Lipomas, Pathology

Article Author:
Ahmad Charifa
Article Editor:
Talel Badri
Updated:
10/27/2018 12:31:41 PM
PubMed Link:
Lipomas, Pathology

Introduction

Lipomas are defined as soft masses of adipose (fat) cells which are often encapsulated by a thin layer of fibrous tissue. Clinically, they often present in the cephalic part of the body, specifically in the head, neck, shoulders, and backs of patients, although they can less commonly be seen elsewhere, for example, the thighs. The tumors typically lie in the subcutaneous tissues of patients. The masses are often benign, and while the age of onset can vary, they most often develop between the age of 40 and 60. There is usually no reason for treatment, as they pose no threat to the patient, unless they are uncomfortable, due to being located on joints or if they are rapidly growing, which is uncommon, as the typical lipoma growth is slow.

Lipomas can sometimes, though rare, be associated with certain disorders such as multiple hereditary lipomatosis, Gardner syndrome, adiposis dolorosa, and Madelung disease. Some unconventional forms of lipomas include the following: angiolipoma, chondroid lipoma, lipoblastoma, myolipoma, pleomorphic lipoma/spindle cell lipoma, intramuscular and intermuscular lipoma, lipomatosis of nerve, lipoma of tendon sheath and joint, lipoma arborescens, multiple symmetric lipomatosis, diffuse lipomatosis, adiposis dolorosa, and hibernoma.

Issues of Concern

It is important to distinguish common lipomas from liposarcoma, They share similar characteristics, although the latter poses a greater risk to the patient. As mentioned earlier, while treatment is not always necessary, if it is decided that a patient should seek treatment, then the options are typically steroid injections or excision of the tumor.

Causes

While the etiology of lipomas is unclear, some studies have shown a genetic link, whereby, about two-thirds of lipomas demonstrate genetic abnormalities.

In addition to the possibility of a genetic link, another theory presents the idea that there is a direct positive correlation between trauma to an area and lipoma production. Research shows a link between adipose tumor growth as a post-traumatic event following a direct impact on that area of soft tissue. In addition to the risk factors listed above, other possible connections that may lead to lipomas are obesity, alcohol abuse, liver disease, as well as, glucose intolerance.

Anatomical Pathology

Lipomas are defined as mesenchymal tumors which typically lie subcutaneously. Less commonly, they can also be found on internal organs, such as stomach and bowels. These masses are not typically attached to underlying muscle fascia. Lipomas are composed of lobulated, slow-growing, mature adipose tissue, having a minimal connective tissue stroma. They are commonly enclosed in a thin, fibrous capsule.

Clinical Pathology

Patients often complain of a soft, mobile mass of tissue they can feel under the skin. These are typically painless unless they encroach joints, nerves, or blood vessels. Patients often see these in the upper part of the body. Rarely, these lipomas can form in muscles or organs.

Lipomas are mostly harmless and are only treated or excised if they cause pain due to their location and/or if they are impacting an organ’s function. However, some patients choose to have these masses removed for cosmetic reasons, as they can often be seen through the skin as they lie subcutaneously.

Biochemical and Genetic Pathology

A genetic link has been demonstrated that cites that about two-thirds of lipomas exhibit genetic abnormalities. In a subgroup of lipomas, the HMGA2 gene (located on 12q14.3) was involved in tumor pathogenesis.

The following structural rearrangements of chromosomes have been associated with lipoma occurrence:

  • 12q13-15 region (65%)
  • 13q portion loss(10%)
  • 6p21-23 region (5%)
  • Other loci anomalies or normal karyotype (15-20)

Morphology

Lipomas are composed of adipose/fat tissue, are mobile, soft to the touch, typically painless and present subcutaneously. These are surrounded by a thin, fibrous capsule that is not attached to the underlying muscle fascia. These masses are typically less than 2 inches wide but may be larger. They are commonly singular. However, some patients have more than one. They typically occur in the upper trunk, head, neck, shoulders, and back of patients.

Mechanisms

A possible mechanism of action of lipoma development is post-trauma to the respective area. It has also been theorized that this is true only for traumas that result in necrosis of adipose/fat cells and subsequent local inflammation, and that these are what are responsible for triggering the lipoma formation.

Clinicopathologic Correlations

Fletcher et al. (1996) cited that there exists a clinicopathological correlation between the cytogenetic aberrations and the morphological subtypes of lipoma tumors. They concluded that such a correlation could serve as a significant diagnostic tool in difficult or histologically borderline cases.

Intradural lipomas of the spinal cord have also been shown to reflect a clinicopathological significance, whereby, they occur most frequently in men between the ages of 20 to 40 years and are observed in the thoracic region of the spine, specifically at the cord. Symptoms, as described by respective patients, included pain, sensory changes, paraparesis, and urinary incontinence.

Clinical Significance

While the age of onset for a lipoma varies, it is typically first seen in patients between the ages of 40 to 60, and no gender bias has been documented. Certain types of lipomas are more frequently seen in other age groups, for example, such as hibernomas clinically present around the age of 30, lipoblastomas and diffuse lipomatosis are commonly found in children older than the age of 3. Approximately 5% of patients present with multiple lipomas.

The prevalence of lipomas has been cited as affecting 1% of the population, while its incidence, which is possibly underreported, is 2.1 per 1000 individuals per year.

Positive diagnosis of a lipoma typically involve the following: 

  • Physical exam performed by a medical doctor
  • An ultrasound of the mass should show that the lipoma or adipose mass is deeper than the surrounding fatty tissue, as well as, exhibiting dissimilar features as compared to the healthy/normal adipose tissue present
  • A biopsy (and subsequent analysis of a tissue sample) is not systematically done in routine practice as the diagnosis is generally made clinically, and since it may be difficult to distinguish lipomas from healthy adipose tissue, histologically speaking

Surveillance

If lipomas are not painful and harmless, there is no need for removal. 

Treatment

The techniques used for such include, intralesional transcutaneous sodium deoxycholate (associated or not to phosphatidylcholine) injections, intralesional steroids combined with isoproterenol (a beta-2 adrenergic agonist) injections, liposuction of the tumor, or surgical excision. This latter is likely the most effective method to prevent them from reoccurring, though the encapsulation must also be removed for the most effective treatment and to decrease the risk of reoccurrence. If the decision is made to excise lipomas, then it should be done while the lesions are smaller rather than after they grow larger to reduce the risk of these encroaching on joints, nerves, and blood vessels, thus making the excision more difficult and invasive.

Prognosis

The prognosis for benign lipomas is very good. Once these tumors are excised, mainly for cosmetic reasons, they often do not return. However, is imperative that the fibrous capsule surrounding the lipoma is entirely removed to prevent such from happening.