Well differentiated liposarcoma

This article will help you read and understand your pathology report for well differentiated liposarcoma.

by Bibianna Purgina MD FRCPC, updated on December 1, 2020

Quick facts:

• Well differentiated liposarcoma is a type of cancer called a sarcoma.
• The tumour is made up of abnormal looking fat cells.
• It can start anywhere in the body but the most common location is the abdomen.
• This tumour affects adults and rarely happens in children.

Normal fat

The human body is made up of many different types of tissue. Fat is a specialized type of tissue that is found throughout the body. It is made up of large cells called adipocytes that look clear when viewed through a microscope. Fat acts as a storage site for energy and provides warmth for our internal organs.

What is well differentiated liposarcoma?

Well differentiated liposarcoma is a cancer made up of fat. It is part of a group of cancers called sarcomas. Sarcomas are cancers that develop from mesenchymal tissues which include nerves, fat, muscle, blood vessels, tendons, ligaments, bone and cartilage. Well differentiated liposarcoma can start anywhere in the body but the most common location for this tumour is the abdomen.

Dedifferentiation

Some well differentiated liposarcomas will change over time so that some of the cells no longer look like normal fat. This process is called dedifferentiation and these cancers are then called dedifferentiated liposarcoma.

When compared to well differentiated liposarcoma, dedifferentiated liposarcoma is associated with worse prognosis because it is more likely to grow back after surgery and spread to other parts of the body. The movement of cancer cells to another part of the body is called metastasis.

How do pathologists make this diagnosis?

The diagnosis of a well differentiated liposarcoma is usually after a small sample of the tumour is removed in a procedure called a biopsy. The biopsy tissue is then sent to a pathologist who examines it under a microscope. Additional tests such as fluorescence in situ hybridization (FISH) may also be performed to confirm the diagnosis (see Genetic tests below).

When examined under the microscope, well differentiated liposarcoma can look like normal fat. However, unlike normal fat, well differentiated liposarcoma contains abnormal-looking cells fat cells, known as lipoblasts.

Grade

Grade is a word pathologists use to describe how different the cancer cells look and behave compared to normal fat cells. The grade can only be determined after a sample of tumour has been examined under the microscope.

Well differentiated liposarcoma is given a grade based on an internationally recognized system created by the French Federation of Cancer Centers Sarcoma Group (FNCLCC).  Your pathologist will determine the French Federation of Cancer Centers Sarcoma Group grade of the tumour by looking for three microscopic features:

1. Tumour differentiation – Tumour differentiation describes how closely the cancer cells look like normal fat cells. Tumours that look very similar to normal fat cells are given are given 1 point while those that look very different from normal fat cells are given 2 or 3 points.
2. Mitotic count – A cell that is in the process of dividing to create two new cells is called a mitotic figure. Tumours that are growing fast tend to have more mitotic figures than tumours that are growing slowly. Your pathologist will determine the mitotic count by counting the number of mitotic figures in ten areas of the tumour while looking through the microscope. Tumours with no mitotic figure or very few mitotic figures are given 1 point while those with 10 to 20 mitotic figures are given 2 points and those with more than 20 mitotic figures are given 3 points.
3. Necrosis – Necrosis is a type of cell death. Tumours that are growing fast tend to have more necrosis than tumours that are growing slowly. If your pathologist sees no necrosis, the tumour will be given 0 points. The tumour will be given 1 point if necrosis is seen but it makes up less than 50% of the tumour or 2 points if necrosis makes more than 50% of the tumour.

Your pathologist will give each feature a certain number of points (from 0 to 3) and the total number of points determines the final grade of the tumour.

• Grade 1 – 2 or 3 points.
• Grade 2 – 4 or 5 points.
• Grade 3 – 6 to 8 points.

According to this system, well differentiated liposarcomas may be either low or high grade tumours. High grade tumors (grades 2 and 3) are associated with worse prognosis.

MDM2

Each cell in your body contains a set of instructions that tell the cell how to behave. These instructions are written in a language called DNA and the instructions are stored on 46 chromosomes in each cell. Because the instructions are very long, they are broken up into sections called genes and each gene tells the cell how to produce piece of the machine called a protein.

MDM2 is a gene that promotes cell division (the creation of new cells). Normal cells and those in non-cancerous tumours have two copies of the MDM2 gene. In contrast, well differentiated liposarcomas have more than two copies of the MDM2 gene.

A test called florescence in situ hybridization (FISH) is commonly used to count the number of MDM2 genes in a cell. An increased number of genes (more than two) is called amplification and supports the diagnosis of well differentiated liposarcoma.

What to look for in your report after the tumour has been removed

Tumour size

The tumour is measured in three dimensions but only the largest dimension is typically included in your report. For example, if the tumour measures 5.0 cm by 3.2 cm by 1.1 cm, the report may describe the tumour size as 5.0 cm in greatest dimension. Tumour size is important because tumours less than 5 cm are less likely to spread to other parts of the body and are associated with better prognosis.

Perineural invasion​

Nerves are like long wires made up of groups of cells called neurons. Nerves send information (such as temperature, pressure, and pain) between your brain and your body. Perineural invasion means that cancer cells were seen attached to a nerve.

Cancer cells that have attached to a nerve can use the nerve to travel into tissue outside of the original tumour. This increases the risk that the tumour will come back in the same area of the body (recurrence) after treatment.

Lymphovascular invasion

Blood moves around the body through long thin tubes called blood vessels. Another type of fluid called lymph which contains waste and immune cells moves around the body through lymphatic channels.

Cancer cells can use blood vessels and lymphatics to travel away from the tumour to other parts of the body. The movement of cancer cells from the tumour to another part of the body is called metastasis. Before cancer cells can metastasize, they need to enter a blood vessel or lymphatic. This is called lymphovascular invasion.

Lymphovascular invasion is important because it increases the risk that cancer cells will be found in a lymph node or a distant part of the body such as the lungs.

Margins

A margin is any tissue that was cut by the surgeon to remove the tumour from your body.  Depending on the type of surgery you have had, the margins can include bones, muscles, blood vessels, and nerves that were cut to remove the tumour from your body. Margins will only be described in your report after the entire tumour has been removed.

A margin is called positive when there are tumour cells at the very edge of the cut tissue. A positive margin is associated with a higher risk that the tumour will recur in the same site after treatment. A negative margin means that no tumour cells were seen at any of the cut edges of tissue.

Treatment effect

​If you received treatment (either chemotherapy or radiation therapy) for your cancer prior to the tumour being removed, your pathologist will examine all of the tissue submitted to see how much of the tumour is still alive (viable).

Lymph nodes​

Lymph nodes are small immune organs located throughout the body. Cancer cells can travel from the tumour to a lymph node through lymphatic channels located in and around the tumour (see Lymphovascular invasion above). The movement of cancer cells from the tumour to a lymph node is called a metastasis.

Many cancers can spread to the lymph nodes, but well differentiated liposarcoma does this very rarely. If lymph nodes were part of the surgery to remove your tumour, your pathologist will assess them under the microscope and report whether they are involved by tumour.

Pathologic stage

​The pathologic stage for well differentiated liposarcoma is based on the TNM staging system, an internationally recognized system originally created by the American Joint Committee on Cancer.

This system uses information about the primary tumour (T), lymph nodes (N), and distant metastatic disease (M)  to determine the complete pathologic stage (pTNM). Your pathologist will examine the tissue submitted and give each part a number. In general, a higher number means more advanced disease and worse prognosis.

Tumour stage (pT) for well differentiated liposarcoma

The tumour stage for well differentiated liposarcoma varies based on the body part involved. For example, a 5 centimeter tumour that starts in the neck will be given a different tumour stage than a tumour that starts deep in the back of the abdomen (the retroperitoneum). However, in most body sites, the tumour stage includes the tumour size and whether the tumour has grown into surrounding body parts.

Head and neck

• T1 – The tumour is no greater than 2 centimeters in size.
• T2 – The tumour is between 2 and 4 centimeters in size.
• T3 – The tumour is greater than 4 centimeters in size.
• T4 – The tumour has grown into surrounding tissues such as the bones of the face or skull, the eye, the larger blood vessels in the neck, or the brain.

Chest, back, or stomach and the arms or legs (trunk and extremities)

• T1 – The tumour is no greater than 5 centimeters in size.
• T2 – The tumour is between 5 and 10 centimeters in size.
• T3 – The tumour is between 10 and 15 centimeters in size.
• T4 – The tumour is greater than 15 centimeters in size.

Abdomen and organs inside the chest (thoracic visceral organs)

• T1 – The tumour is only seen in one organ.
• T2 – The tumour has grown into the connective tissue that surrounds the organ from which is started.
• T3 – The tumour has grown into at least one other organ.
• T4 – Multiple tumours are found.

Retroperitoneum (the space at the very back of the abdominal cavity)

• T1 – The tumour is no greater than 5 centimeters in size.
• T2 – The tumour is between 5 and 10 centimeters in size.
• T3 – The tumour is between 10 and 15 centimeters in size.
• T4 – The tumour is greater than 15 centimeters in size.

Tissue around the eye (orbit)

• T1 – The tumour is no greater than 2 centimeters in size.
• T2 – The tumour is greater than 2 centimeters in size but has not grown into the bones surrounding the eye.
• T3 – The tumour has grown into the bones surrounding the eye or other bones of the skull.
• T4 – The tumour has grown into the eye (the globe) or the surrounding tissues such as the eyelids, sinuses, or brain.

Nodal stage (pN) for well differentiated liposarcoma

Well differentiated liposarcoma is given a nodal stage of 0 or 1 based on the presence of cancer cells in a lymph node. If no cancer cells are seen in any of the lymph nodes examined, the nodal stage is N0. If cancer cells are seen in any of the lymph nodes examined, the nodal stage becomes N1.

Metastatic stage (pM) for well differentiated liposarcoma 

Well differentiated liposarcoma is given a metastatic stage of 0 or 1 based on the presence of cancer cells at a distant site in the body (for example the lungs). The metastatic stage can only be assigned if tissue from a distant site is submitted for pathological examination. Because this tissue is rarely present, the metastatic stage cannot be determined and is listed as MX.