Fatty tumour removal not simple solution

DEAR DR. ROACH: I am an 88-yearold male suffering from a fatty tumour on my gluteus maximus. Two different local gastroenterologists have refused to remove this 2.5-inch-diameter tumour, probably due to my daily blood-thinning medication apixaban. The tumour continues to grow and is becoming an impediment to good health. I am writing to you for a suggestion of how to proceed.

ANSWER: A lipoma is a benign fatty tumour. They are very common. They can occur almost anywhere on the body. The area around your gluteal muscles may seem unusual, but it’s not.

In general, a lipoma should be treated with surgical removal only when there is a good reason to do so.

Pain is one good reason, and another is concern that it may not be just a benign lipoma, but rather a more worrisome tumour.

Growth in the tumour, or a firm rather than typically soft texture, are reasons for concern. Some people have lipomas in cosmetically important areas, and some might also notice constriction of movement due to the lipoma.

The surgery isn’t always as easy as you might think.

In some cases, the expectation of a quick and easy surgery ends up taking far longer and is far more invasive than expected. An anticoagulant like apixaban (Eliquis) could complicate the surgery, and stopping it has associated risks (you’re on an anticoagulant for a reason).

When two surgeons tell you not to operate, you should take their advice seriously.

I’m not sure what you mean by “an impediment to good health,” but I would not rush to ask for surgery unless you have significant symptoms, as the cure is sometimes worse than the disease. Liposuction is a less-invasive option for some people.

DEAR DR. ROACH: I am scheduled for an echocardiogram. It’s set for 3 p.m. Do I need to fast for the day of the test? How about caffeine consumption? Is morning coffee a no-go? Is chocolate milk OK to consume prior to the procedure? What exactly are the dietary guidelines for an echocardiogram?

ANSWER: An echocardiogram uses ultrasound waves to look at the heart. Ultrasound exams of the liver and gallbladder are done while fasting, because food causes the bile ducts to empty, and that makes the examination more difficult. Food does not affect a regular echocardiogram, so you can eat and drink as you’d like.

However, a stress echocardiogram — one where you exercise or are given medicine to speed up the heart — often uses medications that can be affected by caffeine, so drinking coffee and even having chocolate are out for 24 hours due to the possible medication side effects.

It’s usually recommended to fast at least few hours before any exercise stress test simply for comfort.

Exercising to maximal activity is not comfortable and can even be nauseating; doing so on a full stomach is a bad idea.

Of course, asking the physician who ordered the test (or the one performing it) is your best bet for precise information.

DEAR DR. ROACH: I am a 57-year-old woman in excellent health. I practise holistic wellness, which includes eating nutritiously, exercising daily, sleeping seven to eight hours a night and taking minimum alcohol and no drugs.

In May 2019 after a strenuous workout, I developed exercise-induced rhabdomyolysis; my main symptom was swelling of my upper arms. My primary care physician ran my CPK levels, which initially tested at 5,400. I was immediately directed to a nephrologist, and within two weeks I was back to normal.

In March 2021, I again contracted exercise-induced rhabdo. This incident resulted in grossly swollen arms

(Popeye arms) and CPK levels that were 100,000+. After half a day in the ER on an IV, my CPK levels decreased to over 50,000. Over a year later, my CPK levels are normal, but I continue to experience swelling in my arms.

Since the first incident, I have seen two primary care physicians, a nephrologist, two rheumatologists and, most recently, a neuromuscular neurologist. Thankfully all tests came back negative (Lyme, thyroid, rheumatoid arthritis, genetic diseases, etc.) ,however I still experience muscle weakness and slight arm swelling.

Why do I still have these symptoms and what could be at the root of this?

ANSWER: Rhabdomyolysis (from the Greek roots meaning “muscle breakdown”) is an uncommon but dangerous condition.

It typically happens in response to exercise, usually exercise that’s done at a higher intensity or of a longer duration than a person is used to, or performed in hot and humid conditions.

The creatine phosphokinase (CPK or CK) is a reliable blood marker of muscle breakdown. Levels as high as you had put a person at risk for kidney failure, as the kidney struggles to filter all the muscle cell contents from the blood.

A small number of people have rhabdomyolysis due to a genetic condition involving the muscle. You may be at risk for this, based on your recurrent episodes and your persistent symptoms.

If standard testing fails to make the diagnosis, the usual suggested diagnostic test is a muscle biopsy.

For some patients (I have had two), this is the only way to make the correct diagnosis, which is necessary to give the patient personalized recommendations about treatment and whether limitations on exercise will be needed.

The biopsy must be performed by an expert, so the correct stains and reactions are available for the pathologist to make an accurate diagnosis.

Your neuromuscular neurologist is the person to ask to see whether it’s appropriate for you to go this next step.