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Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

AIM To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases. METHODS Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides. RESULTS Giant gastric lipomas are extremely rare: 32 cases reported since 1980, and 2 diagnosed among 117110 consecutive EGDs. Average patient age = 54.5 ± 17.0 years old (males = 22, females = 10). Maximal lipoma dimension averaged 7.9 cm ± 4.1 cm. Ulcerated mass occurred in 21 patients. Lipoma locations: antrum-17, body-and-antrum-4, antrum-intussuscepting-into-small-intestine-3, body-2, fundus-1, and unspecified-5. Intramural locations included submucosal-22, subserosal-2, and unspecified-8. Presentations included: acute upper gastrointestinal (UGI) bleeding-19, abdominal pain-5, nausea/vomiting-5, and asymptomatic-3. Symptoms among patients with UGI bleeding included: weakness/fatigue-6, abdominal pain-4, nausea/vomiting-4, early-satiety-3, dizziness-2, and other-1. Their hemoglobin on admission averaged 7.5 g/dL ± 2.8 g/dL. Patients with GI bleeding had significantly more frequently ulcers than other patients. EGD was extremely helpful diagnostically (n = 31 patients), based on characteristic endoscopic findings, including yellowish hue, well-demarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked-fat signs. However, endoscopic mucosal biopsies were mostly non-diagnostic (11 of 12 non-diagnostic). Twenty (95%) of 21 abdominal CTs demonstrated characteristic findings of lipomas, including: well-circumscribed, submucosal, and homogeneous mass with attenuation of fat. Endoscopic-ultrasound showed characteristic findings in 4 (80%) of 5 cases: hyperechoic, well-localized, mass in gastric-wall-layer-3. Transabdominal ultrasound and UGI series were generally less helpful. All 32 patients underwent successful therapy without major complications or mortality, including: laparotomy and full-thickness gastric wall resection of tumor using various surgical reconstructions-26; laparotomy-and-enucleation-2; laparoscopic-transgastric-resection-2; endoscopic-mucosal-resection-1, and other-1. Two new illustrative patients are reported who presented with severe UGI bleeding from giant, ulcerated, gastric lipomas. CONCLUSION This systematic review may help standardize the endoscopic and radiologic evaluation and therapy of patients with this syndrome.


INTRODUCTION
Gastric lipomas are rare, constituting < 3% of benign gastric tumors, and < 1% of all gastric tumors [1] , and giant gastric lipomas (≥ 4 cm) are extremely rare, with only 32 cases reported since 1980 (Table  1)  . Although small gastric lipomas are usually asymptomatic, giant gastric lipomas typically produce major symptoms from GI obstruction, tumor ulcers, or acute upper gastrointestinal (UGI) bleeding, with 19 cases of UGI bleeding reported since 1980 (Table  1). Due to its extreme rarity, all prior studies of giant gastric lipomas have comprised single case reports. This work systematically reviews the literature since 1980, and collates the case reports scattered among various and sometimes obscure journals, to semi-quantitatively describe the clinical presentation, endoscopic and radiologic findings, and therapy of the disease; and to report two new illustrative cases who presented with massive, life-threatening UGI bleeding among 117110 analyzed esophagogastroduodenoscopies (EGDs) at two large hospitals.

MATERIALS AND METHODS
The literature was systematically reviewed using PubMed for articles published since 1980 with the following medical subject heading (MeSH) or keywords: ("giant lipoma") AND (gastric) OR [("lipoma") and ("gastric") and ("bleeding")]; and by reviewing the section on gastrointestinal lipomas in standard pathology textbooks or monographs. Two authors independently reviewed the literature, and decided by consensus which articles to incorporate in this review. After reviewing one case from 1974 [5] , cases reported before 1980 were selectively excluded because the preoperative evaluation at the time frequently used relatively obsolete tests such as UGI series and often lacked currently mandatory tests such as EGD. Four case reports, written in Spanish [9,11,13,32] , were professionally translated into English. Case reports of large gastric adenomas which did not satisfy the minimal size criteria of giant gastric lipomas (≥ 4 cm) were systematically excluded [3,34] . A video publication was excluded because clinical details were not reported [35] . A clinical series of 16 gastric lipomas were excluded because this series lumped together mediumsized and giant lipomas [36] . Computerized review of the pathology records at William Beaumont Hospitals at Royal Oak and at Troy, Michigan from January 2005-December 2015 using the computerized system of PowerPath (Tamtron) and SOFTPath with the software terms ("lipoma" or "lipomas") AND ("gastric" or "stomach") revealed 2 cases of giant gastric lipomas. Computerized review of the EGD reports using Provations did not reveal any further cases. These 2 cases were thoroughly reviewed based on medical records, including re-review of the original endoscopic photographs by an expert endoscopist, radiologic images by an expert radiologist, and pathologic slides by an expert pathologist. This dual case report received exemption/approval by the IRB at William Beaumont Hospital, Royal Oak, on October 17, 2016.

Illustrative case reports
Case 1: A 63-year-old, nonalcoholic, man with a medical history of hypertension treated with lisinopril, amlodipine, and nifedipine, and hyperlipidemia treated with lovastatin, presented with epigastric pain, early satiety, and involuntary 10-kg-weight-loss during the last 6 mo, and melena and dyspnea on exertion for 3 d. The vital signs were stable, with a blood pressure of 144/74 mmHg, and pulse of 87/min. The abdomen was soft, nontender, and without hepatosplenomegaly or palpable masses. Rectal examination revealed melena. The hemoglobin was 6.2 g/dL, blood urea nitrogen was 27 mg/dL, and creatinine was 1.40 mg/dL. He had 496000 platelets/mL, a normal international normalized ratio (INR), and normal partial thromboplastin time (PTT). He was transfused two units of packed erythrocytes.
EGD revealed a 13-cm-wide submucosal, yellowish, gastric mass primarily in the antrum, covered by smooth mucosa except for focal ulceration (Figure 1A), and exhibiting the pillow sign, of indentation of the mass with moderate pressure applied via a closed forceps [37,38] .

A B
cm × 8.2 cm mass, with attenuation characteristic of fat, arising from the gastric antrum and producing a mass effect on the proximal duodenum ( Figure 2). A 7-mm-wide lesion in the body of the pancreas was also suspected to be a lipoma based on its characteristic attenuation. The patient underwent laparotomy due to the recent bleeding of the giant lipoma. It was resected via subtotal gastrectomy extended by partial bulbar duodenectomy due to lipoma extension into duodenal bulb, with Billroth Ⅱ reconstruction. Gross pathology revealed a homogeneous, soft, submucosal mass with a cut surface exposing yellowish, greasy tissue, measuring 14.5 cm × 8.7 cm × 7.5 cm ( Figure  3A), which microscopically revealed lipoma ( Figure  4A). Immunohistochemical staining revealed positivity for CD34 ( Figure 4B), a finding highly consistent with a spindle cell variant lipoma [39] . The patient was discharged 8 d postoperatively, and had no complications during 8 wk of follow-up.

Case 2:
A 78-year-old, nonalcoholic, woman with a medical history of atrial fibrillation, peripheral neuropathy, hypertension, dyslipidemia, diabetes, chronic renal insufficiency, and hysterectomy for uterine fibroids, presented with melena for three days, associated with fatigue and orthostatic dizziness. Medications included warfarin, furosemide, metoprolol, diltiazem, atorvastatin, pioglitazone, amitriptyline, and glimepiride. Physical examination revealed stable vital signs, with a blood pressure of 124/67 mmHg, and pulse of 68/min. There was a heart murmur, and bilateral 3+ lower extremity edema. The abdomen was soft, and non-tender, with normoactive bowel sounds, and no organomegaly. Rectal examination revealed melena. The hemoglobin was 7.1 g/dL, INR was 4.9, platelet count was 306000/mL, and PTT was 42.5 s. The blood urea nitrogen was 44 mg/dL and creatinine was 1.8 mg/dL. An electrocardiogram revealed atrial fibrillation without acute ischemic changes.
She was transfused 2 units of packed erythrocytes and 2 units of fresh frozen plasma. Two-dimensional echocardiography revealed mild mitral valve regurgitation, moderate-to-severe right atrial dilatation, and severe tricuspid valve regurgitation. Abdominal CT revealed a submucosal, antral, gastric mass measuring 9.5 cm × 6.0 cm × 4.5 cm. EGD revealed a large, focally ulcerated, smooth, antral gastric mass, exhibiting the cushion sign ( Figure 1B). Microscopic examination of multiple mucosal biopsies of the ulcer margin revealed superficial ulceration, granulation tissue, and no malignancy. The patient underwent surgery due to the recent bleeding of the giant lipoma. At laparotomy, the submucosal mass was excised by distal gastrectomy. Gross pathology of the resected mass revealed a relatively homogeneous, 9.0 cm × 6.0 cm × 4.5 cm, focally ulcerated, mass with a greasy, tan-yellow cut surface ( Figure 3B), which microscopically was a lipoma ( Figure 4C and D). The patient was discharged 5 d postoperatively with no further GI bleeding [37][38][39] .

RESULTS
Systematic literature review revealed that giant gastric lipomas are rare, with only 32 cases reported since 1980 (Table 1), and only 2 cases currently identified among 117110 EGDs performed during 11 years at William Beaumont Hospital, Royal Oak, one of the five largest hospitals in the United States, and at William Beaumont Hospital, Troy. The 32 reported patients were on average 54.5 ± 17.0 years old. Thirty were adult patients, and two were pediatric patients. Twentytwo were male, and 10 were female. Twenty-one patients had an ulcerated mass. The lipomas averaged 7.9 cm ± 4.1 cm in maximal dimension. Lipoma locations included antrum-17, body and antrum-4, antrum intussuscepting into small intestine-3, gastric body-2, fundus-1, and unspecified-5. This data confirms previous reports that giant gastric lipomas most commonly occur in the antrum [40] . Intramural locations included submucosal-22, subserosal-2, and unspecified-8. This data confirms previous reports that giant gastric lipomas are generally submucosal, but occasionally subserosal [22,36] . Nineteen patients presented with acute UGI bleeding, including melena-11, hematemesis and melena-7, and hematemesis-1. Giant lipomas can ulcerate and bleed secondary to venous stasis [14] , friction and trauma  of the lipoma tip against the wall contralateral to the lipoma attachment site, or, least likely, from outgrowing their blood supply. Among 19 patients presenting with acute GI bleeding, the hemoglobin on admission averaged 7.5 g/dL ± 2.8 g/dL (unavailable in 2 patients). Symptoms in the 19 patients included: weakness/fatigue-6, abdominal/epigastric pain-4, nausea and vomiting-4, epigastric fullness/early satiety-3, dizziness/presyncope-2, and belching-1. Signs included: pallor-7, epigastric tenderness-3, epigastric mass-3, tachycardia-2, and one each with diaphoresis or hypotension. Among four analyzed variables including age, sex, lipoma size, and lipoma ulceration, only lipoma ulceration was statistically significantly different (more common) in patients presenting with UGI bleeding, than in patients with other presentations (p = 0.004; Table 2). This difference emphasizes the importance of lipoma ulceration in the pathogenesis of bleeding.
Five patients presented predominantly with abdominal pain, without acute UGI bleeding, including 2 presenting with iron deficiency anemia. Additional symptoms in these 5 patients included early satiety-2, and anorexia-1. Five patients presented with nausea and vomiting. These patients had additional symptoms including dyspepsia/abdominal pain-3, weight loss-2, anorexia-1, and early satiety-1. Three patients had asymptomatic giant gastric lipomas incidentally detected: by EGD before bariatric surgery for morbid obesity; by abdominal CT in the evaluation of testicular cancer; and by abdominal CT for severe acute pancreatitis.
Thirty-one of the 32 patients underwent EGD (one other patient, see Methods section). EGD is standardly performed preoperatively to characterize the anatomy and show characteristic endoscopic features of lipomas. However, EGD frequently fails to obtain diagnostic tissue due to failure of superficial mucosal biopsies to reach submucosa. Among 12 patients in whom endoscopic biopsy results were reported in the present review, only 1 (8.3%) had lipoma diagnosed pathologically by endoscopic biopsies [18] . Pathologic findings in the other 11 reported biopsy specimens included chronic or nonspecific inflammation, gastritis, and normal or necrotic tissue. Repeated biopsies at the same site (well technique) may increase somewhat the diagnostic yield of endoscopic biopsies. Repeated or deep biopsies at EGD may expose yellow fat from the lipoma, a finding called the "naked fat" sign [41,42] . In the tenting sign observed at EGD the superficial mucosa retracts from the submucosal mass when it is grasped with a forceps because the submucosal lipoma has a fibrous capsule and does not infiltrate into the mucosa. Submucosal lipomas tend to be smooth except for focally ulcerated areas.
CT is currently the standard imaging modality. Lipomas are identified by having an attenuation ranging from -70 to -120 Hounsfield units, characteristic of fat density [20] .
Twenty (95.2%) of 21 patients undergoing abdominal CT had CT findings highly suspicious for lipoma, and the other one had diagnostically helpful findings. CT findings consistent with a lipoma include: a well-circumscribed, submucosal, and homogeneous, mass with an attenuation characteristic of fat. Seven patients underwent upper gastrointestinal series which revealed mass size, mass location, and a smooth superficial layer, but did not show characteristic features of lipomas [4][5][6]13,18,26,29] . All 7 patients undergoing UGI series were reported in publications from 1998 or before, whereas only 4 of 21 patients undergoing CT were reported in publications from 1998 or before (17 CTs reported in publications from 1999-2016) (p < 0.00001, OR > 3.53, Fisher's exact test). This difference is consistent with replacement of UGI series by EGD and abdominal CT which provide superior characterization. In 9 (82%) of 11 cases abdominal ultrasound showed features suspicious for lipomas of a well-demarcated, submucosal, hyperechoic lesion, but the lesion was missed in 2 cases [4,9,11,16,19,20,22,26,27,29,30] . These results are consistent with abdominal ultrasound being a cheaper, but less definitive test than abdominal CT for giant gastric lipomas.
The currently reported findings are consistent with EUS being an important adjunct test when abdominal CT is non-diagnostic, when a tissue diagnosis is needed preoperatively because of non-diagnostic EGD biopsies, or prior to endoscopic mucosal resection. Both patients undergoing abdominal magnetic resonance imaging (MRI) had important findings showing tumor anatomy and exhibiting signals characteristic of fat [16,20] . Therapy was successful in all 32 patients including laparotomy with full-thickness resection of gastric wall containing tumor either via wedge resection, partial gastrectomy, Billroth I resection or other surgery-26; laparotomy with enucleation-2; laparoscopic transgastric resection-2; endoscopic mucosal resection-1, and successful laparotomy with polypectomy after unsuccessful, attempted endoscopic polypectomy-1. No patient suffered major postoperative or postprocedural complications. No patient died from GI bleeding from the lipoma, from the surgery, or from endoscopic therapy.
When GI bleeding or gastric obstruction are associated with a large, ulcerated gastric mass, gastric malignancy may be suspected. It is critical to preoperatively exclude liposarcomas from giant lipomas because liposarcomas require further genetic analysis of pathologic specimens, and chemotherapy after surgical resection [44] . Lipomas have welldemarcated margins on radiologic imaging due to the presence of a fibrous capsule. They are welldifferentiated, devoid of lipoblasts, and grow slowly.
Liposarcomas have a densitometry close to normal submucosal tissue at abdominal CT [20,45] , and are definitively diagnosed by MDM2 and CDK4 gene amplification [21,26] . Other tumors in the differential diagnosis of giant lipomas include GI stromal tumors, such as leiomyoma and fibroma; and rarely intramural tumors, such as neurilemoma, adenomyoma, Brunner's gland adenoma, and heterotopic pancreas [22] . Treatment for lipomas is not standardized. They are often resected endoscopically when < 4-6 cm, and surgically when > 6 cm [14,22] , but endoscopy has been used to resect up to 9-cm-wide gastric lipomas [25] . Lipomas may sometimes be resected by enucleation because they are encapsulated. Resection via subtotal gastrectomy entails much greater morbidity from potential complications of anastomotic leakage, duodenal stump rupture, obstruction, hemorrhage, decreased acid production, delayed gastric emptying, gastroesophageal reflux, and vitamin B12, folate, iron, or calcium deficiencies [24] .
The current case reports are limited by retrospective analysis, and by only reporting 2 cases due to disease rarity. The current literature review is likewise limited first, by consisting of single case reports due to syndrome rarity; and second, by retrospectively reporting of case reports. Individually reported cases may be subject to selection bias with preferential reporting of more clinically dramatic or more successful therapeutic interventions. Third, cases from different centers reported somewhat variable clinical data, such as variable follow-up and variable imaging tests (e.g., abdominal CT vs MRI). Fourth, the evaluation of lipomas has evolved over time due to development of better diagnostic tests. This effect was minimized by excluding cases reported before 1980. Fifth, imaging tests were interpreted by various radiologists and pathology specimens were interpreted by various pathologists at various hospitals in the prior case reports.
In conclusion, this systematic literature review provides a comprehensive analysis to help optimize the evaluation and management of suspected giant gastric lipomas. CT and EGD are the standard tests to evaluate suspected giant gastric lipomas. When giant gastric lipomas are identified at abdominal CT by characteristic findings of a homogeneous, wellcircumscribed, submucosal mass with characteristic attenuation of fat, EGD with biopsies should be performed, but the endoscopic biopsies may be nondiagnostic. EUS with deep biopsies may be performed to obtain a definitive diagnosis if biopsies from EGD are non-diagnostic. Liposarcoma should be excluded by cytogenetic analysis when necessary. If lipoma is confirmed, endoscopic resection of only the lipoma and its fibrous capsule may be feasible for small-tomoderate sized lesions, with subtotal gastrectomy reserved for especially large lipomas.  [22] , 2012, Thompson et al [36] , 2003 Most commonly located in gastric antrum Thompson et al [36] , 2003, Menon et al [40] , 2014 Yellowish hue Yellow color of adipose tissue in submucosa transmitted to mucosal surface Menon et al [40] , 2014, Chen et al [41] , 2014 Broad base Rarely pedunculated Singh et al [18] , 1987 Cushion or pillow sign: easily deforms like a cushion with mild pressure applied against it by an endoscopic probe (closed biopsy forceps).
Lipoma consists of soft, compressible tissue.
De Beer et al [37] , 1975, Hwang et al [38] , 2005 Tenting sign: Mucosa easily retracts after it is grasped and gently pulled with a forceps Mucosa separates from submucosa when gently pulled via forceps because lipoma has fibrous capsule and does not infiltrate into adjacent tissue Priyadarshi et al [14] , 2015 Naked fat sign: repeated biopsies at same site reveals yellow fatty tissue Multiple biopsies at same site (using well technique) exposes submucosal lipomatous tissue Chen et al [41] , 2014, Patrick et al [42] , 2007 Moderately frequent focal central ulceration of mucosa Likely secondary to giant lipoma abutting and rubbing against contralateral gastric wall. Ischemia may also contribute to ulceration.
Kumar, et al [8] , 2015, Thompson et al [36] , 2003 Highly useful diagnostic test for lipomas Typically strongly suggestive of diagnosis Demonstrates anatomy of mass. Shows if ulcerated or intussuscepting mass. Characteristic findings: yellow hue, smooth overlying mucosa, relatively homogeneous, round margins. Exhibits pillow, tenting or naked fat signs.

Current Report
Endoscopic biopsies Standard endoscopic biopsies usually reveal only normal mucosa and insensitive for pathologic diagnosis.
Standard endoscopic biopsies typically sample superficial mucosa and miss deeper submucosal lipoma. Current Report, Neto et al [22] , 2012 Techniques to increase yield of endoscopic biopsies; use jumbo forceps for endoscopic biopsies; or well technique (repeated endoscopic biopsies at same mucosal site).
Repeated biopsies at same site permits sampling of deeper (submucosal) tissue Wang et al [47] , 2015 Abdominal CT Submucosal mass Typically submucosal, occasionally subserosal, and never mucosal.

Characteristic of adipose tissue
Alberti et al [20] , 1999 Highly useful as diagnostic test for gastric lipomas Demonstrates characteristic findings in about 95% of cases.
Characteristic findings: wellcircumscribed, submucosal, homogeneous mass with an attenuation characteristic of fat.

COMMENTS
Background Gastric

Research frontiers
A systematic review is important to collate all the prior data presented as case reports to establish what is known about the clinical evaluation (tests) for this disease. This systematic review demonstrates that the standard clinical evaluation should include: (1) abdominopelvic computerized tomography (CT) to demonstrate the characteristic CT findings of a giant gastric lipoma of a wellcircumscribed, submucosal, and homogeneous mass with attenuation of fat; and (2) esophagogastroduodenoscopy (EGD) to demonstrate the characteristic endoscopic findings of these lesions of yellowish hue, well-demarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked fat signs. This systematic review demonstrates that the following tests are nonstandard or generally obsolete tests: (1) upper gastrointestinal series has been superseded by EGD and should only be performed in highly unusual circumstances; and (2) traditional abdominal ultrasound has been largely superseded by abdominopelvic CT which is a better diagnostic test for this condition, and the traditional abdominal ultrasound should be performed only if the differential diagnosis is broad and not specifically directed at documenting a giant gastric lipoma.
This work systematically reviews several clinically important but controversial topics, including: (1) the role of endoscopic ultrasound: this work shows that conventional mucosal endoscopic biopsies frequently result in a non-diagnostic pathologic diagnosis because giant gastric lipomas are generally submucosal, and therefore endoscopic ultrasound with ultrasoundguided needle biopsies may be necessary if preoperative tissue diagnosis is not obtained by conventional mucosal endoscopic biopsies; and (2) the relative roles of the available therapies: endoscopic mucosal resection, laparoscopic transgastric resection, laparotomy with enucleation, laparotomy with fullthickness wedge resection, and laparotomy with partial gastrectomy and gastric reconstruction.

Innovations and breakthroughs
While several case reports have recently been published on giant gastric

Applications
This work provides the following highly clinically relevant conclusions: (1) standard evaluation for suspected giant gastric lipomas should include EGD to demonstrate the characteristic endoscopic findings of yellowish hue, welldemarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked fat signs; (2) at EGD a submucosal mass that is a suspected lipoma should be biopsied, even though the yield of superficial endoscopic biopsies in pathologically diagnosing a gastric lipoma is relatively low. The diagnostic yield of biopsies at EGD may be increased by using jumbo forceps for the biopsies, or by repeated biopsies at the same site ("well" or biopsy-onbiopsy technique); (3) abdominopelvic CT is a standard test in the evaluation of suspected giant gastric lipomas to demonstrate the characteristic CT findings of a giant gastric lipoma of a well-circumscribed, submucosal, and homogeneous mass with characteristic attenuation of fat; (4) upper gastrointestinal (UGI) series is now generally considered an obsolete test for evaluation of suspected giant gastric lipomas and should be replaced by EGD; (5) conventional abdominal ultrasound is not the preferred test for highly suspected giant gastric lipomas, and should be replaced for this indication by abdominopelvic CT. However, abdominal ultrasound may be a very useful initial imaging test for numerous abdominal conditions in which giant gastric lipoma is in the differential diagnosis; and (6) due to scant data about this rare lesion, and absence of prospective, controlled, therapeutic trials there is no universally accepted standardization of preferred therapies for giant gastric lipomas. Reported therapies include endoscopic mucosal resection, laparoscopic transgastric resection, laparotomy with enucleation, laparotomy with full-thickness wedge resection, and laparotomy with partial gastrectomy and gastric reconstruction. All the reported therapies result in a highly favorable prognosis with no reported mortality among the 32 currently reviewed cases and rare severe morbidity because this tumor is benign, is characteristically biologically nonaggressive, and is well-encapsulated that renders it readily amenable to resection. There is recent interest on selecting less invasive techniques for lesion removal, including endoscopic mucosal resection or laparoscopic removal, as opposed to the traditional laparotomy for removal. This systematic review shows that further research is needed on the optimal therapy for giant gastric lipomas, and on individualizing the therapy according to the clinical presentation.

Terminology
The term giant gastric lipomas refers to gastric lipomas ≥ 4 cm in diameter. The distinction of size ≥ 4 cm vs size < 4 cm is clinically important because gastric lipomas ≥ 4 cm generally produce major clinical symptoms from GI obstruction, tumor ulcers, or upper gastrointestinal bleeding, whereas smaller lesions are usually asymptomatic or produce minor symptoms. Furthermore, lesion size often affects the selected therapeutic modality, with lipomas < 4 cm