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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lipoma is a common neoplasm&#44; but it is rare in the mediastinum&#46; An extremely large and symptomatic lipoma in the posterior mediastinum is even more rare&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We here report an unusual case of huge posterior mediastinal lipoma causing dysphagia and palpitation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old woman with an unremarkable medical history presented with intermittent dysphagia&#44; which she reported had been causing a problem for approximately 1 year&#46; The patient described a condition in which the passage of food took longer in the chest region&#44; resulting in discomfort&#46; Over time&#44; the symptoms had worsened&#44; and she had lost approximately 2<span class="elsevierStyleHsp" style=""></span>kg in the previous 6 months&#46; She finally sought medical attention in the outpatient department of our hospital&#46; The initial physical examination findings were normal&#44; except for an unexplained sinus tachycardia &#40;an intermittent heartbeat of approximately 110 beats per minute&#41;&#46; A subsequent esophagogram revealed a normal contour of the esophagus and the transit time was normal&#46; Because the symptoms persisted and there was no sign of spontaneous regression&#44; she underwent examination of the upper gastrointestinal tract by endoscopy&#46; This did not provide any evidence of mucosal lesion&#44; but the gastroenterologist did report an abnormal submucosal elevation in the lower third of the esophagus&#44; approximately 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm proximal to the esophagogastric junction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Chest X-ray revealed a huge ovoid opacity in the right lower lung region adjacent to the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Computed tomographic scan indicated an enormous&#44; low-density neoplasm in the posterior mediastinum&#44; with a slight displacement of the esophagus &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#44; liver and inferior vena cava &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; Heart ultrasound revealed minimal right atrial and ventricular compression&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">She was then surgically treated based on the diagnosis of a symptomatic&#44; fat-containing neoplasm&#46; She underwent thoracoscopic excision of the tumor&#46; The approach was through a two-port thoracoscopic method&#44; including one incision of 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm and another of 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; The 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm incision provided adequate visualization with a rigid endoscope 10&#46;5<span class="elsevierStyleHsp" style=""></span>mm in diameter&#46; The larger incision gave working space for all of the instruments and the removal of the specimen&#46; During thoracoscopic dissection&#44; we found the tumor firmly attached to the pericardium&#44; along with pericardial fat and the phrenic nerve &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#44; and there was some adhesion to the visceral pleura of the lung &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; The tumor size was 20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm&#46; The tumor did not extend into the abdomen and was confined to the intrathoracic location&#46; After complete resection of the lesion&#44; an endo-bag was placed in the pleural space and then the specimen was put into the plastic bag before extraction from the pleural cavity&#46; This method was used to prevent seeding of the tumor cells when the specimen was removed&#46; Although enormous in size&#44; the neoplasm was essentially soft and therefore could be safely extracted in a bag through a 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm port incision&#46; After complete resection&#44; more than 3000<span class="elsevierStyleHsp" style=""></span>ml of distilled water was used to irrigate the pleural space in order to eradicate any tumor cells which might have broken free during the surgical procedure&#46; Any such free tumor cells would swell and then rupture in the distilled water&#46; Three days after surgery&#44; the chest tube was removed and she was discharged the following day&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histological examination showed the tumor to be composed of mature adipocytes&#44; with the capsule intact&#46; There were intervening fibrous bands&#44; indicating this tumor to be a variant of a fibrolipoma&#46; There was no evidence of malignancy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A and B&#41;&#46; Her symptoms of dysphagia and prior unexplained sinus tachycardia improved after the operation&#46; During a follow-up of more than 2 years&#44; the patient has had no recurrence &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">A lipoma may develop in any part of the body&#46; Mediastinal lipoma is rare and usually found in the anterior mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> An enormous lipoma in posterior mediastinum was reported in a 50-year-old man which was found incidentally on a chest radiograph&#44; and he was successfully treated by excision via open thoracotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Such a tumor typically grows very slowly&#44; and the presenting symptoms are often related to a direct compression effect&#46; The symptoms may include dysphagia&#44; retrosternal compression and arrhythmia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In this case&#44; however&#44; a heart ultrasound did not find any significant abnormality&#46; The patient&#39;s tachycardia was resolved after complete resection of the lesion&#46; The most likely explanation for this result would be the direct effect of the tumor mass on the adjacent organs&#44; including the esophagus and heart as well as the inferior vena cava&#46; Liposarcoma is one of the diagnostic challenges in such cases&#44; because it has similar imaging characteristics&#46; When there are trabeculates&#44; intracapsular soft tissue growth&#44; thick septa&#44; the presence of nodular and&#47;or globular non-adipose mass-like areas and a decreased percentage of fat composition&#44; the likelihood of malignancy is high&#46; If the soft tissue involvement is difficult to determine on CT scan alone&#44; magnetic resonance imaging &#40;MRI&#41; is frequently helpful&#46; MRI provides an 83&#37; rate of accuracy in diagnosing well-circumscribed liposarcomas&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although percutaneous needle biopsy is feasible in most cases&#44; there are two reasons not to perform a percutaneous needle biopsy&#46; The first reason is a symptomatic lipogenic tumor for which surgical resection is indicated&#46; The second is when the lesion is very large&#44; since a normal biopsy result might not be sufficient to exclude a sarcomatous lesion&#46; Potential treatment options include liposuction&#44; steroid injection and surgical resection&#46; When malignancy cannot be ruled out&#44; complete resection is required&#46; Complete resection&#44; in such circumstances&#44; may assist in the differential diagnosis as well as cure the disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thoracoscopic resection&#44; in such cases&#44; is generally considered to be a safe approach&#46; When video-assisted thoracoscopic surgery is indicated for the resection of an enormous tumor&#44; there are two important aspects to keep in mind&#46; The first one is the nature of the neoplasm&#46; If direct invasion of any vital organs is strongly suspected&#44; such a procedure may carry additional risks and a change to open thoracotomy may be required&#46; The second is the firmness as well as the size of the neoplasm&#46; When the tumor is very soft&#44; a small incision is sufficient for extraction even if the overall size of the neoplasm is very large&#46; In the case reported here&#44; the tumor was enormous&#44; but also very soft&#46; One 2&#46;5-cm incision was therefore sufficient for extraction&#46; A large incision for the extraction was thus not needed&#46; However&#44; if the tumor is solid as well as large&#44; an extensive thoracotomy incision for extraction is unavoidable&#46; Although lipoma is a benign neoplasm&#44; it may easily recur in the surgically treated location if there is a residual lesion&#46; Long-term follow-up is therefore mandatory in all cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p></span></span>"
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Case report
A rare case of dysphagia and palpitation caused by the compression exerted by an enormous mediastinal lipoma
Um caso raro de disfagia e palpitaçãoes causadas pela compressão exercida por um lipoma mediastínico de grandes dimensões
C.-H. Chena,b,d, H. Changb, P.-Y. Tsengb, T.-T. Hunga,d, H.-H. Wuc,
Corresponding author
musclenet2003@yahoo.com.tw

Corresponding author.
a Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
b Graduate Institute of Mechanical and Electrical Engineering, National Taipei University of Technology, Taipei City, Taiwan
c Division of Chest Medicine, Department of Internal Medicine, Taitung Branch of Mackay Memorial Hospital, Taitung County, Taiwan
d Mackay Medicine, Nursing and Management College, Taipei City, Taiwan
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lipoma is a common neoplasm&#44; but it is rare in the mediastinum&#46; An extremely large and symptomatic lipoma in the posterior mediastinum is even more rare&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We here report an unusual case of huge posterior mediastinal lipoma causing dysphagia and palpitation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old woman with an unremarkable medical history presented with intermittent dysphagia&#44; which she reported had been causing a problem for approximately 1 year&#46; The patient described a condition in which the passage of food took longer in the chest region&#44; resulting in discomfort&#46; Over time&#44; the symptoms had worsened&#44; and she had lost approximately 2<span class="elsevierStyleHsp" style=""></span>kg in the previous 6 months&#46; She finally sought medical attention in the outpatient department of our hospital&#46; The initial physical examination findings were normal&#44; except for an unexplained sinus tachycardia &#40;an intermittent heartbeat of approximately 110 beats per minute&#41;&#46; A subsequent esophagogram revealed a normal contour of the esophagus and the transit time was normal&#46; Because the symptoms persisted and there was no sign of spontaneous regression&#44; she underwent examination of the upper gastrointestinal tract by endoscopy&#46; This did not provide any evidence of mucosal lesion&#44; but the gastroenterologist did report an abnormal submucosal elevation in the lower third of the esophagus&#44; approximately 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm proximal to the esophagogastric junction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Chest X-ray revealed a huge ovoid opacity in the right lower lung region adjacent to the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Computed tomographic scan indicated an enormous&#44; low-density neoplasm in the posterior mediastinum&#44; with a slight displacement of the esophagus &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#44; liver and inferior vena cava &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; Heart ultrasound revealed minimal right atrial and ventricular compression&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">She was then surgically treated based on the diagnosis of a symptomatic&#44; fat-containing neoplasm&#46; She underwent thoracoscopic excision of the tumor&#46; The approach was through a two-port thoracoscopic method&#44; including one incision of 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm and another of 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; The 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm incision provided adequate visualization with a rigid endoscope 10&#46;5<span class="elsevierStyleHsp" style=""></span>mm in diameter&#46; The larger incision gave working space for all of the instruments and the removal of the specimen&#46; During thoracoscopic dissection&#44; we found the tumor firmly attached to the pericardium&#44; along with pericardial fat and the phrenic nerve &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#44; and there was some adhesion to the visceral pleura of the lung &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; The tumor size was 20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm&#46; The tumor did not extend into the abdomen and was confined to the intrathoracic location&#46; After complete resection of the lesion&#44; an endo-bag was placed in the pleural space and then the specimen was put into the plastic bag before extraction from the pleural cavity&#46; This method was used to prevent seeding of the tumor cells when the specimen was removed&#46; Although enormous in size&#44; the neoplasm was essentially soft and therefore could be safely extracted in a bag through a 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm port incision&#46; After complete resection&#44; more than 3000<span class="elsevierStyleHsp" style=""></span>ml of distilled water was used to irrigate the pleural space in order to eradicate any tumor cells which might have broken free during the surgical procedure&#46; Any such free tumor cells would swell and then rupture in the distilled water&#46; Three days after surgery&#44; the chest tube was removed and she was discharged the following day&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histological examination showed the tumor to be composed of mature adipocytes&#44; with the capsule intact&#46; There were intervening fibrous bands&#44; indicating this tumor to be a variant of a fibrolipoma&#46; There was no evidence of malignancy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A and B&#41;&#46; Her symptoms of dysphagia and prior unexplained sinus tachycardia improved after the operation&#46; During a follow-up of more than 2 years&#44; the patient has had no recurrence &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">A lipoma may develop in any part of the body&#46; Mediastinal lipoma is rare and usually found in the anterior mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> An enormous lipoma in posterior mediastinum was reported in a 50-year-old man which was found incidentally on a chest radiograph&#44; and he was successfully treated by excision via open thoracotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Such a tumor typically grows very slowly&#44; and the presenting symptoms are often related to a direct compression effect&#46; The symptoms may include dysphagia&#44; retrosternal compression and arrhythmia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In this case&#44; however&#44; a heart ultrasound did not find any significant abnormality&#46; The patient&#39;s tachycardia was resolved after complete resection of the lesion&#46; The most likely explanation for this result would be the direct effect of the tumor mass on the adjacent organs&#44; including the esophagus and heart as well as the inferior vena cava&#46; Liposarcoma is one of the diagnostic challenges in such cases&#44; because it has similar imaging characteristics&#46; When there are trabeculates&#44; intracapsular soft tissue growth&#44; thick septa&#44; the presence of nodular and&#47;or globular non-adipose mass-like areas and a decreased percentage of fat composition&#44; the likelihood of malignancy is high&#46; If the soft tissue involvement is difficult to determine on CT scan alone&#44; magnetic resonance imaging &#40;MRI&#41; is frequently helpful&#46; MRI provides an 83&#37; rate of accuracy in diagnosing well-circumscribed liposarcomas&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although percutaneous needle biopsy is feasible in most cases&#44; there are two reasons not to perform a percutaneous needle biopsy&#46; The first reason is a symptomatic lipogenic tumor for which surgical resection is indicated&#46; The second is when the lesion is very large&#44; since a normal biopsy result might not be sufficient to exclude a sarcomatous lesion&#46; Potential treatment options include liposuction&#44; steroid injection and surgical resection&#46; When malignancy cannot be ruled out&#44; complete resection is required&#46; Complete resection&#44; in such circumstances&#44; may assist in the differential diagnosis as well as cure the disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thoracoscopic resection&#44; in such cases&#44; is generally considered to be a safe approach&#46; When video-assisted thoracoscopic surgery is indicated for the resection of an enormous tumor&#44; there are two important aspects to keep in mind&#46; The first one is the nature of the neoplasm&#46; If direct invasion of any vital organs is strongly suspected&#44; such a procedure may carry additional risks and a change to open thoracotomy may be required&#46; The second is the firmness as well as the size of the neoplasm&#46; When the tumor is very soft&#44; a small incision is sufficient for extraction even if the overall size of the neoplasm is very large&#46; In the case reported here&#44; the tumor was enormous&#44; but also very soft&#46; One 2&#46;5-cm incision was therefore sufficient for extraction&#46; A large incision for the extraction was thus not needed&#46; However&#44; if the tumor is solid as well as large&#44; an extensive thoracotomy incision for extraction is unavoidable&#46; Although lipoma is a benign neoplasm&#44; it may easily recur in the surgically treated location if there is a residual lesion&#46; Long-term follow-up is therefore mandatory in all cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p></span></span>"
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        "resumen" => "<span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 65-year-old woman presented with mild dysphagia&#44; weight loss and intermittent palpitation&#46; Chest radiograph revealed a large opacity in the right lower lung field&#46; Subsequent CT scan showed a large posterior mediastinal lipoma extending from the level of the aortic arch to the thoracoabdominal junction&#46; After thoracoscopic resection&#44; the patient&#39;s dysphagia and palpitation were resolved&#46; After a follow-up of 2 years&#44; the patient has had no evidence of recurrence&#46;</p></span>"
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        "resumen" => "<span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher com 65 anos apresentou-se com disfagia ligeira&#44; perda de peso e palpita&#231;&#245;es intermitentes&#46; A radiografia do t&#243;rax revelou uma grande opacidade no campo inferior do pulm&#227;o direito&#46; A tomografia computorizada mostrou um lipoma mediast&#237;nico de localiza&#231;&#227;o posterior estendendo-se desde o n&#237;vel do arco a&#243;rtico &#224; jun&#231;&#227;o t&#243;raco-abdominal&#46; Ap&#243;s ressec&#231;&#227;o toracosc&#243;pica&#44; a disfagia e as palpita&#231;&#245;es da doente foram solucionadas&#46; Ap&#243;s um acompanhamento de 2 anos&#44; a doente n&#227;o teve qualquer evid&#234;ncia de recorr&#234;ncia&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Upper gastrointestinal endoscopy revealed abnormal submucosal elevation in the lower esophagus which was approximately 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm above the esophagogastric junction&#46; There was no superficial mucosal lesion&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph showed one very large ovoid and well-demarcated opacity in right lower lung field&#46; The silhouette sign is negative because the tumor margin can be differentiated from both the right heart border and diaphragm dome&#44; indicating that the location of tumor is in the posterior mediastinum&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Computed tomographic scans revealed a partial atelectasis of the lung&#44; along with mild displacement of the inferior vena cava and esophagus &#40;A&#41;&#46; The fatty neoplasm extends to the thoracoabdominal junction &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The lesion &#40;white arrow&#41; was found to adhere to the pericardium along with some pericardial fat &#40;green arrow&#41;&#46; With careful dissection&#44; the fatty lesion was separated from the pericardium &#40;A&#41;&#46; There were adhesions between the lung and the tumor &#40;green arrow&#41; &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin&#8211;eosin staining of the specimen revealed a well-circumscribed lipoma with an intact fibrotic capsule containing mature adipocytes &#40;A&#44; 20&#215;&#41;&#46; The mature adipocytes varied slightly in size and shape and had small eccentric nuclei &#40;B&#44; 200&#215;&#41;&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Follow-up chest radiograph 22 months after surgery revealed no evidence of recurrence&#46;</p>"
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                            2 => "G&#46;C&#46; Liu"
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Article information
ISSN: 08732159
Original language: English
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