Soft tissue lesions

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Soft tissue lesions strike fear in many pathologists as they are uncommon and may be difficult to diagnose.

Bone tumours are dealt with in the bone article.

WHO classification of soft tissue lesions/tumours

Morphologic grouping[1]

  1. Adipocytic tumours.
  2. Fibroblastic/myofibroblastic tumours.
  3. "Fibrohistiocytic" tumours.
  4. Smooth muscle tumours.
  5. Skeletal muscle tumours.
  6. Vascular tumours.
  7. Perivascular (pericytic) tumours.
  8. Chondro-osseous tumours.
  9. Tumours of uncertain differentiation.

Biologic potential grouping[2]

  1. Benign.
  2. Intermediate (locally aggressive).
  3. Intermediate (rarely metastasizing).
  4. Malignant.

Prevalence

  • All sarcomas are rare buggers.
    • As the classification has been changing over the past years (with more subtypes being recognized/identified) numbers are variable from study-to-study.
  • Once upon a time almost everything was called malignant fibrous histiocytoma; thus, it is listed as a common entity in some publications.

Most common:[3]

  • Liposarcoma.
  • Leiomyosarcoma.

Molecular testing

  • Molecular testing plays an important role in soft tissue pathology.
  • It is generally seen as an adjunct test that:[4]
    • Often is used to confirm the histomorphologic impression/quality control.
    • Frequently has some prognostic significance.
    • May directly affect treatment.

Adipocytic tumours

Hibernoma

General

  • Consists of brown fat (present in the infants to generate heat).[5]
  • Benign.
  • Usually asymptomatic.[6]

Epidemiology

  • Young adults.

Gross

  • Well-circumscribed.
  • Lobulated and light-brown on sectioning.

Microscopic

Features:[7]

  • Large polygonal/oval cells:
    • Nucleus - central & small.[8]
      • Nucleoli typically prominent.[9]
    • Cytoplasm - multivacuolated, oval, eosinophilic, granular.

Image:

Liposarcoma

  • Most common malignant sarcoma in the retroperitoneum.

Microscopy

Features:

  • Lipoblasts:
    • Large sharply demarcated vacuole.
    • Nucleus:
      • Hyperchromatic (dark staining) nucleus.
      • Eccentric location.
      • Nuclear indentation.

Images:

IHC

  • IHC is of limited value.
  • S-100 +ve ~1/3 of the time.
  • Reticulin ???.

Smooth muscle tumours

Leiomyosarcoma

See gyne notes.

Microscopy

Features:

  • Nuclear atypia.
  • Necrosis.
  • Mitoses.

Fibroblastic/myofibroblastic tumours

Proliferative fasciitis

  • Need to write something here.

Solitary fibrous tumour

General

  • Grouped with hemangiopericytoma in the WHO classification; possibly the same tumour (?).[10]
  • May be benign or malignant; more commonly benign.[11][12]

Microscopic

Features:

  • Well-circumscribed.
  • Fibroblast-like cells (spindle cells).
  • Hemangiopericytoma-like area (staghorn vessels) - not seen on image.
  • Keloid-like collagen bundles.

Images:

Hemangiopericytoma

General

  • Grouped with solitary fibrous tumour in the WHO classification; possibly the same tumour (?).[10]
  • Arises from the pericyte, a connective tissue cell of small vessels that is thought to be involved in flow regulation.
  • Hematologic spread most common - to lungs.[13]
  • Oncogenic osteomalacia - assoc. with hemangiopericytoma.[14]

Presentation

  • Usually painless mass, slow enlargement.

Radiology

  • Intramedullary lytic mass.
  • May be well-circumscribed.
  • +/-Periosteal reaction.
  • +/-Sclerotic border.

May be worked-up with angiography to distinguish from a vascular malformation.[15]

Location

  • Usually extremities - femur or prox. tibial.[16]

Histology

Features:[17]

  • Hypervascular lesion - key diagnostic feature.[18]
    • Abundant thin-walled branching small vessels of variable size.
      • May be described as "staghorn vessels" or "antler-like" vasculature.
      • Cells may "onion-skin" around thin blood vessels.
  • Spindle or ovoid shaped cells in nests or sheets.

IHC

Features:[10][18]

  • Vimentin +ve (usually).
  • Desmin -ve (typical).
  • Factor VIII -ve (marks endothelium).
  • CD34 +ve.
    • CD34 usu. -ve in synovial sarcoma.
  • CD31 -ve (marks benign endothelium).
  • vWF (von Willebrand factor) -ve.

DDx

  • Other vascular tumours.
  • Vascular malformations.
  • Synovial sarcoma.

Desmoplastic fibroblastoma

  • AKA collagenous fibroma.[19]
  • Benign lesion.
  • Classically found in shoulder region.

IHC

  • Beta-catenin -ve.[20]
    • Significance ???

Vascular lesions

Vascular lesions are "too red"; they have too many RBCs.

Hemangioma

General

Comes is various flavours:[21]

  • Tufted.
    • Small clusters of blood vessels.
  • Microvenular hemangioma.
  • Glomeruloid hemangioma.
  • Epithelioid hemangioma.
  • Targetoid hemosideric hemangioma.

Microscopic

Features:

  • Abundance of benign small blood vessels. (???)

Kaposi sarcoma

General

  • Not really a sarcoma.
  • Caused by HHV-8.
  • Associated with immunodeficiency, e.g. HIV/AIDS.

Stages

It is seen in different stages:[22]

  1. Patch stage.
  2. Plaque stage.
  3. Nodular stage.
  4. Lymphangioma-like. (???)

Microscopic

Features:[23]

  • Vascular channels that anastomose - key feature.
  • +/-Nuclear atypia.
  • Hyaline globules (intracytoplasmic)[24] - pale pink globs (that are paler than RBCs) - important feature.
  • +/-Hemosiderin deposits.

DDx:

  • Angiosarcoma (have many mitoses, nuclear atypia).
  • Masson's hemangioma (Intravascular papillary endothelial hyperplasia).

Notes:

  • Hyaline globules have a DDx (hepatocellular carcinoma, lung adenocarcinoma, chondrosarcomas + others).[24]
  • Promontory sign - small vessel protruding into an abnormal vascular space.[25]

Images:

IHC

  • CD31 +ve.
  • CD34 +ve.
  • HHV-8 +ve.

Masson hemangioma

General

  • Benign non-neoplastic lesion - a vessel that has thrombosed and recanalized.
  • AKA intravascular papillary endothelial hyperplasia.[27]
  • Histomorphologically may be confused with low-grade angiosarcoma or other soft tissue sarcomas.[27]

Microscopic

Features:

  • Well-circumscribed - key (low power) feature.
  • Abundant small vascular channels with benign endothelium.

Notes:

  • Looks like Kaposi sarcoma at high power.

Angiosarcoma

General

  • Malignant tumour - with a horrible prognosis.[28]
  • Classically on the scalp or head & neck.
  • May arise secondary to therapeutic radiation or chronic lymphoedema related to breast carcinoma.

Microscopic

Features:

  • Very many small capillaries of irregular shape lined with:
    • Pleomorphic nuclei.
      • May have hobnail morphology.
  • Mitoses.
  • Cytoplasmic vacuoles.
    • Cells trying to form lumina - embryologic.

Notes:

  • Epithelioid variant (with abundant cytoplasm & sheeting architecture) may resemble melanoma or hepatocellular carcinoma.

IHC

  • CD34 +ve.
  • D2-40 +ve. (???)
  • CD31 +ve.

Hemangioendothelioma

General

  • Usually benign.

Microscopic

Features:[29]

  • Well-formed thin vascular channels on a fibrous stroma - key feature.
  • +/-Thrombosis.
  • +/-Calcification.
  • +/-Fibrosis.
  • +/-Myxoid change.

IHC

  • Factor VIII +ve.

Skeletal muscle tumours

Rhabdomyosarcoma

  • Often abbreviated RMS.
  • Most common paediatric sarcoma.
  • ~6% of all childhood cancer.

Histological subdivision:

  1. Alveolar rhabdomyosarcoma.
    • Usually young adults/adolescents.
    • Early mets common.
  2. Embryonal rhabdomyosarcoma.
    • Usual <10 years old.
    • Typically locally invasive.

Molecular and histologic subdivision:

  1. Translocation-positive alveolar RMS.
  2. Translocation-negative alveolar RMS.
  3. Embryonal RMS.

Notes:

  • Translocation-negative alveolar RMS shares characteristics with embryonal RMS.

Microscopy

Alveolar rhabdomyosarcoma:

  • Alveolus-like pattern:
    • Fibrous septae lined by tumour cells.
      • Space between fibrous sepate may be filled with tumour: solid variant of alveolar rhabdomyosarcoma.
  • Eccentric nucleus (???).
  • Cytoplasm - dense pink staining on H&E (if well differentiated).
  • Usu. nuclear pleomorphism +++.
  • Mitoses common.

Molecular diagnostics

Alveolar rhabdomyosarcoma

Common translocations (~80%):

  • t(1,13).
    • PAX7/FKHR fusion gene.
  • t(2,13).[30]
    • PAX3/FKHR fusion gene.

Several uncommon translocations exist.

IHC

  • Desmin (best marker).
  • Actin.

Tumours of uncertain differentiation

Clear cell sarcoma

  • Known among pathologists as "soft-tissue melanoma" and "melanoma of the soft parts", as it has a strong morphological resemblance.[31]
    • Molecular changes and origin distinct from melanoma.
  • Incidence: rare soft tissue tumour.

Clinical

  • Usually - deep soft tissue or extremities.
  • Guarded prognosis.
  • First described in 1965.[32]

Microscopy

Features:[31]

  • Architecture: sheets or fascicular (bundles) arrangement.
  • Cells: Spindle cells or epithelioid cells.
  • Prominent nucleoli - basophilic.
  • Fibrous septae.
  • Uniform

Image:

IHC

Features:[31]

  • S100 +ve.
  • HMB-45 +ve.
  • Melan A (MART-1) +ve; sometimes -ve.
  • BCL2 +ve.
  • CD57 +ve (usually).

Keratins:

  • EMA may be +ve.
  • CAM5.2 -ve.
  • AE1/AE3 -ve.

Molecular studies

  • Chromosomal translocation t(12;22)(q13;q12).[31]
    • Fusion transcripts:
      • EWSR1-ATF1.
      • EWSR1-CREB1 (GI tract associated).

Chondrosarcoma

  • May arise from an enchondroma.
  • Usually a good prognosis.

Microscopic

Features:

  • Resembles cartilage at low power.[33]
  • More cellular than cartilage... but relatively paucicellular compared to other sarcomas.

Images:

Grading

Features:[34]

  • Grade I: moderate cellularity +/- binucleated cells.
  • Grade III: nuclear pleomorphism, mitoses common.
  • Grade II: between Grade I and Grade III.

Synovial sarcoma

General

  • Does not arise from cartilage.[35]
  • Young adults or adolescents.

Microscopic

Comes in three flavours:[35][36]

  1. Spindle cell sarcoma with features of hemangiopericytoma, i.e. staghorn vessels.
  2. Biphasic synovial sarcoma:
    1. Spindle cells with features of hemangiopericytoma.
    2. Epitheliod glands or nests.
  3. Primative round cell type.

Images:

IHC

Features:[35]

  • Vimentin +ve + cytokeratin and/or EMA +ve.
  • CD99 +ve.

Others:

Molecular pathology

Unique translocation:

  • t(X;18)(p11.2;q11.2).[39]

See also

References

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