James W.

Milgram, MD

Intraosseous Lipomas: Radlologic

and Pathologic Manifestations’

Sixty-one cases of surgically treated N analysis of 61 cases of intraos- ondany necrosis; and stage 3, in
solitary intraosseous lipoma were seous lipoma demonstrated that which there is complete or near-com-
staged into three categories depend- the tumor is a well-defined entity plete secondary necrosis.
ing on the degree of involution that may present with various fea- The lipoma appears to be an indo-
present histologically: stage 1, tu- tunes at different stages of evolution. lent lesion causing few symptoms in
mors of viable fat cells; stage 2, tran- The variability of the condition pre- the typical case. Treatment by surgi-
sitional cases composed partly of vi- viously caused it to be confused with cal curettage appears to be adequate
able fat cells but also demonstrating other benign tumors, with cysts, and therapy.
fat necrosis and calcification; and with bone infarction.
stage 3, lesions demonstrating ne- Clinically, the lesion is often
crotic fat, calcification of necrotic asymptomatic and is discovered mci- MATERIALS AND METHODS
fat, variable degrees of cyst forma- dentally or because of a slight mass Preoperative radiographs, clinical his-
tion, and reactive woven bone for- in a subcutaneous bone. When they tories, surgeons’ operative reports, and
mation Each of these stages had ra- consist of live fat cells, lesions are the original microscopic sections were ne-
diologic features that could be cor- quite radiolucent, demonstrate me- viewed. In a few instances, only a radio-
related with the histopathologic sorption of preexisting bone, and graphic report was available, and opera-
tive notes could not be obtained for sev-
findings in the excised tissue. Exam- may be expansile. In other cases,
eral cases. Thirty-three cases were studied
ples of stage 3 lesions have fre- varying zones of fat necrosis are me-
at the Armed Forces Institute of Patholo-
quently been misdiagnosed as un- sponsible for increased radiographic
gy when I was Assistant Pathologist in
usual bone infarcts or other lesions. density due to fat calcification and the Orthopedic Branch. Seventeen cases
Intraosseous lipoma may be a less reactive bone formation. Certain ana- were reviewed in the Henry L. Jaffe
rare lesion than has previously been tomic sites are more common for the Teaching File while these cases were be-
suggested. lipoma, but the lesion has presented ing cataloged for the Department of Or-
in all regions of the skeleton. thopaedic Surgery of the Massachusetts
The surgical features vary between General Hospital. Ten cases were studied
Index terms: Bone neoplasms. 40.319 Fat, ne-
#{149}
solid fat, cystic lesions with fat necro- at Northwestern University Medical
crosis, 40.319 Jaw, neoplasms,
#{149} 24.319 Lipo-
#{149}
School, where they were processed in the
ma and lipomatosis, 10.319, 24.319, 31.319, sis, and differing amounts of very
Onthopaedic Pathology Laboratory of the
40.319 Skull,
#{149} neoplasms, 10.319 #{149}Spine, neo- sclerotic bone and calcified fat. When
plasms, 31.319
Department of Orthopaedic Surgery. One
the tissue is studied microscopically, case was contributed by Leonard B. Kahn,
the uncalcified portion of the tissue M.D., from the Long Island Jewish-Hill-
Radiology 1988; 167:155-160
may consist of enlarged fat cells, side Medical Center. Surgery was per-
which are sometimes myxomatous or formed in all cases, and surgical tissue
amorphous eosinophilic necrotic fat- was obtained for pathologic examination.
ty tissue. Preexisting bone within the A number were whole nesected surgical
lesion is resorbed. Degeneration of specimens or postmortem specimens.

the myxomatous cells may lead to the

formation of true cystic areas, usually
RESULTS
small, but sometimes involving the
whole lesion. Necrosis of the fat is as- While the ages of the patients
sociated with calcification of dead fat ranged from 14 to 75 years, a large
and dank hematoxylin-staining meac- majority of the patients were young
tive bone along the borders of the le- or middle-aged adults with a median
sion. of 37 years of age. There was no pre-
Because of the spontaneous occur- pondemance of the involuted stage 2
rence of involutional changes within and stage 3 lesions in older patients.
these lesions, which produce dramat- None of the 61 patients had any dis-
1 From the Department of Orthopaedic Sur-
gery, Ward Building 9-037, Northwestern Uni- ic alterations of the radiologic and eases known to be associated with
versity Medical School, 303 E. Chicago Ave., pathologic features, the intraosseous bone infarction. No patient was
Chicago. IL 60611. Received August 4, 1987; re- lipoma can be staged into three sepa- known to have had any other bone
vision requested September 16; revision re-
mate clinical patterns: stage 1, in lesion except the lipoma, with the ex-
ceived October 5; accepted October 6. Address
reprint requests to the author. which there is no secondamy necrosis; ception of one patient in whom the
(C RSNA, 1988 stage 2, in which there is partial sec- lipoma was found in a tibia as an in-

155
 Figure 3. Stage
I lipoma. Radiograph in a
32-year-old withmanrheumatoid arthritis
involving both hips. The patient had not re-
ceived steroid therapy. A radiolucent sub-
trochanteric lesion was an incidental find-
ing. It was curetted at the time of hip anthro-
Figure 2. Stage 1 lipoma. Radiograph in a plasty and consisted of fatty tissue with no
woman shows incidental findings of ex- regions of cyst formation.
panded lesion of the proximal fibula. The le-
sion was curetted. There was expansion of
the original cortex with bone remodeling.
The tissue consisted of lipocytes without After surgery, no case had a known
cyst formation. clinical recurrence. However, follow-
b. up data in this series is fragmentary
Figure 1. Stage 1 lipoma. lmages in a 37-
because the majority of the patients
year-old man with a lesion found inciden- were referred from other institutions
tally during a radiographic trauma survey. the lipoma in most of these cases. because of a problem in diagnosis.
(a) On radiograph a radiolucent lesion of the Nontender masses were present in Radiologically, stage 1 lesions,
distal tibial metaphysis with intracortical only seven cases, often in bones with those consisting of viable lipocytes,
bone resorption is seen. Findings of a bone
subcutaneous locations (iliac crest, each demonstrated resorption of the
scan were negative in this region. (b) CT
scan shows resorption of original bone with
ribs, tibia, and fibula). Only one le- preexisting trabecular structure of
tissue having fat attenuation level. The tis- sion, in a fibula, was large in size. A the affected site and replacement
sue was found at surgery to be composed en- pathologic fracture occurred in only with nadiolucent fat (Figs. 1-3). A de-
tirely of fat. one case, a stage 1 lipoma of the prox- gree of cortical expansion was quite
imal femur. common; it was present in half of the
Both the axial and the appendicu- cases in the series. A middiaphyseal
cidental finding when the patient’s lam skeleton could be affected. The location was not uncommon. Few le-
leg was being amputated for osteo- sites of the 61 cases included the sions were metaphyseal in their loca-
sarcoma of the femur. There was a skull (ii = 2), mandible (n 1), cervi- tions, but some affected the whole
male preponderance (33 vs. 21), but cal spine (n 1), sacrum (n 1), ili- end of a bone, and, rarely, lesions af-
this may have been partly influenced um (i = 5), rib (n 4), midhumerus fected as much as a third of the
by the large number of cases from (7l 1), midmadius (n 1), proximal length of the bone. Anatomic loca-
the Armed Forces Institute of Pathol- femur (ii = 21), midfemur (n 1), tion was not a useful criterion for ex-
ogy. Sex was not recorded in seven distal femur (n 1), proximal tibia (n clusion of this diagnosis, except in
cases. = 4), midtibia (n 3), distal tibia (n epiphyses.
A remarkable feature of intraos- 1), proximal fibula (ii 3), midfibula Stage 2 lesions, those consisting of
seous lipomas is their lack of symp- (ii 1), distal fibula (n 2), and cal- viable lipocytes with the presence of
toms. In almost half of the cases (25 caneus (ii = 5). The nibs and pelvis partial necrosis within the lesion,
of 61) the lesion was completely were the common sites in flat bones. were also often expanded radiolucent
without symptoms and was found Twenty-one cases were in the inter- lesions that appeared to have devel-
when nadiographs were obtained for trochantenic or subtmochantenic por- oped slowly so that a new cortex had
some other reason. While mild pain tions of the proximal femur. None formed around the lesional tissue. In
was present in the affected part of were within epiphyses, and no le- addition, sclerotic regions of fat calci-
another 14 patients, it was arguable sions were present in the hands or fication could be noted radiologically
that the symptoms were unrelated to feet except in the calcaneus. (Figs. 4-6). The sclerotic portions of

156 . Radiology April 1988

 ple with the hematoxylin. This bone
frequently formed dense patches and
lacked a typical trabeculam pattern of
formation. This feature undoubtedly
contributed to the marked madioden-
sity within some lipomas. This reac-
tive bone was present in 39 of the 61
cases.
All cases of stage 3 lipoma demon-
strated an absence of original trabec-
ular bone within the lesion. Lipomas
Figures 5, 6. (5) Stage 2 lipoma. Radio- form as expanding masses of cells,
graph in a 29-year-old woman with aching and thus the original bone is me-
of the upper arm reveals a middiaphyseal sorbed in those lesions in which the
expanded lesion of the humerus with focal cells have proliferated to the point of
calcification. At surgery, a solid lesion with infarction. This is a most important
a fatty appearance consisting of lipocytes
feature of these lesions, because it
with fields of necrosis, calcification of
dead fat, and new ossification was found. distinguishes them from bone in-
(6) Stage 2 lipoma. Radiograph in a 41-year- fancts, which also contain dead fat,
old man with left heel pain of 12 days dura- calcification, and reactive ossifica-
tion due to new shoes reveals radiolucent le- tion.
sion with well-defined borders and central
Those lesions that were infarcted
calcification. The surgeon described a cavity
usually contained wide sheets of fea-
partly filled with a “mushy yellowish sub-
Figure 4. Stage 2 lipoma. In a 26-year-old
stance.”
tuneless eosinophilic necrotic fat.
woman, radiograph obtained to evaluate Myxomatous change in the fat cells
pelvis during pregnancy reveals incidental was believed to have been the cause
findings of a large intertrochanteric and
of grossly apparent cysts, which were
subtrochanteric radiolucent lesion with
thick calcified borders and central calcifica- form nadiodensity without the tra- present in each of five resected speci-
tion distally. There is cortical remodeling becular pattern of bone (Fig. 8). The mens. Such cysts were also described
medially. At surgery, much of the lesion was
edges of the lesions were not demar- in other cases that were treated by
a cavity within an extremely thick border. curettage alone. The cysts were emp-
cated from the normal bone. Histo-
At biopsy, myxomatous fat cells were seen. ty of any liquid contents. However,
logically, these variant cases have
been termed ossifying lipomas be- in no case was theme a single cavity
cause the reactive bone was present without significant lesional tissue be-
these lesions could be quite radio- in all fields of tissue examined (Fig. ing present, at least along the periph-
dense and were located within the 9). These cases did not demonstrate ery of such cysts. Documentation of
centers of lesions, as well as margin- histologic involution, so they proba- cyst formation was present in 20 of
the 61 cases in this series.
ally. bly are best considered as stage 1 le-
Stage 3 lesions, those with near sions with unusual reactive bone for- The four tissue regions present
mation. within an involuted stage 3 lipoma
complete or complete involution of
the lipoma, demonstrated resorption The stage 1 lesions were described were (a) infarcted fat, (b) calcified
of normal bone within the lesions ma- by the surgeons as solid lesions of tis- fat, (c) reactive ischemic bone, and
sue resembling normal fat. In fact, (d) empty spaces (cysts) (Fig. lOc).
diologically (Fig. 7). It was this fea-
tune that permitted them to be differ- about half of these cases contained Theme were certain cases with a few
scattered thin trabeculae of bone regions of remaining viable fat cells,
entiated radiographically from cases
of bone infarction. Usually tomo- which were interpreted as incom- but these cases were considered stage
3 lesions because most of the lesion
grams were necessary to make this pletely resorbed tnabeculae (Fig. lOa).
distinction. A second feature of the The lesional cells were lipocytes with had become involuted. Nevertheless,
no distinguishing characteristics to such stage 3 cases with remaining li-
stage 3 lesions was the presence of
considerable radiodensity, both cen- differentiate them from normal fat pocytes also provided evidence that
the totally involuted lesions original-
trally and along the periphery of the cells. Usually the expanded cortex,
which had enlarged the dimensions ly derived from stage 1 lesions or
lesions. Many stage 3 lesions were
of the original bone, was quite hard proliferating lipocytes.
considered characteristic because of
the quite thick, very madiodense bor- and had to be drilled and cut with os-
dens. The diagnosis of bone lipoma teotomes or saws like normal bone.
DISCUSSION
could be strongly considered in the The stage 2 lesions closely resem-
differential diagnosis when these bled the stage 1 lesions grossly and Lipomas have always been consid-
features were present. Expansion of microscopically, with the additional ered mane tumors in bone. Previous
the cortical margins was also present features of regions of necrotic fat that articles have described usually a sin-
within some of these stage 3 cases, had undemgone focal secondary calci- gle case with a review of the litera-
but cortical expansion was only occa- fication (Fig. lOb). Calcification of ture (1-39). This is quite surprising,
sionally present around the many le- necrotic fat was often a striking fea- because lipocytes are widely distnib-
sions of the proximal femur, the most tune of the involuted lipoma. Calci- uted throughout normal bone mar-
common site in this series. fied fat was present in 27 of the 61 row, and lipomas are common tu-
In addition, there were three cases cases. moms of the soft tissues. Each of these
with extensive reactive bone within a In addition, at histologic examina- cases would be considered stage 1 or
lesion of viable lipocytes. These le- tion some cases demonstrated a type stage 2 lesions, with the presence of
sions demonstrated considerable uni- of woven bone that stained dark pun- masses of viable lipocytes replacing

Volume 167 Number 1 Radiology . 157

normal bone marrow elements. To thologist is familiar with the zone of ly been reported in the calcaneus (1,
my knowledge, only my previous me- calcified fat that exists within the 5, 9, 13, 20, 21, 29, 34, 53). Involve-
port of eight proximal femoral le- zone of ischemia around a bone in- ment of the fibula and tibia seems to
sions described 3 intraosseous
stage farct, between the totally dead infarct be more common than involvement
lipomas (40). I contend that although and the live reactive bone bordering of other sites (15, 22, 31, 34-36).
lipomas are an uncommon bone neo- the infarct. It beams emphasis here Spinal involvement is rare (17, 24,
plasm, they are not as rare as the lit- that in bone infancts such fat calcifi- 39).
eratume suggests. This false appear- cation is always zonal and does not The differential diagnosis of the Ii-
ance of rarity is due to the unusual exist within the centers of an infarct poma varies with the stage of the le-
predisposition of these lesions to un- unless the whole infarct is only 1-2 sion. Any expansile bone neoplasm
dergo spontaneous necrosis and thus cm in dimension (56). can resemble madiogmaphically the
appear to be largely necrotic or calci- Cyst formation in lipomas appears stage 1 lesion. CT scans and MR im-
fied fat with varying degrees of cys- to be the result of myxomatous de- ages can demonstrate the presence of
tic degeneration. In this stage they generation within the lipoma and high quantities of fat within a lesion,
have frequently been misdiagnosed then infarction (40, 43, 44, 52). While which might suggest the diagnosis
as bone infancts (41, 42). the hole that is the cyst forms be- (23, 43). An expansile diaphyseal le-
The expansion of the normal bone cause of degenerative processes, one sion of a long bone, particularly with
affected by a lipoma has been de- must understand that prior bone me- some calcification, is typical for a ii-
scribed in about half of reported sorption that created the space in the poma. But usually stage 1 lesions and
cases (19). Bone expansion in this se- bone where the cyst formed is a pro- even most stage 2 lesions are diag-
ries of cases was present in stage 2 cess that can be mediated only by vi- nosed as lipomas only after a patho-
and stage 3 lesions, as well as in stage able bone cells, osteoclasts, with an logic examination of the tissue.
1 lipomas. The apparent cause was intact blood supply. Thus, any cystic However, lesions with involution
slow deposition of peniosteal new lesion of bone, due to any cause, was (necrosis, calcification, cyst forma-
bone around a slowly growing and once a viable neoplastic lesion that tion, and reactive ossification) have
expanding neoplasm. incited bone resorption through cel- been widely confused with other le-
Bone resorption has been a feature lulam expansion of the lesional cells. sions. Chief among these are bone in-
described in all previously reported Dead tissue is utterly incapable of me- farcts (40, 42). It has been empha-
cases. It was also present in each of sorbing bone. Only osteoclasts can sized that lipomas may expand the
the 61 cases of this series. A case resorb bone. omigmnal contours of bones; infamcts
should not be considered a lipoma Since fat is present in the marrow cannot do this. Lipomas cause mesorp-
without evidence of resorption of the of all bones, it is not surprising that tion of the preexisting bone; dead
normal bone tissue. the sites of lipomas include all me- bone cannot resorb bone. And lipo-
The concept of spontaneous infanc- gions of the skeleton. It is important mas can undergo cystic degeneration;
tion of bone marrow fat due to ex- to note that although a large number infarcts always consist of whatever
panding lipomatous tissue within a of cases were located in the upper fe- bone tissue was present before the
rigid cage of tmabecular bone was mum, none were within the femoral infarction occurred, except along the
proposed first by Johnson (33, 40, 43, head (a frequent site of bone in- periphery of a lesion, where reactive
44). Necrosis due to rapid growth is a farcts). Previous cases have frequent- changes can occur within the live
well-known feature of many malig-
nant neoplasms. However, the
growth in a lipoma appears to be
quite slow. Obviously, since the onig-
inal bone tissue is resorbed in a bone
lipoma, the process has allowed os-
teoclastic resorption to occur. One
must postulate that fat cell expansion
or cell multiplication is responsible
for the infarction that occurs in some
but not all cases. Some lesions persist
as stage 1 lesions, whereas partial in-
farction results in stage 2 lesions, and
near total infarction results in stage 3
lesions.
Both calcification and ossification
are well-known features of soft-tissue
lipomas (45-54). However, because of
the honeycomb shell of rigid struts
in bone, infarction seems to occur
more often within bone lipomas than
within soft-tissue lipomas. Calcifica-
tion and the formation of dank pun-
ple-hematoxylin-stamning woven
bone are typical features of lesions in Figure 7. Stage 3 lipoma. Radiographs in a 62-year-old man with progressive pain of both
hips due to degenerative arthritis. (a) Lateral view shows osteoarthritis with loss of joint
which fat has undergone necrosis.
space and osteophytes. In addition, there is a radiolucent lesion of the right femoral neck
This is true in cases of fat necrosis, am- with very sclerotic borders. (b) Femoral head specimen from the total hip arthroplasty con-
teniosclerosis, and osteonecrosis of all tamed about a half of the lesion. Specimen radiograph of a slice shows well the resorption of
etiologies (48, 52, 55). The bone pa- the preexisting bone and the very dense borders around the lipoma.

158 . Radiology April 1988

marrow bordering the infarct. In ad- stage 3 lipoma madiographically is the cartilage tissue. Bone cysts, chondro-
dition to these three features, all of enchondroma (6, 31, 57, 58). The sites myxoid fibmomas, and fibrous dyspla-
which are radiographically detect- of occurrence may be similar, both le- sia can each be confused with lipo-
able, the calcification and ossification sions can expand a bone, the growth mas radiologically (26, 40, 57, 59-61).
are present throughout the lipoma rate of both lesions is slow, patients However, histologic tissue examina-
and not just peripherally as in a med- are frequently without symptoms, tion should reveal features that are
ullary infarct. This can be deter- and radiographic calcification, often not present in lipomas.
mined with tomography. And in intense and centrally located, is fre- The osteoblastoma seems to be con-
many cases the peripheral sclerosis is quent in older enchondnomas. How- sidered in those uncommon ossifying
more wide around a lipoma than ever, tissue examination permits dif- lipomas that demonstrate the exten-
around a medullary infarct. ferentiation of the two lesions quite sive formation of reactive bone, par-
The lesion that most resembles the easily because lipomas contain no ticularly in the variant stage 1 le-
sions, in which such bone is present
in large quantities and little fat ne-
crosis has occurred. Certainly radio-
graphically the two lesions can be
similar, so the differentiation rests on
tissue examination.
The diagnosis of lipoma can be
made more frequently and accurately
when the various morphologic fea-
tures of the involuted forms of in-
traosseous lipomas are appreciat-
ed. U

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Volume 167 Number 1 Radiology 159

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