From the Guidelines
Surgical excision is the most appropriate treatment for flank lipomas, especially if they are symptomatic or cause cosmetic concerns, as it offers the lowest recurrence rate and is supported by the most recent guidelines 1. When considering treatment for flank lipomas, it's essential to first confirm the diagnosis with imaging studies like MRI to rule out other conditions such as lipomatous tumors or soft tissue sarcomas 1. Key considerations for treatment include:
- Size and location of the lipoma
- Presence of symptoms such as pain or cosmetic concerns
- Patient preference Treatment options for flank lipomas include:
- Surgical excision: complete removal of the lipoma under local or general anesthesia, depending on the size of the lesion
- Liposuction: may be used for larger lipomas, but carries a higher risk of recurrence
- Steroid injections: can shrink smaller lipomas, but may need to be repeated every 3-4 weeks According to the UK guidelines for the management of soft tissue sarcomas, surgical resection is the usual treatment for atypical lipomatous tumors (ALT), which can be similar to lipomas in presentation 1. The guidelines also emphasize the importance of molecular diagnosis, such as fluorescence in-situ hybridization, to differentiate between lipomas and ALT/well-differentiated liposarcoma 1. In terms of surgical approach, the guidelines recommend marginal resections as a complete en bloc specimen, even if classified histopathologically as R1, to achieve excellent rates of long-term local control 1. Additionally, adjuvant radiotherapy may be considered in certain cases, such as larger tumors or those where clear margins are difficult to achieve 1. It's also important to note that patients who have undergone inadvertent surgery without a preoperative diagnosis of sarcoma resulting in unplanned positive margins should be fully staged and undergo an MRI of the surgical bed to look for gross residual disease 1. Overall, surgical excision is the most definitive treatment for flank lipomas, offering the lowest recurrence rate and the best chance of cure, especially when supported by recent guidelines and molecular diagnosis 1.
From the Research
Treatment Options for Flank Lipoma
- Liposuction is an excellent alternative to excisional surgery for lipomas that are 4 cm or more in size or are multiple, as it offers decreased surgical time, a shorter scar, a better final contour, and the ability to remove several lipomas through one opening 2.
- Surgical excision is the treatment of choice for lipomas, and techniques such as the Z-incision design can provide a larger surgical field area and are useful for removing large lipomas 3.
- Minimal-scar segmental extraction (MSE) is a technique that employs a small incision and extraction, and is particularly useful in exposed parts of the body, with a low recurrence rate and minimal complications 4.
Preoperative Evaluation
- Current guidelines recommend core needle biopsy (CNB) for all lipomatous masses larger than 3-5 cm, but a study suggests that lipomatous masses smaller than 5 cm without concerning clinical characteristics do not require preoperative imaging or CNB 5.
- Radiographic features such as intramuscular location, septations, nonfat nodules, heterogeneity, and ill-defined margins can guide the need for CNB, and masses larger than 5 cm should undergo routine MRI with subsequent CNB if multiple high-risk radiographic features are present 5.
Complications and Outcomes
- Liposuction carries the risk of major and minor complications, including infection, abdominal wall injury, bowel herniation, bleeding, hematoma, seroma, and lymphoedema, as well as life-threatening complications such as necrotizing fasciitis, deep vein thrombosis, and pulmonary embolism 6.
- The incidence of complications for MSE is low, with a reported rate of 1.6%, and the recurrence rate is 0.8%, making it a cost-effective operation with high patient acceptance 4.