-weighted MRI (Eigure 1B2) demonstrate a large lobulated mass that not only predominantly demonstrates a high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity.
A 54-year-old otherwise healthy male presented with a posterior cervical growing tumor (Eigure lA). Although there was no pain associated with the tumor, it had been growing at a regular pace and the patient had been experiencing symptoms for 1 year. Clinical examination revealed a mobile soft mass. We found no cervical, supraclavicular, or axillary node. An MRI of the neck showed a 150-mm long, well-defined tumor. The axial Tl image with fat suppression (Eigure lBl) and the sagittal T2-weighted MRI (Eigure 1B2) demonstrate a large lobulated mass that not only predominantly demonstrates a high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity.
Figure 1. A, Large posterior cervical tumor. B, The axial Tl with fat suppression (Bl) The sagittal T2weighted magnetic resonance view (B2) demonstrates a large lobulated mass that not only predominantly demonstrates high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity. C, Macroscopic view of the specimen. D, Hibernoma—histological sections; 3 cell types are identified: multivacuolar cells, eosinophils, and mature adipocytes of variable sizes (magnification X400; hematoxylin-eosin staining).
From the Department of Neurosurgery, Mohamed V Military Teaching Hospital, Rabat, Morocco. Acknowledgment date: January 3, 2014. First revision date: January 17, 2014. Second revision date: January 23, 2014. Third revision date: February 4,2014. Fourth revision date: February 14, 2014. Acceptance date: February 15,2014. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Address correspondence and reprint requests to Brahim FIjebbouri, MD, Department of Neurosurgery, Mohamed V Military Teaching Hospital, Rabat, Morocco; F-mail: [email protected] DOI: 10.1097/BRS.0000000000000299 Spine
We hypothesized that the tumor was lipoma or liposarcoma. We surgically removed the tumor. Macroscopically, it was oval, yellowish, crossed by grayish spans of 15 X 10 cm in size (Eigure lC). The patient was discharged on the second postoperative day. Pathological examination led us to diagnose a non-lipoma-like eosinophilic variant hibernoma, according to the Miettinen classification (Eigure ID). Three years later, the patient was asymptomatic without any recurrence. Hibernoma is a slow-growing, benign tumor. It is rare and occurs generally in the limbs; 30% of tumors in the largest published series on hibernomas were located in the thigh. ' Very few cases have been reported in the neck region.^ www.spinejournal.com
919
Spine
IMAGING CORNER
Patients are generally in the fourth or fifth decade of their life, and there is a slight female predominance.' Two histological subtypes have been described.^ They can be distinguished according to the ratio of multivacuolate adipocytes (seen in the brown fat) and univacuolate adipocytes (seen in normal fat and lipoma). Tumors containing more than 70% of multivacuolate adipocytes are generally accepted as nonlipoma-like hibernomas. The non-lipoma-like subtype can have 3 histological appearances. The eosinophilic variant is the classical one; the pale and the mixed variants are less common. The non-lipoma-like subtype always presents particular characteristics on MRI: heterogeneous, hypo- or isointense with hypervascularity.'* It can sometimes push or compress adjacent structures. Thus, the appearance of non-lipoma-like hibernomas on MRI is not diagnostic and may cause confusion with well-differentiated liposarcoma or lipoma variants. At the time of diagnosis, tumor size is generally larger than
920
www.spinejournal.com
Unknown Case; Part 2 • Eljebhouri et al
10 cm. Curative treatment of hibernomas is a complete excision, preserving vital structures. Unlike lipomas, hibernomas present an extensive vascularity that should be treated with care to avoid postoperative bleeding or hematoma. No case of recurrence has been reported.
References 1. Furlong MA, Fanhurg-Smith JC, Miettinen M. The morphological spectrum of hihernoma. A clinicopathologic study of 120 cases. Am } Surg Pathol 2001;25:809-14. 2. Carinci F, Carls FP, Pelucchi S, et al. Hihernoma of the neck. / Cratiiofac Surg 2001;12:284-6. 3. Miettinen MM, Fanhurg-Smith JC, Mandahl N. Hihernoma. In: Fletcher CDM, Unni KK, Mertens F, eds. WHO Classification of Tumours. Pathology, and Genetics of Tumours of Soft Tissue and Bone. Lyon, France: IARC Press; 2002:33^. 4. Ritchie DA, Aniq H, Davies AM, et al. Hihernoma—correlation of histopathology and magnetic-resonance-imaging features in 10 cases. Skeletal Radiol 2006;35:579-89.
May 2014
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
IMAGING CORNER
Unknown Case Part 2 Brahim Eljebbouri, MD, Mohcine Salami, MD, Jawad Laaguili, MD, and Brahim ElMostarchid, MD
PARTI
PART II
A 54-year-old otherwise healthy male presented with a posterior cervical growing tumor (Eigure lA). Although there was no pain associated with the tumor, it had been growing at a regular pace and the patient had been experiencing symptoms for 1 year. Clinical examination revealed a mobile soft mass. We found no cervical, supraclavicular, or axillary node. A magnetic resonance image (MRI) of the neck showed a 150-mm long, well-defined tumor. The axial Tl image with fat suppression (Eigure lBl) and the sagittal T2-weighted MRI (Eigure 1B2) demonstrate a large lobulated mass that not only predominantly demonstrates a high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity.
A 54-year-old otherwise healthy male presented with a posterior cervical growing tumor (Eigure lA). Although there was no pain associated with the tumor, it had been growing at a regular pace and the patient had been experiencing symptoms for 1 year. Clinical examination revealed a mobile soft mass. We found no cervical, supraclavicular, or axillary node. An MRI of the neck showed a 150-mm long, well-defined tumor. The axial Tl image with fat suppression (Eigure lBl) and the sagittal T2-weighted MRI (Eigure 1B2) demonstrate a large lobulated mass that not only predominantly demonstrates a high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity.
Figure 1. A, Large posterior cervical tumor. B, The axial Tl with fat suppression (Bl) The sagittal T2weighted magnetic resonance view (B2) demonstrates a large lobulated mass that not only predominantly demonstrates high T2-signal intensity but also contains septa that demonstrates intermediate-signal intensity. C, Macroscopic view of the specimen. D, Hibernoma—histological sections; 3 cell types are identified: multivacuolar cells, eosinophils, and mature adipocytes of variable sizes (magnification X400; hematoxylin-eosin staining).
From the Department of Neurosurgery, Mohamed V Military Teaching Hospital, Rabat, Morocco. Acknowledgment date: January 3, 2014. First revision date: January 17, 2014. Second revision date: January 23, 2014. Third revision date: February 4,2014. Fourth revision date: February 14, 2014. Acceptance date: February 15,2014. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Address correspondence and reprint requests to Brahim FIjebbouri, MD, Department of Neurosurgery, Mohamed V Military Teaching Hospital, Rabat, Morocco; F-mail: [email protected] DOI: 10.1097/BRS.0000000000000299 Spine
We hypothesized that the tumor was lipoma or liposarcoma. We surgically removed the tumor. Macroscopically, it was oval, yellowish, crossed by grayish spans of 15 X 10 cm in size (Eigure lC). The patient was discharged on the second postoperative day. Pathological examination led us to diagnose a non-lipoma-like eosinophilic variant hibernoma, according to the Miettinen classification (Eigure ID). Three years later, the patient was asymptomatic without any recurrence. Hibernoma is a slow-growing, benign tumor. It is rare and occurs generally in the limbs; 30% of tumors in the largest published series on hibernomas were located in the thigh. ' Very few cases have been reported in the neck region.^ www.spinejournal.com
919
Spine
IMAGING CORNER
Patients are generally in the fourth or fifth decade of their life, and there is a slight female predominance.' Two histological subtypes have been described.^ They can be distinguished according to the ratio of multivacuolate adipocytes (seen in the brown fat) and univacuolate adipocytes (seen in normal fat and lipoma). Tumors containing more than 70% of multivacuolate adipocytes are generally accepted as nonlipoma-like hibernomas. The non-lipoma-like subtype can have 3 histological appearances. The eosinophilic variant is the classical one; the pale and the mixed variants are less common. The non-lipoma-like subtype always presents particular characteristics on MRI: heterogeneous, hypo- or isointense with hypervascularity.'* It can sometimes push or compress adjacent structures. Thus, the appearance of non-lipoma-like hibernomas on MRI is not diagnostic and may cause confusion with well-differentiated liposarcoma or lipoma variants. At the time of diagnosis, tumor size is generally larger than
920
www.spinejournal.com
Unknown Case; Part 2 • Eljebhouri et al
10 cm. Curative treatment of hibernomas is a complete excision, preserving vital structures. Unlike lipomas, hibernomas present an extensive vascularity that should be treated with care to avoid postoperative bleeding or hematoma. No case of recurrence has been reported.
References 1. Furlong MA, Fanhurg-Smith JC, Miettinen M. The morphological spectrum of hihernoma. A clinicopathologic study of 120 cases. Am } Surg Pathol 2001;25:809-14. 2. Carinci F, Carls FP, Pelucchi S, et al. Hihernoma of the neck. / Cratiiofac Surg 2001;12:284-6. 3. Miettinen MM, Fanhurg-Smith JC, Mandahl N. Hihernoma. In: Fletcher CDM, Unni KK, Mertens F, eds. WHO Classification of Tumours. Pathology, and Genetics of Tumours of Soft Tissue and Bone. Lyon, France: IARC Press; 2002:33^. 4. Ritchie DA, Aniq H, Davies AM, et al. Hihernoma—correlation of histopathology and magnetic-resonance-imaging features in 10 cases. Skeletal Radiol 2006;35:579-89.
May 2014
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
