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Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 409-411  

Rare cause of obliteration of the cardiophrenic angle

1 Associate Professor and Incharge, TN Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
2 Department of Pulmonary Medicine, TN Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Submission07-Dec-2020
Date of Decision02-Jun-2021
Date of Acceptance02-Jun-2021
Date of Web Publication01-Mar-2022

Correspondence Address:
Unnati Desai
Department of Pulmonary Medicine, TN Medical College and BYL Nair Hospital, Mumbai - 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_694_20

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The differential diagnosis of mediastinal masses encompasses a vast spectrum ranging from benign tumors to notorious malignancies. Mediastinal lipoma is a very rarely encountered mediastinal mass. It is usually an incidentally unearthed finding. It has a classical radiographic countenance. Knowledge of its existence and presentation aids early diagnosis and can avert unnecessary invasive investigations for alternative diagnosis. The radiographic picture of cardiophrenic obliteration may be seen in a number of heterogeneous conditions such as loculated pleural effusion, pericardial effusion, diaphragmatic hernias, or in certain mediastinal masses. However, mediastinal masses are rarely kept as a differential of this radiological presentation due to a lack of awareness. This leads to performance of invasive tests like thoracocentesis. We herein report an interesting case of mediastinal lipoma incidentally picked up during a chest radiograph done as a part of preoperative evaluation for an unrelated diagnosis. The chest radiograph exhibited a lesion with an obliteration of the right cardiophrenic angle.

Keywords: Lipoma, mediastinal neoplasm, mediastinum

How to cite this article:
Chitnis A, Utpat K, Desai U, Joshi J, Bharmal RN. Rare cause of obliteration of the cardiophrenic angle. Med J DY Patil Vidyapeeth 2022;15:409-11

How to cite this URL:
Chitnis A, Utpat K, Desai U, Joshi J, Bharmal RN. Rare cause of obliteration of the cardiophrenic angle. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:409-11. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/409/338915

  Introduction Top

Lipomas are one of the common benign tumors. The location could be ubiquitous, however, they mostly present subcutaneously.[1] The intrathoracic occurrence of lipomas is rare.[2] Lipomas contribute to 1.6%–2.3% of all the mediastinal masses.[3] They are often incidentally detected findings or found on postmortem, because they remain asymptomatic for long.[1],[3] If symptomatic, mediastinal lipomas may present as dyspnea, chest pain, and dysphagia.[4] Fine-needle aspiration biopsy (FNAB) of the lesion could help reveal the nature of the tumor. However, lipomas have a fibrous capsule which sometimes makes the pathological analysis difficult.[5] Radiology plays a key role in diagnosis. However, it is difficult to preoperatively determine the definitive nature of these mediastinal masses such as lipomas, liposarcomas, or germ cell neoplasms. Asymptomatic lipomas may be conservatively observed, however, all symptomatic intrathoracic suspected lipomas should be surgically resected.[4] However, there is a scarcity of literature pertaining to the presentation and prognosis of intrathoracic lipomas. We hereby present a case of the occurrence of this entity which was incidentally diagnosed in an asymptomatic patient after a suspicion was raised by his chest radiographic appearance. Our case is an example of an unusual cause of a usual radiological occurrence.

  Case Report Top

A 72-year-old female homemaker was referred from the otolaryngology department for preoperative evaluation for biopsy of the external auditory canal mass, in view of chest radiograph suggestive of blunting of the cardiophrenic angle. The patient gave a history of cough predominantly dry for 1 month and discharge from the right ear associated with decreased hearing for 3 months. The patient was a life-long tobacco chewer but gave no history of pulmonary tuberculosis, diabetes, and hypertension. The patient denied a history of any occupational or environmental exposures. On physical examination, the patient was comfortable with stable vitals, normal oxygen saturation at room air. The patient had right lower motor neuron type of facial paresis. Respiratory examination revealed bilaterally equal air entry and no adventitious breath sounds. Chest radiograph [Figure 1] revealed blunting of the right cardiophrenic angle with homogeneous opacity having smooth rounded edges. A pulmonary function test was performed which was suggestive of near-normal lung functions. The patient was prescribed antibiotics in view of features suggestive of upper respiratory tract infection and asked to follow up with contrast-enhanced computed tomography (CECT). CECT thorax [Figure 2]a and [Figure 2]b showed a large well-defined fat density mass in the mediastinum in the right pericardial region measuring 11 cm × 6 cm in transverse and 4.2 cm in superoinferior diameters, without any solid enhancing component and mildly compressing the adjacent right middle and lower lobe and right atrium and ventricle without invasion. This was classical of mediastinal lipoma. The patient was explained about the likely diagnosis and possible complications. However, she denied further invasive workup and opted for a conservative strategy.
Figure 1: Chest radiograph suggestive of smooth rounded homogeneous opacity causing blunting of the right cardiophrenic angle

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Figure 2: (a) Contrast window of contrast-enhanced computed tomography showing a large well-defined fat density mass in the mediastinum in the right pericardial region. (b) Lung window of contrast-enhanced computed tomography showing a large well-defined fat density mass in the mediastinum in the right pericardial region

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  Discussion Top

Lipomas are slow-growing benign masses of adipose tissue. They are typically located subcutaneously, encapsulated in a fibrous tissue.[1] Histologically, they consist of mature adipocytes separated by incomplete fibrous septa.[1] Lipomas are seen at various sites throughout the body such as upper back, neck, and shoulder.[1] They are often painless and require no intervention. The occurrence of lipomas in the mediastinum accounts for only 1.6%–2.3% of their overall incidence.[1] They are deep seated and often located in the anterior mediastinum.[1] Patients with mediastinal lipomas remain asymptomatic for a long period of time.[1] If symptomatic, they present with dyspnea, dysphagia, chest pain, arrhythmia, heart failure, or superior vena cava syndrome, depending on their size and location.[4] Our patient harbored an intrathoracic lipomas, however, she was completely asymptomatic from chest point of view. She had presented to us with a chest radiological abnormality. She had undergone a chest radiograph as a part of routine preoperative evaluation for her auditory canal mass surgery. Her chest radiograph showed a lesion obliterating the right cardiophrenic angle. Obliteration of the cardiophrenic angle is a common radiological phenomenon that can be seen in miscellaneous conditions. The frequent causes for opacity include lower lobe of lung consolidation, lobar collapse, pericardial cysts, and located pleural effusions. However, sometimes rare causes such as lung sequestration, diaphragmatic hernias, and mediastinal masses could also contribute to such a finding.[6],[7] Of the mediastinal masses presenting in this manner, lymphomas are the most common while mediastinal lipomas are extremely rare.

A provisional diagnosis of mediastinal lipoma is made by CECT.[6] However, it is difficult to ascertain their exact nature and differentiate them from liposarcomas and thymolipomas.[5],[8] A FNAB helps in attaining a definitive histopathological diagnosis.[5] However, some of these lipomas have a thick fibrous capsule, which makes the sampling difficult. All the suspected cases of mediastinal lipomas which are clinically symptomatic have the potential to be malignant and require surgical excision.[4] However, in a subset of patients who are incidentally diagnosed to have mediastinal lipoma on CECT and are asymptomatic, may be given an option of conservative management with regular radiological follow-ups.[6] This has to be an informed choice taking into consideration a small but significant risk of malignancy. Our patient was also incidentally detected to have a mediastinal lipoma and was asymptomatic from respiratory point of view. She chose to be under observation and follow-up with interval CECT.

The modalities of resection include a conventional thoracotomy approach or a thoracoscopic approach which is lesser invasive. Once resected, the local recurrence of mediastinal lipoma is uncommon. Thus, a mediastinal lipoma is a rare cause of a mediastinal mass obliterating the cardiophrenic angle. Due to its sporadic incidence, it is usually not kept as one of the differentials when encountered with such opacity. This leads to unwarranted invasive diagnostics such as thoracocentesis or pericardiocentesis without embarking on a CECT. Hence, it is important to be vigilant about the existence of such rare causes even in conventional radiographic appearances. Unless a high index of suspicion is maintained, these etiologies are likely to be missed leading to unwarranted invasive workup.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sakurai H, Kaji M, Yamazaki K, Suemasu K. Intrathoracic lipomas: their clinicopathological behaviors are not as straightforward as expected. Ann Thorac Surg. 2008;86:261-5.  Back to cited text no. 1
Vougiouklakis T, Mitselou A, Agnantis NJ. Giant lipoma: An unusual cause of intrathoracic mass. Pathol Res Pract 2006;202:47-9.  Back to cited text no. 2
Marreez YM, Roy W, Roque R, Findlay E. The rare mediastinal lipoma: A postmortem case report. Int J Clin Exp Pathol 2012;5:991-5.  Back to cited text no. 3
Minematsu N, Minato N, Kamohara K, Hakuba T. Complete removal of heart-compressing large mediastinal lipoma: A case report. J Cardiothorac Surg 2010;5:48.  Back to cited text no. 4
Romero-Guadarrama MB, Durán-Padilla MA, Cruz-Ortíz H, Castro-Gómez L, López-Vancell D, Novelo-Retana V, et al. Diagnosis of thymolipoma with fine needle aspiration biopsy. Report of a case initially misdiagnosed as liposarcoma. Acta Cytol 2004;48:441-6.  Back to cited text no. 5
Pugatch RD, Faling LJ, Robbins AH, Spira R. CT diagnosis of benign mediastinal abnormalities. AJR Am J Roentgenol 1980;134:685-94.  Back to cited text no. 6
Khajotia R. “Silhouette sign: A vital chest radiographic indicator of cardiac and lung pathologies.” EC Pulmonol Respir Med 2019;8.2:178-81.  Back to cited text no. 7
Schweitzer DL, Aguam AS. Primary liposarcoma of the mediastinum. Report of a case and review of the literature. J Thorac Cardiovasc Surg 1977;74:83-97.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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