Liposarcoma is a rare type of cancer that is found within fat cells in deep soft tissues such as those in the thighs or retroperitoneum. Therefore, it is one of the most common types of soft tissue sarcomas in adults. Although surgery is the preferred method of treatment, liposarcoma is very well known for its risk of recurrence, which can occur any time after the primary treatment.  Due to its potential for local recurrence, as well as the spread and growth of cancer cells in distant organs (i.e. distant metastasis),  long-term follow-up is critical. Monitoring strategies have to be carefully tailored based on the subtypes, tumour grade, as well as the treatment method employed.

The long-term care of liposarcoma patients is reliant on the early detection of recurrence cases, as well as management of the late effects of treatment. As a result, patients can seek psychological support while making the necessary lifestyle modifications. This article highlights the best strategies for long-term follow-up based on current evidence and clinical guides to understand the path forward following treatment.

Understanding liposarcoma subtypes and their implications

Liposarcomas are categorised into several subtypes with different prognoses (i.e. the likely course of the disease) and treatment approaches:

• Well-differentiated liposarcoma: a slow growing form that rarely spreads to other parts of the body. However,  due to this, it is more likely to return in the same area, especially at the abdomen region
• Dedifferentiated liposarcoma: may develop from a well-differentiated tumour, thus it is much more aggressive and highly likely to return and spread
• Myxoid/round cell liposarcoma: intermediate behaviour with increased sensitivity to radiotherapy
• Pleomorphic liposarcoma: rare and aggressive with a high risk of spreading

The likelihood of liposarcoma returning and where it will reoccur depends on the subtype, as well as the location from which it first emerged.¹ 

Therefore,  the initial surgery is crucial, as it provides an estimate of how much the chance of recurrence is reduced by.

Goals of long-term follow-up

While some cancers have clear-cut timelines for remission, liposarcoma is much more unique in its ability for recurrence to occur much later compared to other cancers.¹ Some long-term studies have been able to identify that recurrence can occur as late as five to ten years post-treatment, especially in more deep-rooted subtypes.³

The main objectives of follow-up care include:

• Early detection of recurrence: local recurrence is very common
• Detection of late metastasis: certain subtypes like pleomorphic and myxoid liposarcomas have a proneness for late distant metastasis
• Monitoring treatment-related side effects: particularly relevant in patients who underwent radiation or extensive surgery
• Psychosocial and functional support: addressing long-term impacts on quality of life, mobility and mental health

Recommended surveillance schedule

While there is no set protocol for the follow up treatment of all sarcomas, there is a general idea of the structured timelines based on recurrence and subtypes. Some general frameworks have been adapted for different recommendations.^4,5

General guidelines:

• Years 1-2: imaging (MRI or CT depending on location) every 3-4 months
• Years 3-5: imaging every 6 months to check for recurrence
• After year 5: yearly imaging if recurrence-free

High-risk patients:

Patients with high grade tumours, located in the retroperitoneal area and with positive surgical margins may require more frequent imaging and clinical assessment.

Imaging role in follow up

For long-term surveillance to be successful, the use of imaging is essential. CT scans are the most commonly used for retroperitoneal tumours as they are deep and are much more likely to go unnoticed. On the other hand, MRI is preferred for liposarcomas found in the extremities, which includes any part of the body that sticks out, such as your limbs. This is because it offers a better resolution (i.e. the ability to distinguish between the various different tissues that are in close proximity to each other) in the soft tissue planes.⁶

• MRI: preferred for extremity tumours due to soft tissue contrast
• CT scans: useful for retroperitoneal liposarcoma and detecting lung metastases
• Chest X-rays or CT chest: often included to assess for pulmonary metastases

Role of the multidisciplinary team

Long term care should be designed by a multidisciplinary team including oncologists, surgeons, radiologists, pathologists as well as psychosocial support staff.  Follow-up appointments can address multiple domains:

• Medical: assessing symptoms and reviewing imaging
• Functional: evaluating mobility and rehabilitation needs
• Psychosocial: Addressing fear of recurrence, employment concerns as well as mental health

Recurrence risk and patterns

The risk of recurrence depends on the subtypes and location:

• Well-differentiated liposarcoma: High risk of local recurrence but low metastatic potential
• Dedifferentiated liposarcoma and pleomorphic: higher risk of both local and distant recurrence

Most recurrences occur within 5 years post-treatment, but late recurrence can happen beyond 10 years, making it essential to keep up with long-term vigilance.

Strategies to reduce the recurrence risk

While we cannot always accurately predict if or when liposarcoma could return, we can take the steps needed to lower the risk:

• Surgical removal: the most effective and straightforward resolution is to remove the tumour completely with no cancer cells left behind
• Radiation therapy: typically used before or following a surgery of a high-grade tumour, ensuring the prevention of cancer coming back to the same area
• Chemotherapy: not as well understood in its benefits, but is still capable of reducing the risk of spreading or recurring in the more aggressive subtypes⁷

Survivorships care and quality of life

Follow-up care cannot only  consist of medical practices such as regular scans, but must additionally  include sufficient support for the long-term wellbeing of the individuals:

• Nutritional counselling: important for the patients experiencing sudden weight changes or suffering from nutritional deficiencies either during or after treatment
• Physical therapy: to allow for the strength, and mobility to improve so complete recovery can be made following a surgical procedure
• Mental health support: many patients experience emotional challenges including and not limited to anxiety, depression or even post-traumatic stress. These patients would benefit from being able to access counselling or therapy
• Support groups and survivorships clinic: it can provide invaluable emotional support as well as a sense of community amongst patients who are all experiencing the same adjustment to life following treatment

Lifestyle and secondary prevention

• Staying active: regular and fulfilling exercise is essential to boost energy levels, overall improving and aiding physical recovery
• Avoiding smoking and limiting alcohol intake: such good habits are crucial in reducing the risk of cancer returning and prevents any other health issues from arising
• Balanced diet:  balanced meals ensure the immune system is supported in its normal function and therefore improves overall health
• Monitoring for secondary cancer: it is crucial that those who have undergone radiation therapy are receiving constant monitoring to detect any increased risk of developing new cancers over time

The importance of patient education

By providing patients with knowledge about their diseases, as well as the signs of recurrence allows them to know when to seek help.  Carefully written care plans and open communication channels grants adherence to follow up care that improves and overall reduces anxiety.

Summary

Long term follow up treatment for those who have had liposarcoma is essential due to the risk of recurrence, late metastasis and overall treatment-related side effects. A tailored surveillance strategy involves regular imaging, clinical evaluation and supportive care to improve quality of life. An integrated and coordinated response by a multidisciplinary team along with patient-centred education also make up vital components of a fulfilling and effective follow up care.