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.