63 year old female presented with thigh swelling. incision biopsy was done.microscopic pictures attached.



Good afternoon, Curofians. Many thanks to revered Dr. Sumalatha Kasturi madam for posting this interesting case. Microscopic findings : Hematoxylin & eosin stained sections reveal fragments of neoplastic tissue arranged in nondescript sheets and vague storiform formations, characterized by pleomorphic and bizzare cells with abundant foamy cytoplasm, large hyperchromatic nuclei and prominent nucleoli in the background of chronically inflamed collagenous stroma. Few fibroblasts and histiocyte like cells including rare multinucleated forms are also seen. Increased mitotic activity (17-20/Hpf) with atypical mitotic figures appreciated. Elsewhere, there are some strap-like cells. There is evidence of focal necrosis and foci of interstitial hemorrhage. Impresion : HIGH GRADE PLEOMORPHIC SOFT TISSUE TUMOR, PROBABLY NON- LIPOGENIC, suggestive of UNDIFFERENTIATED PLEOMORPHIC SARCOMA, [PLEOMORPHIC MALIGNANT FIBROUS HISTIOCYTOMA] FNCLCC GRADE III. HOWEVER, THE POSSIBILITY OF PLEOMORPHIC RHABDMYOSARCOMA CANNOT BE RULED OUT ON HISTOLOGY ALONE. Suggestions : Advised Immuno-phenotyping with Vimentin, CD68, Desmin, Myogenin, and MyoD1,S100 for further evaluation. How the grading was done as FNCLCC GRADE III. Grading system - French Federation of Cancer Centers Sarcoma Group. Grade 1:Total score of 2-3 points. Grade 2:Total score of 4-5 points. Grade 3:Total score of 6-8 points. A. Tumor differentiation: 1 point:Resembles normal adult mesenchymal tissue, may be confused with a benign lesion, such as well differentiated liposarcoma. 2 points:Histologic typing is certain, such as myxoid liposarcoma. 3 points:Synovial sarcoma, Osteosarcoma, Ewings sarcoma/PNET, Sarcomas of doubtful tumor type, Embryonal & Undifferentiated sarcomas. B. Mitotic count (Count 10 successive high power fields in most mitotically active areas): 1 point:0-9 mitoses, 2 points:10-19 mitoses, 3 points:20 or more mitoses. C. Tumor necrosis: 0 points:No necrosis on any slides, 1 point:Less than 50% necrosis for all examined tumor surface, 2 points:Tumor necrosis of 50% or more of examined tumor surface. Applying that to our case : A. Tumor differentiation: 03 points, B. Mitotic count: 03 points, C. Tumor Necrosis : 01 point. Summing up : A + B + C = 3+3+1=7, Hence Grade III, as the total score is 07. Closest Differential Diagnosis : 1. Pleomorphic Rhabdomyosarcoma : Large, pleomorphic rhabdomyoblasts, which may show cytoplasmic cross-striations. 2. Pleomorphic liposarcoma : It is a cellular, pleomorphic sarcoma with lipoblasts. Most show features of pleomorphic MFH. Lipoblasts must be present. Cytoplasmic vacuole or vacuoles must be sharply defined. Must indent and distort nucleus. Please note : The findings and interpretations described above are purely based on the quality of the slides posted above, and cannot be substituted with actual microscopic observation. Kindly leave your comments. Thank you very much kind madam.

Biopsy from the thigh swelling shows high cellularity of sheets of spindle shaped cells arranged in sheets. The individual cells have round to oval hyper chromatic nuclei, moderate cytoplasm and prominent nucleoli. Many bizarre atypical cells are also noted. Few lymphocytes are also seen in the background. Histopathological features are suggestive of high grade sarcoma. Most likely possibility of pleomorphic liposarcoma based on site and histology. Advise : immunihistochemistry for further confirmation.

Respected mam, thank you for posting this case ( for me soft tissue tumours are always a nightmare). Section shows fragments of tissue with an infiltrating neoplasm composed of highly Pleomorphic spindle to oval cells arranged in sheets and interlacing fascicles. The neoplastic cells have rounf to oval hyperchromatic nuclei and moderate indistinct cytoplasm. Many bizarre cells and mitotic fig are noted. Scant necrosis is seen (image 2). Also noted are cells with foamy cytoplasm and cells with vacuolated cytoplasm. Mild lymphoplasmacytic infiltrate and vascular spaces are noted. Image 7 from 10 to 11 o'clock position a cell with indented nuclei with septations is seen suggestive of LIPOBLAST. Anyhow mam check for more convincing lipoblasts. Impression : Incision biopsy from thigh swelling showing features of a HIGH GRADE SARCOMA. The possibilities in order of priority : 1. Pleomorphic liposarcoma : I am placing it first since I saw a lipoblast. 2. Undifferentiated Pleomorphic sarcoma or Malignant fibrous histiocytoma : Cd68+, is more like a waste basket ie when ur not able to identify the specific lineage we tend to categorise under MFH. 3. Atypical fibroxanthoma : usually superficial and small 4. Other sarcomas: LEIOMYOSARCOMA, MPNST, RMS, Angiosarcoma ( unlikely in this case but needs exclusion). Mam if you have IHC then probably go ahead and run a basic panel of markers for soft tissue tumours. But Pleomorphic LPS is purely based on morphology, one has to look carefully for lipoblasts before calling as Undifferentiated Pleomorphic sarcoma. Thank you mam. Keep us updated on this cae. Regards...

dear mam, sections from the incisional biopsy of thigh swelling showed a cellular neoplasm composed of round to oval pleomorphic cells with hyperchromatic nuclei and some with prominent nucleoli. The tumor cells are arranged in sheets and focal fascicular pattern. they exhibit atypical mitosis and bizarre tumor giant cells are also seen. few cells with vacuolated cytoplasm ( xanthoma) cells are also seen. Necrosis was not made out. Impression : soft tissue sarcoma probably malignant fibrous histiocytoma kindly look for the size of the swelling and plane of location . and confirm with IHC CD 68, vimentin D/D: 1. myxoid liposarcoma: vacuolated lipoblasts, plexiform capillary network, S100 + 2. fibrosarcoma : herring bone battern, , diagnosis of exclusion 3. atypical fibroxanthoma: supl variant of MFH, less common in limbs , look for plane of the swelling thank you.

Thank you sirs and ma'ms. Regarding this case many of the tumor cells are showing intracytoplasmic lumina containing RBC, but distinct vessels are not seen. Basing on these findings I concluded it as malignant vascular neoplasm, epithelioid hemangioendothelioma. for confirmation this case is submitted for immunohistochemistry, referred to higher centre. I will let you know the ihc findings later. thank you....

tumor cells having round to oval nucleii with clear to eosinophilic cytoplasm,inflamatory cells are seen,tumor cells having vacuole trying to form vessel s-Haemangioendothelioma

DDs : *Pleomorphic Sarcoma of any lineage. *Undifferentiated Pleomorphic Sarcoma. Advised IHC.

Sections show malignant spindle cells arranged predominantly in sheets (no particularly specific pattern identified like herring bone). The cells are pleomorphic with oval to round hyperchromatic nuclei with mod eosinophilic cytoplasm. Many large bizarre cells noted. Incresed mitotic activity seen. Lipoblast seen (fig 6,7,8). Small areas of necrosis seen (fig 2). Dig- Pleomorphic liposarcoma D/D- MFH


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