Spindle cell lipoma of the forehead overlying the supraorbital nerve associated with chronic cluster-like headaches: a case report

What is known about this subject in regard to women and their families? Spindle cell lipomas (SCL) are rare benign tumors more commonly found in middle-aged men located on the neck, back, and shoulders, and are, therefore, rarely seen in women. If discovered in a woman, SCLs should be solitary, mobile, and painless. What is new from this article as messages for women and their families? Due to the fact that SCLs tend to appear earlier in life and outside the aforementioned anatomical locations in women, diagnosis can be complicated in atypically presenting. Although the patient suffered from debilitating headaches, she believed they were associated with the mass in her forehead, and treatment was delayed by 6 months, ultimately impacting her quality of life. This case highlights the importance of recognizing atypical diagnoses and symptoms in women in order to provide timely and appropriate treatment. Introduction Spindle cell lipomas (SCL) are a rare variant of lipomas that are painless, solitary, and slow-growing with no metastatic potential reported in the literature.1 In 90% of cases, these benign tumors arise in the subcutaneous tissue of the neck, back, and shoulder areas of middle-aged men.1,2 Incidence within the orbital, oral, and facial region is quite rare.2 Although the pathogenesis of SCL remains unclear, unique histological and immunohistochemical features distinguish SCL from other lipomatous tumors. Histologically, SCL contains mature adipocytes, bland spindle cells, and ropey collagen fibers, as observed in this case. Immunohistochemical staining for CD34 is diffusely positive in spindle cells.1,3,4 The recommended treatment for SCLs is local excision, as recurrence is rare even with incomplete removal.2 Case report A 31-year-old female with a history of mixed hyperlipidemia and acne vulgaris presented with a mobile, 1.0 cm forehead mass superior to the right eyebrow. The mass appeared over the course of a month and was reported to be associated with new right ipsilateral headaches. At the initial consultation with dermatology, it was recommended to delay excision despite the onset of headaches due to the location and the risk of scarring. Plastic surgery was consulted 2 months later due to perceived enlargement and persistent daily ipsilateral cluster-like headaches that significantly impacted her quality of life (Fig. 1). Over-the-counter medications did not provide relief. She denied a history of trauma and a personal/family history of frequent headaches, migraines, or lipomas.Fig. 1.: Photograph depicting forehead mass 2 months after initial evaluation.Ultrasound incompletely identified a well-defined hyperechoic lesion measuring 1.1 × 1.2 × 0.3 cm, closely abutting the deep fascia without demonstrable vascularity (Fig. 2A). During excision 4 months later, the mass was found overlying the right supraorbital nerve. Histologic examination revealed features suggestive of an SCL (Fig. 2B). CD34 staining was positive and HMGA2 staining was negative, supporting the diagnosis of SCL (Fig. 2C).Fig. 2.: (A) Ultrasound image detailing forehead mass located to the right of midline, 1 cm superior to the eyebrow. (B) Mature adipocytes with intermixed bland spindle cells and ropey collagen fibers in a focal myxoid background, without cytological atypia, necrosis, or significant mitotic activity. (C) CD34-positive spindle cells.At the 2-week postoperative follow-up, there was moderate swelling at the surgical site, but no bleeding, discharge, or signs of infection. Since removal, the patient reported no recurrence of cluster-like headaches and marked improvement in her quality of life. Discussion In women, SCLs are rare, presenting earlier in life and in different anatomical locations in comparison to men.4 The location of the SCL in this unique case likely contributed to the patient’s persistent headaches due to the proximity of the supraorbital nerve. Although benign tumors are often managed conservatively to avoid unnecessary invasive treatment, this case underscores the importance of recognizing atypical symptoms that may warrant timely intervention, especially when quality of life is affected. Additionally, differentiation of pleomorphic lipomas (characterized by their multinucleated floret-like giant cells) from SCL may aid in differentiating these unique tumors from the malignant soft tissue tumors that they may mimic.5 Conflicts of interest None. Funding None. Study approval This study protocol was reviewed and approved by the Rocky Vista University IRB, approval number 2025-099. Author contributions SN: Participated in research design, writing of the paper, performance of research, and data analysis. JG: Writing of the paper and data analysis. RB: Writing of the paper and data analysis. LST: Participated in research design, writing of paper, and data analysis. Patient consent Written informed consent was obtained from this patient for publication of the details of their medical case and any accompanying images.