CAS CLINIQUE / CASE REPORT
LARGE THYMOLIPOMA CAUSING PRIMARILY RESPIRATORY DISTRESS
http://www.lebanesemedicaljournal.org/articles/60-2/case2.pdf
Moussa ABI GHANEM , Georges HABAMBO , Joudy BAHOUS , Camil CHOUAIRY , Bassam ABU KHALIL
1 1
Abi Ghanem M, Habambo G, Bahous J, Chouairy C, Abu
Khalil B. Large thymolipoma causing primarily respiratory
distress. J Med Liban 2012 ; 60 (2) : 106-109.
ABSTRACT : Thymolipoma, is an anterior mediastinal
tumor that is benign in origin. It is often asymptomatic,
but can enlarge significantly prior to diagnosis. It con-
sists of thymic and fatty tissue and is surrounded by a
capsule.
Less than a hundred cases have been reported world-
wide. Although rare, it should be considered in the dif-
ferential diagnosis of mediastinal tumors.
In this paper, we report the case of a 44-year-old
woman presenting with a giant thymolipoma causing
symptoms of severe respiratory distress. The patient
underwent surgical resection, which is the main treat-
ment, and remains free of disease.
INTRODUCTION
Thymolipoma is a slow growing mediastinal tumor of
thymic origin that is benign. It occurs between 2 and 9%
of all thymic neoplasms. It accounts for 1.1% of all solid
mediastinal tumors [1].
Patients with thymolipoma, usually remain asympto-
matic until the tumor achieves enormous proportions,
causing airway and parenchymal compression [2]. That’s
why most thymolipomas are diagnosed incidentally after
routine radiographic imaging [3].
Thymolipoma may be rarely associated with myasthe-
nia gravis, as well as with aplastic anemia and Grave’s
disease. [4]
Our patient had severe shortness of breath, occurring at
rest, due to the enormous size of her thymolipoma. This
incapacitating dyspnea pushed her to seek medical care.
An urgent and succesfull surgery was sufficient to re-
lieve all her symptoms.
CASE DESCRIPTION
This is a 44-year-old woman complaining of shortness of
breath, nasal congestion and sneezing for five months.
She was treated with bronchodilators initially. Later she
developed a productive cough and early weakness. Her
dyspnea was incapacitating at rest and she also had tachy-
pnea and palpitation. Her physical examination revealed
decrease breath sounds on the right side.
These symptoms worsened over the last two weeks
Saint George Hospital University Medical Center, Beirut, Lebanon. Departments of Surgery, Cardiothoracic Surgery Division;
Medicine, Pulmonary Medicine Division; Anatomic Pathology.
2 3
Correspondence to: Moussa Abi Ghanem, MD. St George Hospital University Medical Center. PO Box 166378. Beirut. Lebanon.
e-mail: moussaabighanem@hotmail.com
2 3 1
Abi Ghanem M, Habambo G, Bahous J, Chouairy C, Abu
Khalil B. Large thymolipome entraînant une détresse respira-
toire sévère. J Med Liban 2012 ; 60 (2) : 106-109.
RÉSUMÉ : Le thymolipome est une tumeur bénigne
du médiastin antérieur. Il est souvent asymptomatique,
mais peut devenir assez énorme avant d’être diagnos-
tiqué. Il est constitué de tissus thymique et adipeux en-
tourés par une capsule.
Moins de cent cas ont été décrits dans la littérature.
Bien que rare, il doit être considéré dans le diagnostic
différentiel des tumeurs médiastinales.
Dans cet article, on présente le cas d’une patiente âgée
de 44 ans présentant un thymolipome géant entraînant
des symptômes de détresse respiratoire sévère. La pa-
tiente a subi une résection chirurgicale, qui est la moda-
lité de traitement de choix. Elle est toujours asymptoma-
tique, sans aucune récurrence.
prior to admission. Her pulmonary function tests showed
severe obstruction with a forced vital capacity (FVC)
of 1.72 L and a forced expiratory volume (FEV1) of
50%. Her arterial blood gas (ABG’s) was: pH: 7.41;
pCO2: 42 mmHg; pO2: 65 mmHg; HCO3: 22 mEq/L. She
had a normal echocardiogram.
Her chest X-ray (Fig. 1) showed a large mass in the
anterior mediastinum, extending to the right hemithorax
with collapse of the right inferior and middle lobes. Com-
puter tomography scan (Fig. 1) demonstrated a large right
subpulmonary fat containing lesion, extending to the
upper anterior mediastinum, and across the midline, to the
left. Its transverse diameter was 23 cm, and its height
17 cm. The mass was suspicious for a fatty tumor. A trans-
thoracic biopsy revealed the presence of fatty tissue.
It was decided to proceed with a right thoracotomy to
either resect the tumor or to obtain an open biopsy. The
surgical procedure was performed under general double
lumen endotracheal anesthesia through a right thoraco-
tomy. The mass was occupying the majority of the chest
without any local invasion.
The tumor appeared as a solid well circumscribed and
encapsulated mass, composed of yellow soft adipose tis-
sue with small randomly scattered solid gray white areas
(Fig. 2). The mass was removed in two parts due to its
size. A 23.5 x 14.5 x 5 cm mediastinal mass was first
excised and sent for frozen section biopsy, followed by the
remaining mass measuring 21.5 x 20 x 15 cm. The two
masses weighed 520 g and 1610 g respectively, which
adds up to a total of 2130 g. Microscopically (Fig. 3), the
1
FIGURE 1. Chest X-ray shows a large mass in the anterior mediastinum, extending to the right hemithorax with collapse of the right inferior
and middle lobes. CT scan shows a large right subpulmonary fat containing lesion, extending to the upper anterior mediastinum, and
across the midline, to the left. Its transverse diameter is 23 cm, and its height 17 cm.

FIGURE 2. Macroscopic finding: 21.5 x 20 x 15 cm mass of adipose tissue covered by a thin translucent capsule.

FIGURE 3. Histologic findings: Mature adipose tissue (black filled star) with intimately admixed benign non neoplastic thymic tissue (open star)
where we can find several Hassall’s corpuscles (arrow).

M. ABI GHANEM et al. – Large thymolipoma Lebanese Medical Journal 2012 • Volume 60 (2) 107
yellow fatty tissue consisted of mature adipose tissue
devoid of atypia. The scattered gray white areas were
composed of thymic tissue showing typical cortical and
medullary zones with Hassall’s corpuscles. The final diag-
nosis was a benign thymolipoma without evidence of any
malignancy.
Resection of the tumor resulted in immediate improve-
ment in the patient’s pulmonary status. The postoperative
course was uneventful and the patient was discharged
home in seven days. At one month her pulmonary function
tests (PFTs) returned to normal (FVC: 1.98 L and FEV1:
84%) and her oxygenation increased (pO2: 85 mmHg).
Today, after four years of follow-up, the patient is still
doing fine without any complaint or any evidence of recur-
rence on chest X-rays.
DISCUSSION
The first case of thymolipoma was described by Lange in
1916, where the tumor was discovered by chance during
the autopsy of a patient who died from metastasis of the
corpus uteri [5]. Andrus first successfully removed this
tumor via a right thoracotomy [6]. Hall in 1948 suggested
the term “thymolipoma” for tumors consisting of fat and
thymus tissue [7].
Thymolipoma accounts for 2 to 9% of all thymus neo-
plasms and 1.1% of all solid mediastinal tumors [1]. They
are found in children and adults with an average age of
33 years, with no gender predilection [8].
Most reports state that this is an asymptomatic tumor.
However, others note that more than 50% of patients pre-
sent with symptoms, secondary to the local growth and
mechanical compression of the neighboring organs [3].
Symptomatic patients mostly have dyspnea, chest pain,
upper respiratory infections and chest heaviness. Less
frequently patients report easy fatiguability, dysphagia,
hemoptysis and weight fluctuation.
Ten percent of these tumors can be associated with
myasthenia gravis, aplastic anemia, Grave’s disease, lym-
phangioma, chronic lymphatic leukemia, Hodgkin’s dis-
ease, erythematous systemic lupus, hypogammaglobulin-
emia, and erythroblastopenia [9].
Thymolipomas are slow growing, non-infiltrating be-
nign tumors. Thus they usually are discovered accidently
at autopsy. They usually do not recur after surgical resec-
tion [9].
The differential diagnosis includes: mediastinal cyst,
lipoma, mediastinal lipomatosis, thymoma, mature ter-
atoma, malignant neoplasm (liposarcoma, lymphoma,
and thymic carcinoma), and aneurysm of the ascending
aorta.
Thymolipomas usually attain huge size (68% weighing
> 500 g, 23% > 2 kg, and one weighed over 12 kg) [10].
On gross examination they have a flat surface, and are
surrounded by a capsule of connective tissue with a light
yellowish-white surface. Histologically they consist most-
ly of mature fatty tissue, and small islands of thymus tis-
sue that can be normal, hyperplasic or showing regressive
108 Lebanese Medical Journal 2012 • Volume 60 (2)
changes. Also Hassall’s corpuscules and lymphocytes are
seen.
The two reports with the biggest number of thymolipo-
ma cases were: “Thymolipoma: Analysis of 27 cases”
published in 1994 [11], and “Thymolipoma: Clinico-
pathologic review of 33 cases” published in 1995 [8].
The first report is a retrospective review of 27 cases
collected over 43 years. There were 15 male patients and
12 female patients with age ranging from 2 to 66 years
(mean age 26.7 years). Eight patients (30%) were asymp-
tomatic, 15 patients (56%) had symptoms and four pa-
tients with unknown clinical history. All tumors were
found in the anterior mediastinum. Their sizes ranged from
4 to 36 cm in longest dimension (mean size 18.4 cm). Only
one case had large components in both hemithoraces and
was resected in two pieces (one 33 cm and the other 17 cm
in longest dimension).
The second report described 33 cases of thymolipoma
identified from the files of the Department of Pulmonary
and Mediastinal Pathology at the Armed Forces Institute
of Pathology, Washington, D.C. and the Department
of Pathology and Laboratory Medicine, Mount Sinai
Medical Center of Greater Miami, Florida. There were
18 male patients and 15 female patients with age ranging
from 2 to 64 years (mean age 33 years). Eighteen patients
(54.5%) were asymptomatic. All tumors were located in
the anterior mediastinum. The tumors varied in size from
4,5 to 36 cm in greatest dimension. No complications
were observed in any of those patients after complete
surgical resection.
Despite many case reports and large clinicopathologic
reviews, the pathogenesis of thymolipoma remains un-
clear and very controversial [12]. Normally the thymus
undergoes regression in late childhood and adulthood
where the parenchyma is replaced with fatty tissue. With
thymolipoma there is a definite increase in the thymus and
fatty tissue. The vast majority of authors believe that thy-
molipoma is a benign, mixed tumor of mesenchymal-
endodermal origin, and that what induces the concomitant
proliferation of fatty and thymus tissue is not known.
Based on different histopathological and clinical find-
ings, R. Hudacko et al. discussed three possible theories
of thymolipomas pathogenesis [12].
The 1st theory advocates a neoplastic origin from the
mesenchymal tissue (lipoma of thymic fat) or a mixed
tumor of both endodermal and mesenchymal origins
(mixed neoplasm of adipose and thymic tissue).
The 2nd theory advocates a hamartomatous origin from
the thymic epithelium and adipose tissue.
The 3rd theory advocates a regression category that
includes two theories of thymic involution (involuted thy-
moma v/s involuted thymic hyperplasia).
The association of thymolipoma with myasthenia gravis
and other autoimmune disorders suggests that these tumors
are at least related [13]. This is in favor of the theory
suggesting that thymolipoma originates from a thymoma,
with subsequent involution and replacement with adipose
tissue.
M. ABI GHANEM et al. – Large thymolipoma
 On the other hand, Kitano et al. suggest that thymo-
lipoma may be closely related to massive thymic hyper-
plasia, in which the thymic tissue is gradually replaced by
adipose tissue over time. The normalization of lymphocy-
tosis that occurs with resection of both massive thymic
hyperplasia and thymolipoma lends some credibility to
this theory [14].
Regardless of their origin, thymolipomas are benign
tumors.
CONCLUSION
In conclusion, thymolipoma is a rare benign, well encap-
sulated slowly growing tumor of unknown genesis. Thy-
molipomas are usually asymptomatic, but can present with
respiratory failure.
Treatment consists of surgical removal.
Long-term prognosis is excellent with no malignant
transformation or recurrences reported.
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