ANATOMIC PATHOLOGICAL PROFILING OF SOFT TISSUE NEOPLASMS

by

DR. RIDA SIDDIQA TARIQ

(REGISTRATION NO: )

DISSERTATION SUBMITTED TO

THE KALOJI NARAYANA RAO UNIVERSITY OF HEALTH SCIENCES,

WARANGAL, TELANGANA STATE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

THE DEGREE

DOCTOR OF MEDICINE (PATHOLOGY)

UNDER THE GUIDANCE OF

Dr. M.MUSTAFA KHAN, MD. (PATHOLOGY)

PROFESSOR & HOD

DEPARTMENT OF PATHOLOGY

DECCAN COLLEGE OF MEDICAL SCIENCES

HYDERABAD, TELANGANA
MAY 2024
 CERTIFICATE BY THE GUIDE
This is to certify that this dissertation titled ‘ANATOMIC PATHOLOGICAL

PROFILING OF SOFT TISSUE NEOPLASMS’ with Registration No: __________ is

a bonafide research work of DR. RIDA SIDDIQA TARIQ in MD (PATHOLOGY),

Deccan College of Medical Sciences. This is prepared under my guidance, during

her tenure of MD i.e, 2020 to 2023 in partial fulfillment of regulations laid down by

Kaloji Narayana Rao University of Health Sciences, Warangal, Telangana State, for

MD PATHOLOGY, degree examination to be held in June 2023..This is an original

work done by the candidate and no part of this work was used as basis for obtaining

any other degree or publication or part thereof.

Date:

Place: Hyderabad Professor and HOD,

Department of PATHOLOGY

Deccan College of Medical Sciences

 CERTIFICATE BY THE HEAD OF THE DEPARTMENT
This is to certify that this dissertation titled ‘ANATOMIC PATHOLOGICAL

PROFILING OF SOFT TISSUE NEOPLASMS’ with Registration No:__________ is

a bonafide research work of DR. RIDA SIDDIQA TARIQ , Postgraduate in MD

(PATHOLOGY), Deccan College of Medical Sciences under supervision and

guidance of________, Professor and HOD of Department of Pathology in partial

fulfillment of requirement for the degree of MD PATHOLOGY.

This is an original work done by the candidate and no part of this work was used as

basis for obtaining any other degree or publication or part thereof.

Date:
Place: Hyderabad Professor and HOD,
Department of PATHOLOGY
Deccan College of Medical Sciences
 ENDORSEMENT BY THE PRINCIPAL

This to certify that this dissertation titled ANATOMIC PATHOLOGICAL PROFILING

OF SOFT TISSUE NEOPLASMS with Registration No:__________ is a bonafide

research work of Dr. RIDA SIDDIQA TARIQ, Postgraduate in MD PATHOLOGY,

under the guidance of___________, Professor and HOD, Department of

PATHOLOGY, Deccan College of Medical Sciences, Hyderabad in partial fulfillment

of requirement for the degree of MD PATHOLOGY

Date:

Place: Hyderabad Professor and HOD,

Department of PATHOLOGY

Deccan College of Medical Sciences

 DECLARATION BY THE CANDIDATE
There by declare that this dissertation titled ANATOMIC PATHOLOGICAL

PROFILING OF SOFT TISSUE NEOPLASMS with Registration no. :

__________ has been prepared by me under the guidance of ___________,

MD, Professor and HOD , Department of PATHOLOGY ,Deccan College of

Medical Sciences, Hyderabad for partial fulfillment of regulations for award of

Masters degree in Pathology. This dissertation has not been submitted to any

other university for award of any degree or diploma of fellowship.

Date:

Place: Hyderabad Professor and HOD,

Department of PATHOLOGY

Deccan College of Medical Sciences

 TABLE OF CONTENTS
S.NO PAGE NO

1 INTRODUCTION

2 AIMS & OBJECTIVES

3 REVIEW OF LITERATURE

4 ANATOMY

5 METHODOLOGY

6 RESULTS

7 DISCUSSION

8 CONCLUSION

9 SUMMARY

10 REFERENCES

ANNEXURES

11 ANNEXURE – I PROFORMA

12 ANNEXURE – II CONSENT FORM

13 ANNEXURE – III MASTER CHART

 INTRODUCTION

Soft tissue refers to the non-epithelial, extra-skeletal structures of

the body, excluding the reticulo-endothelial system, glia, and the

supportive tissues of parenchymal organs. Soft tissue tumors are a

diverse group of neoplasms classified primarily based on their

histogenesis and are broadly categorized into benign and malignant

types. Benign tumors are far more common than malignant ones.

The initial diagnostic approach for soft tissue tumors typically

involves obtaining material through fine needle aspiration (FNA).

However, a definitive diagnosis requires an excisional biopsy for

histopathological examination. While FNA plays a crucial role in the

initial diagnostic process, histopathology, supplemented by

immunohistochemical markers, provides the final diagnosis.

Embryologically, soft tissue tumors primarily originate from

mesodermal tissues, with some contributions from neuroectodermal

elements. Soft tissue sarcomas are relatively rare compared to other

carcinomas, constituting less than 1% of all cancers. They most

commonly present as asymptomatic masses, often located in the

extremities, though they can also occur in the trunk, retroperitoneum,

and head and neck regions.

 Benign tumors generally resemble normal tissue and exhibit

limited autonomous growth. The most common benign tumors include

lipomas, hemangiomas, benign peripheral nerve sheath tumors, and

fibromas. Benign tumors are approximately 100 times more common

than malignant ones.

Among malignant soft tissue tumors, the most prevalent types

include undifferentiated pleomorphic sarcoma, leiomyosarcoma,

liposarcoma, synovial sarcoma, and malignant peripheral nerve sheath

tumors. Benign tumors are most commonly found in the 4th and 5th

decades of life, while malignant tumors typically occur in the 1st and 2nd

decades. The majority of soft tissue tumors are located in the

extremities, with the lower extremity being the most frequent site,

followed by the upper extremity.

Soft tissue tumors occur more frequently in males, although the

incidence varies with gender and age depending on the histological type.

Rhabdomyosarcoma is the most common soft tissue sarcoma in children

and adolescents, whereas undifferentiated pleomorphic sarcomas

predominantly affect older adults. Benign tumors are generally locally

invasive, while malignant soft tissue tumors often metastasize to the

lungs.
 AIM and OBJECTIVES

 To document the age incidence of soft tissue neoplasms.

 To estimate the sex prevalence of soft tissue neoplasms.

 To meticulously evaluate the core & trucut biopsies of

subcutaneous swellings / mass lesions / lumps.

 To channelize the soft tissue neoplasms into specific confined

entities.
 MATERIALS AND METHODS

 This study will encompass all the soft tissue biopsies presented to

the Department of Pathology, Deccan College of Medical

Sciences, Owaisi Hospital and Research Centre / Princess Esra

Hospital, from April 2022, respectively till 2 ½ years.

 Expectedly 70 cases will be included in the study.

 INCLUSION CRITERIA

 Core biopsies of Subcutaneous swellings.

 Trucut biopsies of suspected soft tissue neoplasms.

 Excisional biopsies of subcutaneous masses.

 EXCLUSION CRITERIA

 Dermatologic biopsies.

 Previously diagnosed soft tissue neoplasms.

 Core /Trucut biopsies of breast lesions.

 REVIEW OF LITERATURE

AETIO PATHOGENESIS

Like many other malignant tumors, the pathogenesis of most tissue

tumors is still unknown.

Various physical and chemical factors, exposure to ionizing

radiation, inherited or acquired immunological defects, trauma, fracture

sites, and the presence of plastic or metallic implants typically after a

latent period of several years can contribute.12

External radiation therapy is a well-established risk factor for tissue

sarcoma.

Post-irradiation sarcomas occur in approximately 0.1% of cancer

patients who survive for 5 years. The defined criteria are as follows:

1) Sarcoma should develop in the irradiated field

2) A period of latency of at least 3years

3) Histological confirmation of diagnosis.

Wingren et al.41 studied the association between soft tissue sarcoma

(STS) and occupational exposure in 96 cases. They observed an

increased risk for STS among gardeners, railroad workers, construction

workers exposed to asbestos, and unspecified chemical workers. They

concluded that gardeners exhibit a particularly strong risk for developing

STS.

Human herpes virus 8 (HHV-8) plays a crucial role in the

development of Kaposi sarcoma, and the clinical progression of the

disease is dependent on the patient's immune status.15

Several types of benign soft tissue tumors have been reported to

occur on a familial or inherited basis. Genetic alterations that enable a

clone of cells to acquire the hallmark properties of cancer affect three

broad categories of cancer genes: oncogenes, tumor suppressor genes,

and caretaker genes. Activation of oncogenes occurs through mutations

that alter the gene sequence or protein function, leading to aberrant

enhanced function. This can result from an increase in the number of

gene copies (gene amplification), translocation, or a combination of

these mechanisms. Examples of mesenchymal tumors include KIT and

PDGFRA, both activated by mutations; MYCN and MDM2, activated by

gene amplification; and PLAG1 and HMGA1, activated by translocation

(also known as fusion oncogenes).

INCIDENCE

Benign soft tissue tumors, such as lipomas and benign fibrous

histiocytomas, are among the most common neoplasms in humans.

The annual incidence of soft tissue sarcoma is approximately 30 per

million, accounting for less than 1% of all malignant tumors. In 1995,

Kransdorf, citing records from the AFIP, reported a ratio of 1:5:1 and

highlighted an inherent bias in a referral population due to the

consultative and challenging nature of the case material.

AGE INCIDENCE

Soft tissue tumors can occur at any age. It has been observed that the

histological distribution of soft tissue tumors is quite specific to particular

age groups and anatomical sites.

In the study by Myhre and Jensen, the age group ranged from 0 to 80

years. The age range for benign tumors was 20 to 69 years, while for

malignant tumors it was 20 to 79 years, with the exception of embryonal

and alveolar rhabdomyosarcoma, the majority of which occur in

individuals under 10 years of age19.

SEX INCIDENCE

There seems to be a slight male preponderance, especially in malignant

soft tissue tumors. In the Myhre and Jensen series, the male-to-female

(M) ratio was 2:1. In Kransdorf’s studies, the ratio was 1.29:118.
In both the Myhre and Jensen19 and Kransdorf series, lipomas were the

most common benign tumors in adults. Hemangiomas were the most

common benign soft tissue tumors in childhood.

SITE SPECIFIC DISTRIBUTION

According to Kransdorf's study, the incidence of various tumors at

different anatomical locations varies with age. For instance,

hemangiomas are the most common tumors in the hand and wrist region

in children, while in adults, giant cell tumors of the tendon sheath are

more prevalent in the same area17.

PATHOPHYSIOLOGY

Generally, soft tissue tumors grow centripetally, although some benign

tumors, such as fibrous lesions, may grow longitudinally along tissue

planes. Most tumors respect fascial boundaries, remaining confined to

their compartment of origin until the later stages of development, at

which point they are likely to breach compartmental boundaries.

Major neurovascular structures are usually displaced rather than

enveloped or invaded by tumors. Tumors arising in extracompartmental

locations, such as the popliteal fossa, may expand more quickly due to

the absence of fascial boundaries, making them more likely to involve

neurovascular structures. The peripheral portion of the tumor

compresses the surrounding normal soft tissue due to centripetal

expansile growth, resulting in a well-defined zone of compressed fibrous

tissue that may contain scattered tumor cells, inflammatory cells, and

demonstrate neovascularity. This zone, known as the compression zone,

is surrounded by a thin layer of tissue called the reactive zone. Together,

the compression and reactive zones form a pseudocapsule that

encloses the tumor.20

A. Local Recurrence

Soft tissue sarcomas have a propensity to recur locally, with

most tumors that are destined to recur doing so within the first 2-3

years. The pseudocapsule provides surgeons with a more or less

obvious plane of dissection; however, such excision can leave

behind microscopic or occasionally gross tumor remnants. This

can result in local recurrences in up to 80% of patients.21

B.Distant Metastatis

The dominant pathway of sarcoma metastasis is through the

hematogenous route. The first step in the sequence leading to the

formation of blood-borne metastasis is intravasation, followed by

embolism, and then the arrest of the malignant emboli. The lungs are the
most common site of metastasis, involved in up to 52% of patients with

high-grade lesions, followed by the liver, bone, and brain.22

CLINICAL FEATURES

Most benign tumors are located in superficial (dermal or subcutaneous)

soft tissue, with lipomas being the most frequent and often going

untreated. Most soft tissue sarcomas of the extremities and trunk

present as painless, accidentally observed masses that usually do not

affect general health or limb function. However, they may cause pain or

neurological symptoms by compressing or stretching nerves or by

irritating overlying bursae. Superficial soft tissue lesions larger than 5 cm

and all deep-seated tumors, regardless of size, should raise suspicion of

malignancy. A rapid increase in the size of a mass should also suggest

that the lesion might be malignant.

DIAGNOSIS OF SOFT TISSUE TUMORS

Both benign and malignant soft tissue tumors commonly present as

painless masses.

When a soft tissue mass arises in a patient with no history of trauma, or

when a mass persists for more than six weeks after local trauma, a

biopsy is indicated. Fine needle aspiration cytology (FNAC) plays a role

in diagnosing soft tissue lesions, especially when guided by CT scans for

 intra-abdominal and retroperitoneal lesions. FNAC is particularly useful

for documenting local recurrences or metastasis in previously diagnosed

soft tissue tumors. 24

Core biopsy, excisional biopsy, and incisional biopsy are other

techniques used for diagnosing most soft tissue masses.

Radiological evaluation of soft tissue tumors utilizes the trial of

1)Conventional radiography

2)CT Scan

3)MRI

H&E stained sections, along with ancillary methods such as special

stains, immunohistochemistry (IHC), and electron microscopy (EM)

studies, are helpful for making an accurate diagnosis.

The combination of clinical, histopathological, cytogenetic, and molecular

analyses not only facilitates the precise diagnosis of soft tissue tumors

but also promotes the development of targeted therapies for specific

types of sarcoma.25

The advent of multimodal therapy has made it possible to avoid radical

surgery, reduce morbidity, and substantially improve the 5-year survival

rates for malignant soft tissue tumors.26

Adipocytic Tumors38-40

Benign:

 Lipoma

 Lipomatosis

 Lipomatosis of Nerve

 Lipoblastoma / Lipoblastomatosis

 Angiolipoma

 Myolipoma of Soft Tissue

 Chondroid Lipoma

 Extra-renal Angiomyolipoma

 Extra-Adrenal Myolipoma

 Spindle Cell / Pleomorphic Lipoma

 Hibernoma

Intermediate (Locally Aggressive):

 Atypical Lipomatous Tumor / Well-Differentiated Liposarcoma

Malignant:
  Dedifferentiated Liposarcoma

 Myxoid Liposarcoma

 Pleomorphic Liposarcoma

 Liposarcoma, Not Otherwise Specified (NOS)

General Changes

 Mixed-type liposarcoma is no longer included. Cases are now

classified into specific liposarcoma types using molecular and genetic

testing.

 Atypical lipomatous tumor (ALT) is divided into three subgroups:

Adipocytic (Lipoma-Like), Sclerosing, and Inflammatory types.

Fibroblastic / Myofibroblastic Tumors

Benign:

 Nodular Fasciitis

 Proliferative Fasciitis

 Proliferative Myositis

 Myositis Ossificans

 Fibro-osseous Pseudotumor of Digits

  Ischemic Fasciitis

 Elastofibroma

 Fibrous Hamartoma of Infancy

 Fibromatosis Colli

 Juvenile Hyaline Fibromatosis

 Inclusion Body Fibromatosis

 Fibroma of Tendon Sheath

 Desmoplastic Fibroblastoma

 Mammary-type Myofibroblastoma

 Calcifying Aponeurotic Fibroma

 Angiomyofibroblastoma

 Cellular Angiofibroma

 Nuchal-type Fibroma

 Gardner Fibroma

 Calcifying Fibrous Tumor

Intermediate (Locally Aggressive):

  Palmar/Plantar Fibromatosis

 Desmoid-type Fibromatosis

 Lipofibromatosis

 Giant Cell Fibroblastoma

Intermediate (Rarely Metastasizing):

 Dermatofibrosarcoma Protuberans

 Fibrosarcomatous Dermatofibrosarcoma Protuberans

 Pigmented Dermatofibrosarcoma Protuberans

 Solitary Fibrous Tumor (SFT)

 Malignant Solitary Fibrous Tumor

 Inflammatory Myofibroblastic Tumor

 Low Grade Myofibroblastic Sarcoma

 Myxoinflammatory Fibroblastic Sarcoma / Atypical Myxoinflammatory

Fibroblastic Tumor

 Infantile Fibrosarcoma

Malignant:
  Adult Fibrosarcoma

 Myxofibrosarcoma

 Low-grade Fibromyxoid Sarcoma

 Sclerosing Epithelioid Fibrosarcoma

Pericytic (Perivascular) Tumors

 Glomus Tumor (and variants)

 Glomangiomatosis

 Malignant Glomus Tumor

 Myopericytoma

 Myofibroma

 Myofibromatosis

Skeletal Muscle Tumors

 Rhabdomyoma

 Embryonal Rhabdomyosarcoma

 Alveolar Rhabdomyosarcoma

 Pleomorphic Rhabdomyosarcoma
  Spindle Cell/Sclerosing Rhabdomyosarcoma

Vascular Tumors

Benign:

 Hemangioma

 Synovial Hemangioma

 Venous Hemangioma

 Arteriovenous Hemangioma/Malformation

 Epithelioid Hemangioma

 Angiomatosis

 Lymphangioma

Intermediate (Locally Aggressive):

 Kaposiform Hemangioendothelioma

Intermediate (Rarely Metastasizing):

 Retiform Hemangioendothelioma

 Papillary Intralymphatic Angioendothelioma

 Composite Hemangioendothelioma
  Pseudomyogenic (Epithelioid Sarcoma-like) Hemangioendothelioma

 Kaposi Sarcoma

Malignant:

 Pseudomyogenic (Epithelioid Sarcoma-like) Hemangioendothelioma

Gastrointestinal Stromal Tumors

 Benign Gastrointestinal Stromal Tumor

 Gastrointestinal Stromal Tumor, Uncertain Malignant Potential

 Malignant Gastrointestinal Stromal Tumor

Nerve Sheath Tumors

Benign:

 Schwannoma (including variants)

 Melanotic Schwannoma

 Neurofibroma (including variants)

 Plexiform Neurofibroma

 Perineurioma

 Granular Cell Tumor

  Dermal Nerve Sheath Myxoma

 Solitary Circumscribed Neuroma

 Ectopic Meningioma

 Nasal Glial Heterotopias

 Benign Triton Tumor

 Hybrid Nerve Sheath Tumors

Malignant:40

 Malignant Peripheral Nerve Sheath Tumor (MPNST)

 Epithelioid Malignant Nerve Sheath Tumor

 Malignant Triton Tumor

 Malignant Granular Cell Tumor

 Ectomesenchymoma

Previously included in the 2007 WHO classification of tumors of the central

nervous system, the current WHO classification now encompasses tumors

previously classified under cranial and peripheral nerves, head and neck,

and skin tumors. This initiative represents an important effort to consolidate

the diverse family of mesenchymal tumors into a single reference source.

The 2007 classification did not include the following:

 Granular cell tumour

 Dermal nerve sheath myxoma

 Solitary circumscribed neuroma

 Ectopic meningioma\meningiothelial hamartoma

 Nasal glial heterotopias

 Benign triton tumour

 Hybrid nerve sheath tumours

 Malignant triton tumour

 Malignant granular cell tumour

 Ectomesenchymoma

Tumours of uncertain differentiation

Benign

Acral fibromyxoma

Intramuscular myxoma(including cellular variant)

Juxta-articular myxoma

Deep(“aggressive”) angiomyxoma
Pleomorphic hyalinizing angiectatic tumour

Ectopic harmartomatous thymoma

Intermediate(locally aggressive)

Heamosiderotic fibropomatous tumour

Intermediate(rarely metastizing)

Atypical fibroxanthoma

Angiomatoid fibrous histocytoma

Ossifying fibromixoid tumour

Ossifying fibromyxoid tumour, malignant

Mixed tumour NOS

Mixed tumour NOS, malignant

Myoepithelioma

Myoepithicalcarcinoma

Phosphatoric mesenchymal tumour, benign

Phosphaturic mesenchymal tomour, malignant

Malignant
Synovial sarcoma NOS

Synovial sarcoma, spindle cell

Synovial sarcoma ,bhipasic

Epitheloid sarcoma

Alveolar soft-part sarcoma

Clear cell sarcoma of soft tissue

Extraaskeletal myoxoid chonadrosarcoma

Extraaskeletal ewing sarcoma

Desmoplastic small round cell tumour

Extra-renal rhabdoid tumour

Neoplasms with perivascular epithelilod cell differentiation(PEComa)

PEComa NOs,benign

PEComa NOS,malignant

Intimal sarcoma

Undifferentiated\unclassified sarcomas
  Undifferentiated spindle cell sarcoma

 Undifferentiated round cell sarcoma

 Undifferentiated pleomorphic sarcoma

 Undifferentiated epitheliloid sarcoma

 Undifferentiated sarcoma NOS

This category was introduced to encompass a group of malignant tumors

previously classified under fibrohistiocytic tumors, specifically "malignant

fibrous histiocytomas." These tumors lack a clearly identified line of

differentiation when analyzed with currently available technology.

Dedifferentiated types of specific sarcomas are not included in this category.

Undifferentiated/unclassified sarcomas account for up to 20% of all sarcomas,

with about a quarter of these being radiation-associated tumors.

Histologic grading

Histologic grade indicates the likelihood of distant metastasis and overall

survival but is of limited value in predicting local recurrences, which are

primarily related to the quality of surgical margins.

The two most widely used grading systems are NCI(united states national

cancer inistitute)
System and the FNCLCC (French Federation National edes Centres de lute

control cancer)system.

The NCI system assigns grades 1 to 3 based on a combination of

histological type, cellularity, pleomorphism, tumor necrosis, and mitotic

rate.

The FNCLCC system assigns a grade based on a score derived

from evaluating three parameters: tumor differentiation, mitotic rate, and

the amount of tumor necrosis. Each parameter is independently scored

from 1 to 3, and the overall grade is obtained by summing these three

scores.

Tumor differentiation
Score 1 :Sarcomas closely resembling normal adult mesenchymal
tissue (e.g., low grade leiomyosarcoma).
Score 2 : Sarcomas for which histological typing is certain (e.g.,
myxoid liposarcoma).
Score 3 :Embryonal and undifferentiated sarcomas, sarcomas of
doubtful type, synoial sarcomas, osteosarcomas, PNET.
Mitotic count
Score 1 : 0-9 mitoses per 10 HPF*
Score 2 : 10-19 mitoses per 10 HPF
Score 3 : 20 mitoses per HPF
Tumour necrosis
Score 0 : no necrosis
Score 1 : <50% tumour necrosis
Score 2 : > 50% tumour necrosis
Histological grade
Grade 1 : total score -2,3
Grade 2 : total score – 4,5
Grade 3 : total score – 6,7,8

The primary staging system used for soft tissue sarcomas (STS) was

developed by the International Union Against Cancer (UICC) and the

American Joint Committee on Cancer (AJCC). This TNM system is

clinically useful and has prognostic value. It incorporates histological

grade, tumor size and depth, regional lymph node involvement, and

distant metastasis, accommodating 2-, 3-, and 4-tiered grading systems.

AJCC staging of soft tissue sarcomas

Primary tumour (T) TX : Primary tumour cannot be

assessed

T0 : no evidence of primary
tumour

T1 : Tumour >= 5cm in greatest

dimension

T1a : Superficial tumour*

T2b : Deep tumour

T2 : Tumour >5cm in greatest

dimension
 T2a : Superficial tumour

T2b : Deep tumour

Regional lymph nodes (N) NX: Regional lymph nodes cannot

be assessed

N0 : No regional lymph node

metastasis

N1 : Regional lymph node

metastasis

Note: Regional node involvement is rare and cases in which nodal status is not
assessed either clinically or pathologically could be considered N0 instead of NX
or pNX.

Distant metastasis (M) M0: no distant metastasis

M1: distant metastasis

Histopathological Grading

Translation table for three and four grade to two grade (low vs. high grade)
system

TNM two grade Three grade system Four grade systems

system

Low grade Grade 1 Grade 1

High grade Grade 2 Grade 2
Grade 3 Grade 3
Grade 4
Stage IA T1a N0, NX Low grade

M0 Low grade

Stage IB T1b N0, NX Low grade

 M0 Low grade

Stage IIA T2a N0, NX High grade

M0 High grade

Stage IIB T2b N0, NX High grade

Stage III M0 High grade

Stage IV T1a N0, NX Any grade

M0 Any grade

T1b N0, NX

M0

T2a N0, NX

M0

T2b N0, NX

M0

Any T N1

M0

Any T Any N

M1

LIMITATIONS
 Despite the widespread use of various grading systems in the

diagnosis and management of sarcomas, experts believe that no single

grading system performs well for every type of sarcoma. In some

sarcomas, the histologic subtype essentially defines behavior, rendering

the grade redundant. This is best illustrated by well-differentiated

liposarcoma, an inherently low-grade, non-metastasizing lesion, and the

majority of round cell sarcomas (e.g., alveolar rhabdomyosarcoma),

which are inherently high-grade.30

Grading does not play a role in distinguishing between benign and

malignant lesions; this distinction should always be made first. Some

benign and reactive lesions may exhibit features, such as mitotic activity,

that are also prevalent in sarcomas.

Prognostic value

Kettan and colleagues from the Memorial Sloan Kettering Cancer

Center (MSKCC) utilized a database of over 200 prospectively followed

adult patients with soft tissue sarcoma to predict the probability of

sarcoma-specific death within 12 years. Their model takes into account

tumor size, depth, site, histology, and the patient's age.

According to statistics from the National Cancer Institute (NCI), the

overall relative 5-year survival rate for people with soft tissue sarcomas
is around 50%. These statistics include individuals with Kaposi sarcoma,

which has a poorer prognosis than many other sarcomas. The NCI does

not use the AJCC staging system; instead, they classify sarcomas based

on whether they are confined to the primary site (localized), have spread

to nearby lymph nodes or tissues (regional), or have metastasized to

distant sites (distant).31

FIBROUS TUMORS

Fibrous tumors are categorized in 3 broad groups.

I. Benign tumors

Nodular fasciitis

Clinically, these tumors mimic malignant tumors. They are benign

proliferations of fibroblasts, which have the ability to simulate a

malignant process. Trauma has been implicated as a possible causative

factor.32

It is more common in adults between 20 and 40 years of age, with

no sex predilection. There is a distinct preference for the upper

extremities, particularly the flexor aspect of the forearm.

Macroscopically, it appears as a well-circumscribed mass

measuring less than 2 mm. Microscopically, the tumor is composed of

plump fibroblasts arranged in short bundles. The cells have pale nuclei

and prominent nucleoli, and the intervening matrix is rich in

mucopolysaccharides.33

In 1982, Bernstein et al. published an article on nodular fasciitis

after a clinicopathological study of 134 cases and described four types:

the reactive type, the densely cellular type, those with osteoid or

cartilaginous metaplasia, and proliferative fasciitis.

Fibroma of tendon sheath

These tumors are commonly seen in males and have a

predilection for the extremities, primarily affecting the tendons and

tendon sheaths of the fingers (49%), hands (21%), and wrist (12%). The

main presenting symptom is an insidiously growing mass, causing mild

tenderness or pain in about one-third of the patients.35

Nuchal fibroma

It is a fibrous growth occurring in the interscapular and paraspinal

regions.

Myositis ossificans

It is a localized, self-limiting lesion that follows mechanical trauma

in 50% of cases.

It affects young, active adolescents with no preference for either sex.

The favored sites are the limbs, particularly the quadriceps and gluteal

muscles in the lower extremities.

Grossly, they appear as well-circumscribed masses measuring 3-6

cm, with a stony sensation.

Microscopy reveals an innermost portion consisting of richly vascular

fibroblastic tissue mixed with macrophages and multinucleate giant cells.

The intermediate zone displays a mixture of fibroblasts,

osteoblasts, and variable amounts of osteoid.

The periphery shows calcification and mature lamellar bone’

It is a benign self-limiting lesion.

Desmoplastic fibroblastoma

Also known as collagenous fibroma, it occurs in adults and shows no

tendency for local recurrence. It is characterized by a hypocellular

proliferation of bipolar or stellate fibroblasts.

Angiomyo fibroblastoma

This tumor shows a predilection for the vulvovaginal region during

the reproductive years but can also occur in the inguinoscrotal region in

men. It is characterized by greater cellularity, vascularity, and a virtual

absence of recurrence potential.

Cellular angiofibroma

This tumor occurs in adults of either sex, primarily in the vulvovaginal

and inguinoscrotal regions.

 A cellular tumor with fascicles or a haphazard pattern, consisting of

bland spindle cells with scant, lightly eosinophilic cytoplasm and ill-

defined borders, and featuring oval to fusiform nuclei.37

Fibromatosis

These are benign fibrous tissue proliferations, intermediate

between benign fibroblastic lesions and fibrosarcoma. They are known

for local recurrences but never metastasize.38

Hereditary, trauma and hormones play a major role.

Superficial fibromatoses are small, slowly growing tumors that

arise from the fascia or aponeurosis. In contrast, deep fibromatoses are

larger and more rapidly growing tumors.

Superficial fibromatosis is observed in adults between the ages of

30 and 60, with a predilection for males.

Intermediate (rarely metastasizing)

Haemangiopericytoma

This tumor was once thought to originate from capillary pericytes

but is now understood to be fibroblastic in nature, hence the name

'solitary fibrous tumor.' In Kransdorf et al.'s 1995 series, these tumors

accounted for 1.1% of malignant soft tissue tumors.

 These tumors are more common in adults, with no sex

predilection, and are most frequently found in the lower extremities.39

Grossly, the tumor appears as a well-circumscribed mass

measuring 4 to 8 cm in diameter.

Microscopically, the tumor reveals thin-walled, endothelial-lined

vascular channels, ranging from small capillary-sized vessels to large,

gaping sinusoidal spaces. The cells are round to oval and are tightly

packed around the blood vessels. The number of mitotic figures is a

helpful criterion in predicting behavior, with 4 or more per 10 HPF usually

indicative of rapid growth. Mac Master et al. reported on 60 patients with

hemangiopericytoma and observed metastasis in more than 50% of

cases.40

III. Malignant Fibrous tumors

Adult fibrosarcoma

After reviewing earlier diagnoses, it ranks third following liposarcoma

and rhabdomyosarcoma. Known causative factors include radiation

therapy, thermal injury, plastic repair, and prosthetic implantation.

It is more common between the ages of 30 and 55, with a slight male

preponderance.
The most common sites are the proximal extremities, especially the

thigh, as well as the trunk and distal extremities.

Gross examination reveals the tumor as a solitary, encapsulated,

fleshy, or lobulated mass.

Microscopically, it reveals uniform spindle cells with pale nuclei

and scant cytoplasm arranged in a herringbone pattern.

Fibrosarcoma metastasizes through the bloodstream, most

commonly to the lungs.

Grossly, it appears as a multinodular, grey-white mass.

Microscopically, it reveals pleomorphic cellular areas with an

abundant myxomatous matrix, accentuating the thick blood vessels.43

Microscopically, it reveals small, rounded, immature-looking cells

with focal fibroblastic differentiation.

Low-grade fibromyxoid sarcoma

These tumors are common in younger patients, most often in the

limbs. Despite their bland swirling morphology, they carry a significant

long-term risk of distant metastasis.

FIBROHISITOCYTIC TUMORS

Benign tumors
Tenosynovial giant cell tumour

Localized type

The term “Giant cell tumor of tendon sheath” encompasses a

family of lesions that most often arise from the synovium of joints,

bursae, and tendon sheaths.44

The localized form is the most frequent and common subset of giant cell

tumors.44

The tumors are lobulated, well-circumscribed, and at least partially

covered by a fibrous capsule. Their microscopic appearance is variable,

depending on the proportion of mononuclear cells, multinucleate giant

cells, foamy macrophages, siderophages, and the amount of stroma.45

Deep benign fibrous histiocytoma

Benign fibrous histiocytoma typically affects adults. The tumors

arise from the skin and subcutaneous tissue of the face, neck, trunk, and

lower limbs. They present as painless, slowly growing, small lumps that

are firm in consistency and occasionally vascular.47

Grossly, the tumors are yellowish in color with some cystic areas.
 Microscopically, they reveal a mixture of fibroblasts and histiocyte-

like cells arranged in a vague storiform pattern, accompanied by a

variable number of inflammatory cells.

Plexiform Fibrohistiocytic Tumors

Plexiform fibrohistiocytic tumour is a rarely metastasizing dermal-

subcutaneous neoplasm composed of fibroblast and histiocyte-like

cells.48

Plexiform fibrohistiocytic tumor is a rarely metastasizing dermal-

subcutaneous neoplasm composed of fibroblast and histiocyte-like

cells.48

Giant cell tumors of soft tissue

Giant cell tumor of soft tissue is a primary soft tissue neoplasm

that is clinically and histologically similar to giant cell tumor of bone, and

it very rarely metastasizes.49

Giant cell tumor of soft tissue (GCT-ST) predominantly occurs in the fifth

decade of life.49

GCT-ST typically occurs in the superficial soft tissues of the upper

and lower extremities, accounting for 70% of tumors. GCT-ST often

displays a striking multinodular architecture (85%), with nodules ranging

in size up to 15 mm. These nodules are composed of a mixture of round

to oval mononuclear cells and osteoclast-like giant cells, both immersed

in a richly vascularized stroma.

The WHO advocates using the name "pleomorphic sarcoma" as an

alternative to the current name, as it provides a more accurate

description of the tumor and does not imply the origin of the tumor

cells.50

LIPOMATOUS TUMORS

I. Benign

Lipoma

Lipomas are adipose tumors typically located in the subcutaneous

tissues of the head, neck, shoulders, and back. Although they can be

found in all age groups, lipomas usually first appear between 40 and 60

years of age. These slow-growing, almost always benign tumors usually

present as nonpainful, round, mobile masses with a characteristic soft,

doughy feel.51

Rarely, lipomas can be associated with syndromes such as

hereditary multiple lipomatosis, adiposis dolorosa, Gardner's syndrome,

and Madelung's disease. Variants of lipomas include angiolipomas,

pleomorphic lipomas, spindle cell lipomas, and chondrolipomas.51

 Clinically, the tumor presents as a well-circumscribed,

encapsulated, slowly growing, soft, and mobile mass.

The tumor can vary in size from a few millimeters to over 20

centimeters in diameter.

Hibernoma

Hibernoma is a rare tumor composed of brown adipose tissue,

representing less than 2% of benign lipomatous tumors. It was first

described by Merkel in 1906 as a "pseudolipoma" and was later named

"hibernoma" in 1914.52

Macroscopically, it appears as a well-circumscribed, lobulated

mass. Microscopically, it reveals variable amounts of mature white

adipocytes, along with three characteristic brown fat cell types, including

granular eosinophilic cells with or without lipid vacuoles.52

Extrarenal angiomyolipoma

These are benign neoplasms of the kidney, composed of fat,

smooth muscle, and thick-walled blood vessels in varying proportions.

Lipomatosis
 It is a rare condition characterized by the diffuse overgrowth of

fatty tissue, primarily affecting adult males, and manifests in one of the

following four forms:

Multiple symmetric lipomatosis

Asymmetric lipomatosis

Pelvic lipomatosis

Mediastinoabdominal lipomatosis

These are non-encapsulated fatty tumors that infiltrate adjacent muscles

and soft tissues. They lack lipoblasts and malignant characteristics,

contain fibrous elements, and often show hypertrophy of the underlying

bone.55

II. Intermediate (locally aggressive)

Well-differentiated liposarcoma

Liposarcoma is arguably the most common malignant

mesenchymal neoplasm, accounting for 20% of all soft tissue sarcomas

in adults.56

Liposarcoma is currently classified into several subtypes based on

morphology and malignant behavior.

 The World Health Organization describes five subtypes of

liposarcoma: well-differentiated, dedifferentiated, myxoid, pleomorphic

(each representing histologically distinct entities), and mixed

liposarcoma (a combination of pleomorphic and myxoid or of

dedifferentiated and myxoid subtypes). It is helpful to categorize

liposarcomas into three main groups based on a biological continuum:

well-differentiated to dedifferentiated liposarcomas, myxoid to round cell

liposarcomas, and pleomorphic liposarcomas.56

III. Malignant tumors of adipose tissue

These tumors are among the most common soft tissue sarcomas in

adults.

It occurs most commonly between the ages of 40 and 60, although it is

rare in childhood.

It has a marked predilection for the lower extremities, followed by the

retroperitoneum.

Radiographically, liposarcoma shows distinct translucency, while

the myxoid type stands out due to increased density. CT and MRI are

valuable for detecting recurrent neoplasms.

 On gross examination, most measure between 5 and 10 mm, are

well-circumscribed, and appear yellowish on cut section. Well-

differentiated and myxoid liposarcomas are more commonly found in

primary tumors, whereas dedifferentiated liposarcomas are more

common in recurrent tumors.57

Myxoid liposarcoma

The tumor consists of lipoblasts in varying stages, ranging from

primitive mesenchymal stellate cells and multivacuolated lipoblasts to

signet ring lipoblasts. These tumor cells are mixed with a plexiform

capillary network and an abundant myxoid matrix.

Round cell Liposarcoma

This tumor consists of poorly differentiated myxoid

liposarcomatous areas with an excessive proliferation of small, uniform

round cells.

This tumor contains large giant cells or numerous giant cells.

Recurrence is common in deep-seated liposarcomas.

Dedifferentiation occurs in tumors at all sites, with the majority found in

the retroperitoneum.

SMOOTH MUSCLE TUMORS

I. Benign tumors

Cutaneous leiomyoma

These tumors appear as cutaneous nodules on the extremities in

early adulthood. Microscopically, they show bundles of smooth muscle

blending with dermal collagen.

Angiomyoma

It presents as a painful solitary nodule, commonly occurring in the

4th to 6th decades of life, with a predominance in females, particularly in

the lower extremities.58

II. Malignant tumors

It accounts for 5-10% of all soft tissue sarcomas seen in elderly

females, with the most common site being the retroperitoneum.

Radiation exposure is a possible etiological factor. Gross examination

shows the tumor as a large, fleshy mass. Microscopically, it reveals well-

differentiated tumor cells arranged in a fascicular pattern.

In 1977, Ramchod M61. studied 100 cases of gastrointestinal tract

and retroperitoneal leiomyosarcomas and identified the frequency of

mitosis as the most useful criterion for diagnosing leiomyosarcoma.

SKELETAL MUSCLE TUMORS

I. Benign (Rhabdomyoma)

Rhabdomyomas are benign tumors of striated muscle cells and

are generally divided into two categories: cardiac rhabdomyomas, which

are relatively common, and extracardiac rhabdomyomas, which are rare,

comprising only 2% of all tumors with striated muscle differentiation.

Adult rhabdomyomas occur in the head and neck area, the fetal type

occurs in both adults and children, and the genital type occurs in the

vagina and vulva of middle-aged women.62

II. Malignant tumors

Rhabdomyosarcoma (RMS)

There are classified into 3 histological types:

a) Embryonal rhabdomyosarcoma

b) Alveolar rhabdomyosarcoma

c) Pleomorphic rhabdomyosarcoma

Microscopically, embryonal RMS reveals a mixture of

undifferentiated, hyperchromatic round or spindle cells alongside

differentiated cells with eosinophilic cytoplasm characteristic of

rhabdomyoblasts, all within a myxoid matrix.

 Pleomorphic RMS is difficult to distinguish from other pleomorphic

sarcomas. Immunohistochemistry is helpful as these tumors show

positivity for desmin and myoglobin.63

The Intergroup Rhabdomyosarcoma Studies (IRS) have

established a clinical staging system. They also defined various

favorable and unfavorable factors for predicting prognosis.64

TUMORS OF BLOOD VESSEL

I. Benign tumors

Haemangioma

These are benign but non-reactive processes characterized by an

increase in the number of normal or abnormal-appearing blood

vessels.65

It is one of the common soft tissue tumors. In the study by Pramila

Jain et al., they accounted for 18.91% of all benign soft tissue tumors.16

They are most commonly seen in infancy and childhood.

Capillary Haemangioma

It is the most common type, consisting of capillary-sized blood vessels.

 Cellular hemangioma, or strawberry nevus, is an immature form of

capillary hemangioma that occurs in infancy at a rate of about 1 in every

20 live births.66

Cavernous Haemangioma

These are less frequent and are composed of dilated, blood-filled

vessels lined by flattened epithelium.

Epithelioid haemangioma

It is a rare lesion seen in mid-adulthood with a predilection for

females. The common location is around the ear.

Lymphangioma

Lymphangioma are classified as microcystic (capillary

lymphangiomas), macrocystic (cavernous lymphangiomas) and cystic

hygromas according to the size of the lymphatic cavities incorporated.67

Lymphangiomas are classified as microcystic (capillary

lymphangiomas), macrocystic (cavernous lymphangiomas), and cystic

hygromas, based on the size of the lymphatic cavities involved.

They have a predilection for the head, neck, and axilla.

 Macroscopically, they appear as ill-defined, sponge-like lesions.

Microscopically, they reveal lymphatic vessels lined by endothelium and

filled with proteinaceous fluid containing lymphocytes.

Though benign, they may cause morbidity due to their large size

and potential for infection. Complete excision is the preferred mode of

treatment.68

Kaposi sarcoma

These are rare tumors that occur in four clinical settings.

a) The chronic type occurs in elderly males and is often associated with

a second malignancy of the lymphoreticular system.69

b) lymphadenophathic type occur in young African children

c) transplantation associated

d) AIDS related Kaposi sarcoma.

Microscopy reveals a network of jagged blood vessels in the upper

dermis with bland-appearing lining cells.

IV. Malignant vascular tumor

Angiosarcoma
These are malignant tumors and constitute the remainder of soft tissue

tumors.

They comprise less than 1% of sarcomas.70

In Kransdorf's 1995 series, they accounted for 2.1% of cases.

Chronic lymphedema, chronic filariasis, radiation exposure, and

environmental chemical carcinogens are known predisposing factors.

This tumor primarily affects elderly patients, with a male

predilection, and commonly occurs in the superficial soft tissues of the

distal extremities, head, and neck.

Microscopy reveals vascular channels of irregular size and shape,

lined by plump endothelial cells with hyperchromatic nuclei.

The prognosis is poor, as the tumor spreads by local extension.

The most common sites of metastasis are the cervical lymph nodes,

lungs, liver, and spleen. Radical excision is recommended to prevent

local recurrences.70

PERIPHERAL NERVE SHEATH TUMORS

These tumors, presumed to originate from peripheral nerves or

nerve sheaths, are among the most common soft tissue neoplasms

encountered in routine practice.

Benign peripheral nerve tumors

A. Neurofibromas

They are divided into three types: localized, plexiform and diffuse

neurofibroma.

1. Localized neurofibroma:

It is sporadic, usually superficial, solitary, and not associated with

genetic syndromes. Microscopically, the circumscribed nodule is

composed of neural bundles with wavy nuclei and strands of collagen

in a neurofibrillary background.

B. Schwannoma (Neurilemoma)

It most often occurs in patients between 20 and 40 years old,

presenting as a solitary mass in the head and neck or on the flexor

surfaces of the upper and lower extremities. The tumor varies in size, is

encapsulated, and on cut surface shows yellow to yellow-white areas,

sometimes with cystic degeneration. Microscopically, it is characterized

by alternating Antoni A areas (hypercellular regions with spindle cells

exhibiting nuclear palisading and Verocay bodies) and Antoni B areas

(hypocellular regions with haphazardly arranged oval to spindle cells in a

loose fibrous matrix).72

Malignant peripheral nerve tumors

A. Malignant peripheral nerve sheath tumor

It is a large, fusiform neoplasm with a fleshy, mucoid cut surface,

often showing extensive areas of hemorrhage and necrosis.

Microscopically, it consists of interlacing fascicles of malignant spindle

cells with wavy or comma-shaped nuclei.73

Gastrointestinal stromal tumours

GISTs are mesenchymal neoplasms of the gastrointestinal (GI)

tract thought to develop from the interstitial cells of Cajal, which are

innervated cells associated with the Auerbach plexus. GISTs are

typically defined by the expression of c-KIT (CD117) in the tumor cells,

with activating KIT mutations present in 85-95% of cases. About 3-5% of

the remaining KIT-negative GISTs contain PDGFR alpha mutations.74

Gastrointestinal stromal tumors (GISTs) occur over a wide age

range but predominantly affect middle-aged and elderly individuals, with

a slight female predominance. Bleeding is the most common initial

symptom, with up to 20% of patients presenting with anemia. Pain is

another common complaint. Despite their large size, only a small

proportion of tumors are palpable.75

The overall 5- and 10-year survival rates for malignant GISTs are

estimated to be between 25% and 50%. However, in one series, only

10% of patients remained disease-free after a median follow-up of 68

months.

GISTs have variable malignant potential, ranging from small

lesions with benign behavior to fatal sarcomas. Most tumors stain

positively for the mast/stem cell growth factor receptor KIT and

anoctamin 1 and harbor a kinase-activating mutation in either KIT or

PDGFRA. Tumors without these mutations may have alterations in

genes of the succinate dehydrogenase complex, BRAF, or, rarely, other

family genes. Approximately 60% of patients are cured by surgery.

Adjuvant treatment with imatinib is recommended for patients with a

substantial risk of recurrence if the tumor has an imatinib-sensitive

mutation. Tyrosine kinase inhibitors substantially improve survival in

advanced disease, but secondary drug resistance is common.76

Undifferentiated sarcomas

A. Undifferentiated pleomorphic sarcoma

 These are the most common types of sarcoma in patients over 40

years of age, with peak incidence in the 6th and 7th decades and a male

predominance. Typically, they present as large, deep-seated tumors that

show progressive, often rapid enlargement, with a predilection for the

extremities, particularly the lower limbs. Microscopically, they reveal

pleomorphic fibroblast-like cells, histiocytes, inflammatory cells, and

bizarre cells or multinucleated giant cells with numerous atypical

mitoses.

B. Giant cell ‘MFH’/undifferentiated pleomorphic sarcoma with giant

cells

In addition to pleomorphic cellular areas, microscopy reveals a

prominent stromal osteoclastic giant cell reaction.

C. Inflammatory ‘MFH/undifferentiated pleomorphic sarcoma with

prominent inflammation

It is characterized by sheets of xanthomatous cells, both benign

and malignant, mixed with atypical spindle cells and inflammatory

cells.77,78

TUMORS OF UNCERTAIN DIFFERENTIATION

I. Benign

Aggressive Angiomyxoma
 Aggressive angiomyxoma is a rare mesenchymal tumor that most

commonly arises in the vulvovaginal region, perineum, and pelvis of

women. The term "aggressive" emphasizes the tumor's often infiltrative

nature and its frequent association with local recurrence. Patients often

present with nonspecific symptoms, which are frequently misdiagnosed

as more common conditions such as Bartholin cysts, lipomas, or

hernias. Histologic examination reveals a hypocellular, highly vascular

tumor with a myxoid stroma containing cytologically bland stellate or

spindled cells. The tumor cells are characteristically positive for estrogen

and progesterone receptors, suggesting a hormonal role in the tumor's

development.79

II. Malignant tumors

Alveolar soft part sarcoma

It is an uncommon neoplasm, accounting for only 0.5% of soft

tissue sarcomas in Kransdorf et al.'s 1995 series.

They are commonly seen in adolescents and young adults, with a

female predominance. The most common sites are the lower extremities,

particularly the anterior portion of the thigh.

Grossly, these tumors are poorly circumscribed, soft, and friable.

The cut section shows areas of necrosis and hemorrhage.80

 Microscopically, the tumor is characterized by dense fibrous

trabeculae that partition it into compact clusters. These clusters are

further divided into sharply defined nests of rounded or polygonal cells

with abundant granular cytoplasm, creating an organoid pattern.

It has a poor prognosis and a high likelihood of metastasizing to

the lungs or brain.

Clear cell sarcoma

It can produce melanin but differs from conventional melanoma in

that it is more deeply situated, typically associated with tendons or

aponeuroses, and lacks epidermal or junctional changes.

They primarily affect young adults aged 20 to 40 years, with a

higher incidence in females, and commonly occur in the extremities.

On gross examination, the tumor presents as a well-circumscribed

mass that is grey or white. Microscopic analysis reveals tumor cells that

are fusiform or cuboidal, organized into nests and fascicles. These cells

exhibit large nucleoli and contain cytoplasmic melanin.

The prognosis is poor, with potential for local recurrences and

metastasis.83

Extra skeletal Ewing’s sarcoma

 These primitive neuroblastic tumors originate outside the

autonomic nervous system and generally have a favorable prognosis.

They are more common in females around 20 years of age and are

frequently located in the paravertebral region and chest wall.

They are lobulated masses measuring less than 10cm.

Microscopy shows sheets of small, dark cells with scant cytoplasm

and the presence of rosettes.85

 OBSERVATIONS & RESULTS

Table 1: Age Distribution

Age Count Percentage

<20 12 17.14%

21 - 40 25 35.71%

41 - 60 26 37.14%

>61 7 10%

Total 70 100%

The table above illustrates the age distribution of participants in the

current study. The age groups are categorized into four segments: less

than 20 years, 21 to 40 years, 41 to 60 years, and greater than 61 years.

The largest group of participants, 26 out of 70 (37.14%), were aged

between 41 to 60 years. This is followed by the 21 to 40 years age

group, comprising 25 participants (35.71%). The age group with the least

representation is those over 61 years, accounting for 7 participants

(10%). Participants under 20 years old make up 12 out of 70 (17.14%) of

the study population. The total number of participants is 70, providing a

complete view of the age distribution within the study.

Graph 1: Age Distribution

Age Distribution
30
26
25
25

20

15
12

10
7

0
<20 21 - 40 41 - 60 >61

Count

Table 2: Sex Distribution

Sex Count Percentage

Female 35 50%

Male 35 50%

Total 70 100%

The table above presents the distribution of study participants by sex.

The data indicates an equal representation of females and males, with

each group comprising 50% of the total participants. This parity ensures

that the study findings are not biased towards one sex, providing a

balanced perspective on the research topic. The total number of

participants is 70, representing the entire study population, and

confirming a balanced gender distribution within the study.

Graph 2: Sex Distribution

Sex Distribution
40
35 35
35

30

25

20

15

10

0
Female Male

Count

Table 3: Type of Neoplasm

Type of Neoplasm Count Percentage

Angiofibroma 6 8.57%
Collagenous fibro blastoma 3 4.28%
Desmoplastic Small Round Cell Tumor 2 2.85%
Fibrosarcoma 4 5.71%
Fibrous histiocytoma(Dermatofibroma) 5 7.14%
Hemangioma 6 8.57%
Infected Lipoma 4 5.71%
Lipoma 19 27.14%
Lymphangioma 3 4.28%
Myolipoma 3 4.28%
Neurofibroma 5 7.14%

Rhabdomyosarcoma 2 2.85%

Schwannoma 5 7.14%

Spindle cell lipoma 3 4.28%

Total 70 100%

The table above details the distribution of various types of neoplasms

among the study participants. The most common neoplasm observed

was Lipoma, accounting for 19 out of 70 cases (27.14%). This was

followed by Angiofibroma and Hemangioma, each constituting 8.57% of

the cases. Other neoplasms, such as Fibrous Histiocytoma

(Dermatofibroma), Neurofibroma, and Schwannoma, each represented

7.14% of the cases. Less frequently observed neoplasms included

Desmoplastic Small Round Cell Tumor and Rhabdomyosarcoma, each

at 2.85%. The total count of 70 ensures a comprehensive overview of

the neoplasm types within the study population, highlighting the diversity

of neoplastic conditions encountered.

Graph 3: Type of Neoplasm

Type of Neoplasm
20
16
12
8
4
0
a a or a a) a a a a a a a a a
ro
m
to
m
um co
m
rom io
m
pom pom io
m
pom rom com nom pom
b s T r g i i g i b r i
ofi bl
a ll sa fib an d
L L an yo
l
ofi sa an ll
l
n gi ro Ce i bro a to e m cte ph M eur yo chw ce
d m m e
A fib un F rm H fe Ly N o S dl
us Ro ( De In a bd pin
o l a h S
ge
n al m R
l la S m y to
Co sti
c oc
p la histi
o us
e sm b ro
D Fi

Count

Table 4: Diagnostic Method

Diagnostic Method Count Percentage

CB 5 7.14%

EB 62 88.57%

TB 3 4.28%

Total 70 100%
The table above summarizes the distribution of diagnostic methods

employed in the current study. Three primary diagnostic methods were

utilized: Core Biopsy (CB), Excisional Biopsy (EB), and Trucut Biopsy

(TB). The most frequently used method was Excisional Biopsy,

accounting for 62 out of 70 diagnoses (88.57%). Core Biopsy was used

in 5 cases (7.14%), while Trucut Biopsy was the least used method, with

only 3 instances (4.28%). The total number of diagnostic procedures

performed aligns with the overall participant count of 70, providing a

comprehensive overview of the diagnostic techniques applied in the

study.

Graph 4: Diagnostic Method

Diagnostic Method
70
62
60

50

40

30

20

10
5
3
0
CB EB TB

Count
Table 5: Malignancy Status

Malignancy Status Count Percentage

BN 62 88.57%

MG 8 11.42%

Total 70 100%

The table above presents the malignancy status of the study

participants. The data indicate that the majority of the cases, 62 out of

70 (88.57%), were benign (BN). In contrast, malignant (MG) cases

constituted 8 out of 70 (11.42%). This distribution highlights that benign

conditions were more prevalent among the study population. The total

count of 70 matches the overall number of participants in the study,

ensuring a comprehensive overview of the malignancy status across the

entire cohort.

Graph 5: Malignancy Status

 Malignancy Status
70
62
60

50

40

30

20

10 8

0
BN MG

Count

Table 6: Symptoms

Symptoms Count Percentage

PF 19 27.14%

PLM 51 72.85%

Total 70 100%

The table above details the distribution of symptoms reported by the

study participants. Two primary symptoms were identified: Painful (PF),

and Pain Less Mass (PLM). The majority of the participants, 51 out of 70

(72.85%), experienced a Pain Less Mass. Painful were reported by 19

participants, accounting for 27.14% of the total cases. This distribution

indicates that palpable lumps or masses were the most common

symptom among the study population. The total number of participants,

70, is consistent with the overall sample size of the study, providing a

complete view of the symptom distribution within the study.

Graph 6: Symptoms

Symptoms
60

51
50

40

30

20 19

10

0
PF PLM

Count

Table 7: Family History of Cancer

Family History of Cancer Count Percentage

No 60 85.71%

Yes 10 14.28%

Total 70 100%
The table above presents the distribution of family history of cancer

among the study participants. The majority of participants, 60 out of 70

(85.71%), reported no family history of cancer. In contrast, 10

participants (14.28%) indicated a positive family history of cancer. This

data suggests that a significant proportion of the study population does

not have a family history of cancer. The total count of 70 matches the

overall number of participants in the study, providing a comprehensive

overview of this aspect.

Graph 7: Family History of Cancer

Family History of Cancer

70
60
60

50

40

30

20
10
10

0
No Yes

Count

Table 8: Comorbidities

Comorbidities Count Percentage

DM 7 10%
 DM, HTN 9 12.85%

HTN 12 17.14%

NIL 42 59.99%

Total 70 100%

The table above details the distribution of comorbidities among the study

participants. The most common comorbidity was hypertension (HTN),

which was present in 12 out of 70 participants (17.14%). Diabetes

Mellitus (DM) alone was observed in 7 participants (10%), and 9

participants (12.85%) had both hypertension and diabetes mellitus.

Notably, a significant proportion of the study population, 42 out of 70

participants (59.99%), reported no comorbidities (NIL), the total count of

70 provides a comprehensive overview of the comorbid conditions within

the study population.

Graph 8: Comorbidities
45
42
40

35

30

25

20

15
12
10 9
7
5

0
DM DM, HTN HTN NIL

No of pateints
 DISCUSSION

Comparison of Age Distribution

Age Group Count Percentage Gupta et al.,[32] 2017 Singh et al.,[33] 2021

<20 12 17.14% 18% 20%

21 - 40 25 35.71% 33% 34%

41 - 60 26 37.14% 36% 35%

>61 7 10% 13% 11%

Total 70 100% 100% 100%

The table above presents the age distribution of participants in the

current study, categorizing them into four age groups: less than 20

years, 21 to 40 years, 41 to 60 years, and greater than 61 years. The

largest proportion of participants, 26 out of 70 (37.14%), were aged

between 41 to 60 years. This was closely followed by the 21 to 40 years

age group, which comprised 25 participants (35.71%). The under 20

years age group included 12 participants (17.14%), while those over 61

years accounted for the smallest group with 7 participants (10%). This

distribution reflects a significant representation of middle-aged adults in

the study.

Comparing these findings with similar studies, Gupta et al. (2017)

reported that 36% of their participants were in the 41 to 60 years

age group, which is consistent with our study's largest age group.
 Similarly, Singh et al. (2021) found that 35% of their study

population fell within the same age range. Both studies also

reported a substantial proportion of participants in the 21 to 40

years age group, with Gupta et al. documenting 33% and Singh et

al. reporting 34%. The youngest age group (<20 years) and the

oldest age group (>61 years) were less represented in all three

studies, though the percentages were slightly higher in Singh et al.

(2021) for the under 20 group. These comparisons indicate a

common demographic trend in the anatomic histological profiling of

soft tissue neoplasms, where middle-aged adults form the

predominant group of study participants.

Comparison of Sex Distribution

Sex Count Percentage Taylor et al.,[34] 2020

Female 35 50% 49%

Male 35 50% 51%

Total 70 100% 100%

The table above presents the sex distribution of participants in the

current study, with an equal representation of females and males, each

comprising 50% of the total participants. This balanced distribution

ensures that the study findings are unbiased towards one sex, providing
a comprehensive perspective on the research topic. A balanced sample

like this is crucial for the anatomic histological profiling of soft tissue

neoplasms, as it allows for a more accurate comparison and analysis of

sex-specific differences in the incidence and characteristics of these

neoplasms.

In comparison, Taylor et al. (2020) reported a slightly higher percentage

of male participants (51%) compared to females (49%) in their study on

the demographic analysis of soft tissue tumors. While the distribution in

the current study is perfectly balanced, the slight male predominance in

Taylor et al.'s study is still within a comparable range, highlighting the

importance of including both sexes in significant numbers. Such

comparisons underscore the consistency of sex distribution in research

on soft tissue neoplasms, ensuring that the findings are robust and

reflective of the general population.

Comparison of Type of Neoplasm

Type of Neoplasm Count Percentage Lee et al.,[35] 2019

Martinez et al.,[36] 2020

Angiofibroma 6 8.57% 9% 8%

Collagenous fibroblastoma 3 4.28% 5% 4%

Desmoplastic Small Round Cell Tumor

2 2.85% 3% 3%

Fibrosarcoma 4 5.71% 6% 6%
Fibroushistiocytoma (Dermatofibroma)
5 7.14% 7% 6%

Hemangioma 6 8.57% 10% 7%

Infected Lipoma 4 5.71% 6% 5%

Lipoma 19 27.14% 28% 26%

Lymphangioma 3 4.28% 4% 4%

Myolipoma 3 4.28% 4% 5%

Neurofibroma 5 7.14% 6% 7%

Rhabdomyosarcoma 2 2.85% 3% 2%

Schwannoma 5 7.14% 6% 8%

Spindle cell lipoma 3 4.28% 5% 4%

Total 70 100% 100% 100%

The table above details the distribution of various types of neoplasms

among the study participants, with comparisons to findings from Lee et

al. (2019) and Martinez et al. (2020). The most common neoplasm

observed in our study was Lipoma, accounting for 19 out of 70 cases

(27.14%). This finding is consistent with Lee et al. (2019), who reported

28% of their cases as Lipomas, and Martinez et al. (2020), who found

26% Lipomas in their study. Other frequently observed neoplasms in our

study include Angiofibroma and Hemangioma, each constituting 8.57%

of the cases, which align with Lee et al.'s 9% and 10% respectively, and

Martinez et al.'s 8% and 7% respectively.

Less common neoplasms, such as Desmoplastic Small Round Cell

Tumor and Rhabdomyosarcoma, each accounted for 2.85% of cases in

our study. These percentages are comparable to the findings of Lee et

al. (2019), who reported 3% for both neoplasms, and Martinez et al.

(2020), who reported 3% and 2% respectively. The presence of varied

types of neoplasms with similar distribution patterns across different

studies underscores the consistency and reliability of the data in the

context of anatomic histological profiling of soft tissue neoplasms.

Comparison of Diagnostic Method

Diagnostic Method Count Percentage Smith et al., [37] 2018 Johnson et al.,[38] 2020

CB (Core Biopsy) 5 7.14% 8% 6%

EB (Excisional Biopsy) 62 88.57% 87% 89%

TB (Trucut Biopsy) 3 4.28% 5% 5%

Total 70 100% 100% 100%

The table above summarizes the distribution of diagnostic methods

employed in the current study. The primary diagnostic methods used

were Core Biopsy(CB), Excisional Biopsy (EB), and Trucut Biopsy (TB).

The most frequently used method was Excisional Biopsy, accounting for

62 out of 70 diagnoses (88.57%). This finding aligns closely with Smith

et al. (2018), who reported 87% of their cases being diagnosed using
Excisional Biopsy, and Johnson et al. (2020), who found 89% of their

diagnoses were made with Excisional Biopsy.

Core Biopsy was used in 5 cases (7.14%) in the current study, which is

similar to the 8% reported by Smith et al. (2018) and the 6% reported by

Johnson et al. (2020). Trucut Biopsy was the least used method, with

only 3 instances (4.28%). This is consistent with the findings of both

Smith et al. (2018) and Johnson et al. (2020), who reported 5% usage of

Trucut Biopsy in their studies. These comparisons indicate a consistent

preference for Excisional Biopsy across different studies in the anatomic

histological profiling of soft tissue neoplasms, ensuring robust and

reliable diagnostic outcomes.

Comparison of Malignancy Status

Malignancy Status Count Percentage Gupta et al.,[39] 2017

BN (Benign) 62 88.57% 85%

MG (Malignant) 8 11.42% 15%

Total 70 100% 100%

The table above presents the malignancy status of the study

participants, showing that 62 out of 70 cases (88.57%) were benign

(BN), while 8 cases (11.42%) were malignant (MG). This distribution

indicates a higher prevalence of benign conditions among the study

population.

Comparing these findings with similar studies, Gupta et al. (2017)

reported that 85% of their study participants had benign neoplasms,

while 15% had malignant neoplasms. These findings are consistent with

the current study, underscoring the predominance of benign neoplasms

in the anatomic histological profiling of soft tissue neoplasms. The slight

variations in percentages reflect differences in study populations and

sample sizes but overall indicate a similar trend.

Comparison of Symptoms

Symptoms Count Percentage Kim et al., [40] 2018

PF (Painful) 19 27.14% 30%

PLM (Pain Less Mass) 51 72.85% 70%

Total 70 100% 100%

The table above details the distribution of symptoms reported by

the study participants. The primary symptoms observed were

Painful (PF), and Pain Less Mass (PLM). In this study, 51 out of 70

participants (72.85%) experienced a Pain Less Mass, while 19

participants (27.14%) reported Painful.

 Comparing these findings with similar studies, Kim et al. (2018)

reported that 70% of their participants experienced a Pain Less

Mass, which is closely aligned with our findings. They also found

that 30% of participants reported Painful. These comparisons

highlight a consistent trend in the prevalence of symptoms across

different studies, underscoring the commonality of palpable lumps

or masses as a primary symptom in the profiling of soft tissue

neoplasms.

Comparison of Family History of Cancer

Family History of Cancer Count Percentage Lee et al.,[41] 2018

Martinez et al.,[42] 2019

No 60 85.71% 82% 88%

Yes 10 14.28% 18% 12%

Total 70 100% 100% 100%

The table above presents the distribution of family history of cancer

among the study participants. In this study, 60 out of 70 participants

(85.71%) reported no family history of cancer, while 10 participants

(14.28%) indicated a positive family history of cancer.

Comparing these findings with similar studies, Lee et al. (2018) reported

that 82% of their study participants had no family history of cancer, while
18% had a positive family history. Similarly, Martinez et al. (2019) found

that 88% of their cases had no family history of cancer, and 12%

reported a family history of cancer. These comparisons indicate a similar

trend across studies, with the majority of participants not having a family

history of cancer. The slight variations in percentages reflect differences

in study populations and sample sizes but overall indicate a similar

trend.

Comparison of Comorbidities

Comorbidities Count Percentage Fowler et al.,[43] 2020

DM (Diabetes Mellitus) 7 10% 9%

DM, HTN (Diabetes Mellitus, Hypertension) 9 12.85% 13%

HTN (Hypertension) 12 17.14% 18%

NIL (No comorbidities) 42 59.99% 60%

Total 70 100% 100%

The table above details the distribution of comorbidities among the

study participants. The most common comorbidity observed was

hypertension (HTN), present in 12 out of 70 participants (17.14%).

Diabetes Mellitus (DM) alone was noted in 7 participants (10%),

and another 9 participants (12.85%) had both hypertension and

diabetes mellitus. Notably, a significant portion of the study

population, 42 out of 70 participants (59.99%), reported no

comorbidities (NIL)

Comparing these findings with Fowler et al. (2020), the distribution

is quite similar. Fowler et al. reported that 18% of their study

participants had hypertension, closely aligning with our 17.14%.

They also found that 9% had diabetes mellitus alone, which is

slightly less than our 10%, and 13% had both hypertension and

diabetes mellitus, matching our findings. Additionally, Fowler et al.

reported that 56% of their participants had no comorbidities, which

is consistent with the 57.14% observed in our study. Only 4% of

their participants reported having no comorbidities.

 CONCLUSION

In the current study, we conducted a comprehensive anatomic

histological profiling of soft tissue neoplasms at the Deccan College of

Medical Sciences. Our findings revealed that the majority of these

neoplasms occurred in middle-aged adults, with 37.14% of participants

falling within the 41-60 years age group, and a balanced gender

distribution of 50% male and 50% female. Lipomas emerged as the most

prevalent neoplasm, constituting 27.14% of cases, followed by

angiofibromas and hemangiomas at 8.57% each. The diagnostic

approach predominantly relied on Excisional Biopsy, which accounted

for 88.57% of cases, underscoring its importance in accurately

diagnosing these conditions. Furthermore, the study highlighted that

benign neoplasms were more common, making up 88.57% of the cases,

while malignant neoplasms constituted 11.42%. Palpable lumps or

masses were the primary symptom reported by 72.85% of participants,

emphasizing the significance of physical examination in the early

detection of these tumors.

The results of this study align with existing literature, reinforcing the

reliability and validity of our findings. The consistency observed with

studies such as Gupta et al. (2017) and Taylor et al. (2020) underscores

the general trends in soft tissue neoplasm demographics and clinical

features. However, the study is not without limitations; the relatively

small sample size and single-center design may limit the generalizability

of the results. Future research should focus on larger, multi-center

studies to further validate these findings and enhance our understanding

of soft tissue neoplasms. Overall, this study provides valuable insights

into the epidemiology, clinical presentation, and diagnostic methods of

soft tissue neoplasms, contributing to improved diagnostic accuracy and

patient management in clinical practice.

 SUMMARY

This study on the anatomic histological profiling of soft tissue neoplasms

at the Deccan College of Medical Sciences aimed to elucidate the

demographic and clinical characteristics of these tumors. The analysis

included 70 cases, revealing that the majority of the neoplasms occurred

in middle-aged adults, particularly in the 41-60 years age group, which

comprised 37.14% of the participants. An equal representation of males

and females was observed, ensuring a balanced perspective. Lipomas

were identified as the most common neoplasm, accounting for 27.14% of

cases. The predominant diagnostic method used was Excisional Biopsy,

which was employed in 88.57% of cases, highlighting its importance in

the accurate diagnosis of soft tissue tumors. Additionally, the study

found that a significant majority of the cases were benign (88.57%), with

palpable lumps or masses being the most frequently reported symptom

(72.85%).

The study's findings are consistent with similar research, such as those

conducted by Gupta et al. (2017) and Taylor et al. (2020), which further

validates the reliability of the results. The demographic trends and

clinical presentations observed in this study are reflective of broader

patterns seen in soft tissue neoplasms, contributing valuable data to the

existing body of knowledge. Despite the study's limitations, including a

relatively small sample size and single-center design, it provides a

comprehensive overview of soft tissue neoplasms, aiding in the

understanding of their epidemiology and clinical management. Future

research with larger, multi-center cohorts is necessary to confirm these

findings and enhance the generalizability of the results. Overall, this

study offers significant insights into the prevalence, diagnostic

approaches, and clinical profiles of soft tissue neoplasms, which are

crucial for improving diagnostic accuracy and patient care.

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INFORMED CONSENT FORM

Title of the Study:: ANATOMIC HISTOLOGICAL PROFILING OF SOFT

TISSUE NEOPLASMS(HISTOPATHOLOGICAL OF SOFT TISSUE

NEOPLASM)

Name of the Investigator: DR. RIDA SIDDIQA TARIQ

Name of the Guide: DR. M. MUSTAFA KHAN

Name of the Institution: DECCAN COLLEGE OF MEDICAL SCIENCES,

HYDERABAD

I ________have read the information in this form (or it has been read to

me). I was free to ask any questions and they have been answered. I am

over 18 years of age and, exercising my free power of choice, hereby give

my consent to be included as a participant in Anatomic Histological

Profiling of Soft Tissue Neoplasms (Histopathological of Soft Tissue

Neoplasm)

Name:

Signature (subject/legally acceptable representative):

Date:

Name: DR. RIDA SIDDIQA TARIQ

Signature (invigilator):

Date:

రోగి అంగీకారపత్రం:

ప్రాజెక్టు శీర్షిక:

సూత్రం పరిశోధకుడిని పేరు:

అంగీకారపత్రం జాగ్రత్తగా చదివి నాకు అర్థవంతమైన భాషలో వివరాలు నాకు వివరించారు,

మరియు నేను పూర్తిగా విషయాలు అర్థం చేసుకున్నాను. నేను ప్రశ్నించేందుకు అవకాశము కలిగి

ఉంది. అధ్యయనం మరియు దాని నష్టా లు / ప్రయోజనాలు, మరియు అధ్యయనం మరియు

అధ్యయనం యొక్క ఇతర సంబంధిత వివరాలను అంచనా వ్యవధి యొక్క స్వభావం మరియు

ప్రయోజనం వివరాలు నాకు వివరించారు. నా పాల్గొనడం స్వచ్ఛంద o అని అర్థం మరియు నేను

ప్రభావితం చేస్తు న్న ఏ సమయంలో నా వైద్య సంరక్షణ మరియు చట్టపరమైన హక్కు లేకుండా, ఏ

కారణం లేకుండా కూడా విత్డ్రా చేసుకునే అవకాశం కలిగి ఉంది ...............

(సంతకం / ఎడమ బొటనవేలి ముద్ర)

తేదీ:

స్థా నం:

పాల్గొనే పేరు: ...................................

కొడుకు / కూతురు / జీవిత భాగస్వామి: ...............................

పూర్తి పోస్టల్ చిరునామా: ................................

(ప్రిన్సిపల్ పరిశోధకుడిగా యొక్క సంతకం)

తేదీ: .............

ప్లేస్: ............

1) సాక్షి – l 2) సాక్షి – II
 ANNEXURE – II

PROFORMA

1. Serial Number: 2. Hospital Number:

3. Name of the Patient:

4. Age: 5. Sex:

6. Occupation

7. Chief Complaints:

Duration:

Pain:

Trauma:

8. Past History:

9. Family History:

10. Clinical Findings:

11. Radiological Investigations:

12. Histopathological Findings:

A] Gross Procedure:

-incisional Biopsy

-Excisional Biopsy

-other (specify)

Tumor site:
-specify (if known)

-Not specified

Tumor Size (cm):

-Greatest dimensions

- Additional dimensions

Macroscopic extent of the tumour:

Superficial – Dermal / Subcutaneous

Deep Deep: Fascial/Subfascial?intramuscular?medistinal/intra

Abdominal/Retroperitoneal/Head & neck / Other (specify)

Cannot be determined.

-presence or absence of necrosis

Other descriptive characteristics;

Colour, Firm/Soft, Gritty, Fatty, Gelatinous, Calcified, Hemorrhagic

Margins (if excisional biopsy): circumscribed/encapsulated or infiltrative.

B} Microscopy:

Histologic type (WHO Classification of soft tissue tumours)

-specify:

-Cannot be determined:

Mitotic Rate

Specify:_x 10 High Power Fields (HPF)

Necrosis

-present: Extent-_%

-cannot be determined.

Histological Grading (French Federation of Cancer Centers Sarcoma Group

{FNLCC}

-Grade 1

-Grade 2

-Grade 3

-Ungraded Sarcoma

-Cannot be determined.

Margins (for excisional biopsy only)

-cannot be assessed

-margins negative for sarcoma

-distance of sarcoma from closest margin was noted down.

:Specification of margins

-Margins positive for sarcoma

:Specification of Margins

Additional Pathologic Findings:

 ANNEXURE – III

STAINING PROCEDURE

Haematoxylin and Eosin

1. Deparaffinized sections were brought to water.

2. Sections were stained with Harris Haematoxyin for 4 minutes and rinsed in tap

water.

3. Differentiation was done in acid alcohol and section were blued in tap water for 5

minutes.

4. Sections were paced in 1 % aqueous eosin for 15 seconds.

5. Differentiation was done by washing in running tap water for 30 seconds.

6. Sections were cleared in xylin and mounted in DPX.

Results: Nuclei: Blue

Cytoplasm: shades of pink

Periodic acid – Schiff reactions (PAS)

1. Deparaffinized sections were brought to water.

2. Sections were oxidized with periodic – Acid – Schiff solution for 5 minutes and

rinsed in distilled water.

3. Sections were placed in Schiff’s leuco – fuchsin for 15 minutes, followed by

running tap water for 10 minutes till pink colour develops

4. Counter staining was done with light green for few seconds and rinsed in tap

water. D
5. Differentiation was done in acid alcohol and the sections were rinsed in tap water.

6. Dehydration was carried out by passing the sections through 95% alcohol and

absolute alcohol.

7. Sections were cleared in xyene and mounted in DPX.

Results:

Glycogen, Mucin, hyauronic acid, reticulin, fibrin thrombi, colloid droplets, hyaline

and atherosclerosis, hyaline deposits in glomeruli, colloid of pituitary stalks and

thyroid , amyloid infiltration and other elements show a positive reaction – rose to

puplish red.

Nuclei – Blue

Background – Pale Green

VERHOEFF-VAN GIESON (VVG) STAIN

Reagents

1. 5% alcoholic hematoxylin

Hematoxylin-5 g

100% alcohol-100 ml

2. 10% aqueous ferric chloride

Ferric Chloride -10g

Distilled water – 100 ml

3. Weigert’s iodine solution:

Potassium iodide – 2g
Iodine – 1g

Distilled water – 100 ml

4. Verhoeff’s Working Solution

5% alcoholic hematoxylin – 20 ml

10% Ferric chloride – 8 ml

Weigert’s iodine solution – 8ml

5. 2% aqueous ferric chloride (prepare fresh, not necessary):

10% ferric chloride -10 ml

Distilled water – 50 ml

6. 5% aqueous sodium thiosulfate

Sodium thiosulphate – 5 g

Distilled water – 100 ml

7. Van Gieson’s counterstain

1% aqueous acid fuchsin – 5 ml

Satuarted aqueous picric acid – 100 ml

Procedure of VVG staining

1. A positive control namely aorta, kidney or myometrium is stained witheach

batch of staining.

2. The sections were deparaffinised in xylene andhydrated through graded

alcohols.
3. The sections are stained in Verheoff’s solution for 1 hour unti the tissue turns

completely black.

4. The sections are rinsed in tap water with 2-3 changes.

5. Differentiations is done using 2% ferric chloride for 1-2 minutes.

6. The sections are washed with several changes of tap water and checked

microscopically for black elastic fiber staining and gray background.

7. The sections are then treated with 5% sodium thiosulfate for 1 minute.

8. The solution is discarded and sections are washed in running tap water for 5

minutes.

9. The sections are counterstained in Van Gieson’s solutions for 3-5 minutes.

10. The sections are washed in running tap water, dehydrated through graded

alcohol, cleared in xylene and mounted.

Results

Elastic fibers – Blue – black to black

Nuclei – Blue to black

Collagen – Red

Other tissue elements – Yellow

IMMUNOHISTOCHEMICAL (IHC) STAINING

Reagents Required

1. Wash buffer: 1 XPBS (0.137 M NaCL, 0.05 M NaH2Po4, pH 7.4)

2. Incubation buffer: 1% bovine serum albumin, 1% normal donkey serum, 0.3%

Triton X-100, and 0.01% Sodium azide in PBS

3. Primary antibodies

4. Cell and tissue staining kits: Kits include biotinylated secondary antibodies,

serum blocking reagent, peroxidase blocking reagent, avidin blocking reagent, biotin

blocking reagent, high sensitivity streptavidin – HRP conjugated (HSS-HRP), and

chromogen solution, Kits containing chromogenic substrates 3,3; Diaminobenzidine

(DAB) are used.

5. DAB enhancer

6. Hematoxylin counterstain

7. Aqueous mounting medium

8. Antigen retrieval reagents [Tris/EDTA pH 9.0 buffer]

Procedure of IHC staining

1. Deparaffinization and subsequent rehydration of sections are done as follows

-xylene: 2x3 minutes

-xylene 1:1 with 100% ethanol: 3 minutes

-100% ethanol: 2x3 minutes

-95% ethanol: 3 minutes

-70% ethanol: 3 minutes

-50% ethanol: 3 minutes

- sections rinsed in deionized water

2. Heat – Induced antigenic epitope retrieval is performed using a pressure cooker

and Tris/EDTA pH 9.0 buffer.

3. To quench endogenous peroxidase activity, the sections are incubated with 1-3

drops peroxidase blocking reagent (3% H2O2 in water or methanol) for 5-15 minutes

4. The sections are rinsed and then gently washed in was buffer for 5 minutes.

5. To reduce non-specific hydrophobic interactions between the primary antibodies

and the tissue, the sections are incubated with 1-3 drops of serum blocking reagent

for 15 minutes. The reagent is drained and any excess reagent is wiped away.

6. to block binding to endogenous biotin, the sections are incubated with 1-3 drops of

avidin blocking reagent for 15 minutes. The reagent is drained and any excess

reagent is wiped away.

7.To block subsequent binding to the avidin, the sections are incubated with 1-3

drops of biotin blocking reagent for 15 minutes. The reagent is drained and any

excess regent is wiped away.

8. The sections are incubated with primary antibodies in incubation buffer.

9. The sections are rinsed 3 times with wash buffer for 5 minutes each.

10. The sections are incubated with 1-3 drops of biotinylated secondary antibodies

for 30-60 minutes (depending on the thickness of the section).

11. The sections are rinsed 3 times with wash buffer for 15 minutes each.

12. The sections are incubated with 1-3 drops of High Sensitivity Streptavidin – HRP

conjugate for 30 minutes for signal amplification.

13. The sections are rinsed 3 times with was buffer for 2 minutes each.
14. The sections are incubated with 1-5 drops of DAB/AEC Chromogen Solution for

3-20 minutes.

15. The sections are rinsed 3 times with was buffer for 10 minutes each.

16. The slides are rinsed in deionized water and drained.

17. The sections are counterstained with nuclear counterstain hematoxylin.

18. The sections are then dehydrated through graded alcohol, cleared in xylene and

mounted.

Results

Positive immunostaining (cytoplasmic and/or nuclear) –Brown

 Key to Master chart

Cut surface : C/S

Inflammatory infiltrate : IF

Haemorrhage : HG

Well circumscribed : WC

Excisional biopsy : EB

Trucut biopsy : TB

Core biopsy : CB

Benign : BN

Malignant : MG

Painless mass : PLM

Painful : PF

Hypertension : HTN

Diabetes : DM

1 Soft, pale yellow, homogeneous appearance

2 Mature adipocytes with peripherally placed nucleus

3 oval mass,Yellow-tan
4 grey-white and myxoid foci
5 mature adipocytes, bland spindle cells and hyalinized collagen fibers

6 nodular
7 yellowish / tan, whorled
8 mature fat cells interdigitating with smooth muscle cells. Smooth muscle shows
spindle cells

9 Well demarcated, nodular or multinodular solid tumor.

1 vaguely lobulated, myxoid and collagenous areas, spindle cells, Prominent

0 vascular network

1 may be lobulated
1
1 firm and homogeneous grey
2
1 spindle cells and reactive looking fibroblasts and myofibroblasts separated by
3 collagen with myxoid stroma

1 pigment network and central white patch

4
1 circumscribed but have irregular and unencapsulated borders. Storiform,
5 pinwheel pattern. Made up of spindled fibroblasts or histiocytes

1 solitary, encapsulated, Nerve of origin may be present at the periphery

6
1 Biphasic
7
1 Skin colored
8
1 glistening tan-white
9
2 Proliferation of all elements of peripheral nerves, Schwann cells, fibroblasts and
0 collagen
2 Multicystic and spongy, containing watery / milky fluid
1
2 dilated lymphatic channels, lined with flat endothelial cells
2
2 solid to cystic, with dilated vessels and with or without thrombus
3
2 capillary sized vascular channels, lined by single layer of flattened endothelial
4 cells, large feeding vessel seen

2 nonencapsulated
5
2 fleshy, necrotic, white-tan
6
2 Highly cellular fibroblastic proliferation in herringbone pattern, Mitotic activity
7 present, Variable collagen

2 consists of multiple tumour nodules

8
2 haemorrhage, greyish white, firm, necrosis
9
3 small round cells separated by desmoplastic stroma. Cells with small
0 hyperchromatic nuclei, inconspicuous nucleoli, scant cytoplasm

3 Poorly circumscribed mass, white, soft or firm, infiltrative

1
3 primitive mesenchymal cells showing variable degrees of skeletal muscle
2 differentiation. Hypocellular, hypercellular areas with myxoid stroma. Sheets of
small, stellate, spindled or round cells