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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 348-352
A clinico‐pathologic study of soft tissue neoplasms: An experience from a rural tertiary care hospital


Department of Pathology, S.R.T.R. Government Medical College, Ambajogai, Maharashtra, India

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Date of Web Publication22-Jun-2017
 

   Abstract 

Context: Soft tissue is a non-epithelial extra skeletal tissue of the body exclusive of reticuloendothelial system, glia and supporting tissue of the various parenchymal organs. Aims: To study the clinico-pathological correlation, relative incidence of benign & malignant neoplasms, frequency of age, sex & site wise distribution & histopathological pattern of soft tissue neoplasms [STNs]. Setting and Design: Comprises of soft tissue neoplasms studied during six months. Cases of STNs diagnosed based on history and clinical examination and subjected to biopsy or surgery and subsequent histopathological examination were included while patients who were treated conservatively or referred to other hospitals and STNs of systemic organs were excluded. Materials & Methods: The tissues were fixed in 10% formalin and were processed. Sections of approximately 5 microns were cut and stained by routine hematoxylin and eosin [H & E] and immunohistochemistry [IHC] was done where ever required. All STNs were classified as per 2013 WHO classification. Result: Out of 70 cases of STNs recorded, 95.72% were benign and 04.28% were malignant. STNs in general had slightly male preponderance. Of all benign soft tissue neoplasms, the commonest was lipoma (64.28%) followed by peripheral nerve sheath (11.4%), vascular (8.5%), fibroblastic (4.28%), fibro-histiocytic (2.8%) and tumors of uncertain differentiation (2.8%) in the decreasing order to frequency. Conclusion: Availability of a modern, more logical histopathologic classification and standard nomenclature now offers a better clinic-pathological co-relation. The clinico-morphological evaluation is still the gold standard for the proper diagnosis of soft tissue neoplasms.

Keywords: Benign, histopathology, malignant, neoplasms, soft tissue
Key message: Data regarding clinico-pathological study of STNs in rural set up are lacking in literature. Here an attempt has been made to collect and evaluate the same in this study and compare the results with other studies.

How to cite this article:
Baste B D, Swami SY, Narhire V V, Dhamecha M P, DíCosta G. A clinico‐pathologic study of soft tissue neoplasms: An experience from a rural tertiary care hospital. Ann Trop Med Public Health 2017;10:348-52

How to cite this URL:
Baste B D, Swami SY, Narhire V V, Dhamecha M P, DíCosta G. A clinico‐pathologic study of soft tissue neoplasms: An experience from a rural tertiary care hospital. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Jun 26];10:348-52. Available from: http://www.atmph.org/text.asp?2017/10/2/348/208703

   Introduction Top


Soft tissue neoplasms (STNs) are defined as mesenchymalproliferations that occur in the extra skeletal, nonepithelial tissues of our body, excluding the viscera, coverings of brain and lympho-reticular system.

Like many other malignant tumors, the pathogenesis of most of the STNs is still unknown. Recognized causes include various chemical and physical factors, exposure to ionizing radiations, and inherited or acquired immunologic defects. Evaluation of the exact cause is difficult because of the long latent period. STNs can occur at any age. It has been noted that the histologic distribution of STNs is rather specific for a particular age group at a particular anatomical site.[1],[2]

They arise nearly everywhere in the body, the most important locations being the extremities, trunk, abdominal cavity, and head and neck region.[3]

Both benign and malignant STNs commonly present as a painless mass. When a soft tissue mass arises in a patient with no history of trauma or when a mass is persisting even after 6 weeks after a local trauma, a biopsy is indicated.

Fine needle aspiration cytology (FNAC) has a role to play in the diagnosis of soft tissue lesions and FNAC under imaging guidance is done in intra-abdominal and retroperitoneal lesions.[4]

STNs and tumor-like lesions have fascinated pathologist for many years because of their remarkably wide variety and the close histopathologic similarities between certain tumors with only subtle differences detectable on careful microscopic examination. This poses a diagnostic challenge to the histopathologist. They arise nearly everywhere in the body, the most important locations being the extremities, trunk, abdominal cavity, and head and neck region.[4] It is sometimes possible to make an accurate diagnosis by detailed clinical history, physical examination, and naked eye examination of the tumors. Clinical features like age of the patient, location, and size of the tumor help greatly in narrowing down the differential diagnosis.

There are special techniques that have been successfully applied to increase diagnostic accuracy; these include conventional special stains, electron microscopy, immunohistochemistry, and cytogenetic and molecular methods.

Availability of a modern, more logical histogenetic classification and standard nomenclature now offers a better clinico-pathologic correlation.


   Aims and Objectives Top


  1. To study the clinico-pathologic correlation of STNs.
  2. To find out the relative incidence of benign and malignant STNs.
  3. To study the frequency of age, sex, and sitewise distribution of these cases.
  4. To study the histopathologic pattern for understanding the classification and type of STNs.



   Materials and Methods Top


The present study comprises of all the STNs received in histopathologic section. Study was undertaken for a period of 6 months. The parameters included were age, sex, anatomical location, clinical diagnosis, relevant investigations, histopathologic features, and immunohistochemistry wherever necessary.

Inclusion criteria

Cases of STNs diagnosed on the basis of history and clinical examination and subjected to biopsy or surgery and subsequent histopathologic examination were included in this study.

Exclusion criteria

Patients who were treated conservatively or patients referred to other hospitals were excluded from this study. STNs of systemic organs (like leiomyoma of uterus)were excluded from this study.

Anatomical sites were categorized as upper extremity (including arm, forearm, wrist, and hand), lower extremity (including buttock, thigh, leg, and foot), trunk and others (including abdomen, shoulder, back, and chest wall), and head and neck.

The tissues were fixed in 10% formalin and processed through standard paraffin-embedding technique. Sections of approximately 3 µm were taken and stained by routine hematoxylin and eosin [H and E]. All STNs were classified according to 2013 WHO classification.[5]


   Observation and Results Top


The study was performed over a period of 6 months. During this period, total 1,286 surgical specimens were received for histopathologic examination in the histopathology section of our hospital. Out of these, 70 specimens were STNs.

The following results were drawn:

  • Seventy cases of STNs were recorded in the department of pathology during 6 months.
  • Benign STNs were 95.72%, while malignant constituted 04.28% of all STNs with a benign to malignant ratio of 22.3:1 [Table 1].
    Table 1: Relative incidence of benign and malignant STNs

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  • STNs in general had slightly male preponderance with a M:F of 1.8:1 [Table 2].
    Table 2: Age and sex incidence in STNs

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  • The male-to-female ratio among the benign STNs was 1.7:1 and among the malignant STNs was 2:1 [Table 3].
    Table 3: Sex incidence of all STNs

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  • Malignant STNs had a peak age incidence in the sixth decade.
  • Of all benign neoplasms of soft tissue, the commonest neoplasm was adipocytic (64.28%) followed by peripheral nerve sheath (11.4%), vascular (8.5%), fibroblastic (4.28%), fibro-histiocytic (2.8%), and tumors of uncertain differentiation (2.8%) in the decreasing order of frequency [Table 4].
    Table 4: Incidence of benign and malignant STNs

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  • The benign STNs had predilection for extremities and head and neck while the malignant STNs had predilection for the lower extremities [Table 5].
    Table 5: Site distribution of benign and malignant STNs

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   Discussion Top


Soft tissue is a nonepithelial extra skeletal tissue of the body exclusive of reticuloendothelial system, glia, and supporting tissue of the various parenchymal organs. It is represented by the voluntary muscles, adipose tissue, and fibrous tissue along with the vessels serving these tissues. They are classified according to the tissue they recapitulate (muscle fat, fibrous tissue, vessels, and nerves). Some STNs have no normal tissue counterpart but have consistent clinico-pathologic features warranting their designation as distinct entities.[6]

In present study, the frequency of benign STNs [Figure 1] and [Figure 2] was 95.72% and malignant STNs [Figure 3] was 4.28% [Table 6], which is comparable with the studies done by Umarani et al.,[7] Jain et al.,[6] and Batra et al.,[8] whereas Kransdorf[1],[2] reported 60.2% benign and 39.8% malignant STNs in their study. Petersen et al.[11] had done a retrospective study and found 49% malignant, 11.4% intermediate, 35% benign, and 4.6% as tumors of uncertain potential. In other study of STNs of head and neck by Makino[12] benign neoplasms were 96% and malignant were 45%. In all these studies, benign neoplasms predominated the malignant ones.
Figure 1: A: Angiomyoma: showing thick walled blood vessels surrounded by bundles of smooth muscles. [H&E: 40X] B: Schwannoma: showing Antony A and Antony B areas. [H&E: 40X] C: Hemangioma: showing numerous capillary sized blood vessels. [H&E: 10X] D: Hamartoma: showing vascular, lymphatic, smooth muscle, fibrous and adipocytic components. [H&E: 10X]

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Figure 2: A: Angiomatoid fibrous histiocytoma [Gross]: showing haemorrhagic and cystic area. B: Angiomatoid fibrous histiocytoma: showing cystic hemorrhagic area without endothelial lining & surrounded by tumor tissue. [H&E: 10X] C: Angiomatoid fibrous histiocytoma: showing spindle cells arranged in storiform pattern admixed with histiocytes & hemosiderin laden macrophages. [H&E: 40X]

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Figure 3: A: Liposarcoma [Gross]: showing greyish white tumour with cystic and haemorrhagic areas. B: Liposarcoma: showing plenty of adipocytes and occasional lipoblasts (Arrow). [H&E: 40X]

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Table 6: Distribution of cases in various studies

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A single case of undifferentiated pleomorphic sarcoma on lower extremity was observed in 60-year-old male patient. On gross examination, the tumor was 5 cm in diameter, grayish white irregular with areas of necrosis, hemorrhage, and myxoid component. Microscopically, it revealed chordoma-like areas admixed with giant cells, spindle cells, and areas of necrosis [Figure 4]. IHC revealed strong positivity with Vimentin [Figure 5].
Figure 4: Undifferentiated pleomorphic sarcoma [Gross]: showing greyish white tumour tissue with areas of haemorrhage, necrosis and myxoid component. B: Undifferentiated pleomorphic sarcoma: showing chordoma like areas. [H&E: 40X] C: Undifferentiated pleomorphic sarcoma: showing pleomorphic sarcoma component. [H&E: 40X] D: Undifferentiated pleomorphic sarcoma: showing myxoid component. [H&E: 10X]

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Figure 5: Undifferentiated pleomorphic sarcoma: showing strong positivity with Vimentin. [IHC: 40X]

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The relative frequency of benign to malignant STNs is difficult to estimate accurately, since many of the benign neoplasms cause not much problems and hence patients do not report to the clinicians, thereby these lesions are not removed. All around the world, many workers analyzed various aspects of STNs like age and sex distribution, site, clinical features, and so on, which have been published in many literatures. Specific sarcomas tend to appear in certain age groups.[6]

There is male preponderance in almost all STNs. In the present study, there were 45 males and 25 females out of total 70 cases of STNs, with M: F ratio of 1.8:1 [Table 7], which is same as in the study done by Beg et al.[3]. Our study is also comparable with that of Kransdorf[1] and Myhre-Jensen et al.[9] Lazim et al.[10] studied 213 cases of STNs in 1 year and reported a male preponderance in all STNs with M:F ratio of 1.7:1.
Table 7: Sex distribution of cases

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Regarding the site of STNs, in fair number of studies, the commonest site was extremities. Soft tissue tumors may arise in any location, although approximately 40% occur in lower extremities.[6]

In the present study, 33.13% of benign STNs were seen in extremities followed by head and neck region (32.23%), which is comparable with the finding of Beg et al.'s study.[3] The studies by Beg et al.,[3] Lazimet al.,[10] and Zhi-wei et al.[14] stated that the commonest site for malignant STNs was the lower extremities followed by trunk and abdomen, whereas in case of Mandong et al.,[13] extremities were the most common site followed by head and neck region.


   Conclusion Top


The diagnosis and management of STNs require a team perspective. Even though soft tissue sarcomas are rare and usually present just as painless mass, the clinician must be able to diagnose it early for better management.

A careful gross examination of the specimen and adequate sampling of the tumor is essential. Immunohistochemistry and special stains are helpful in addition to the routine H and E for the proper diagnosis of STNs. Availability of a modern, more logical histopathologic classification and standard nomenclature now offers a better clinic-pathologic correlation.

The clinico-morphologic evaluation is still the gold standard for the proper diagnosis of soft tissue tumors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kransdorf MJ. Benign soft-tissue tumors in a large referral population: distribution of specific diagnoses by age, sex, and location. Am J Roentgenol 1995;164:395-402.  Back to cited text no. 1
    
2.
Kransdorf MJ. Malignant soft tissue tumors in a large referral population: distribution of specific diagnosis by age, sex and location. Am J Roentgenol 1995;164:129-34.  Back to cited text no. 2
    
3.
Hassawi BA, Suliman AY, Hasan IS. Soft tissue tumors-histopathological study of 93 cases. Ann Coll Med Mosul 2010;36:92-8.  Back to cited text no. 3
    
4.
Beg S, Vasenwala SM, Haider N, Ahmad SS, Maheshwari V, Khan MA.A comparison of cytological and histopathological findings and role of immune-stains in the diagnosis of soft tissue tumors. J Cytol 2012;29:125-30.  Back to cited text no. 4
  [Full text]  
5.
Fletcher C.D.M., Unni K.K., Mertens F. (Eds.): World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of Soft Tissue and Bone. IARC Press: Lyon 2002.  Back to cited text no. 5
    
6.
Pramila Jain, Archana Srivastava, Rani Malik. Clinico-morphological assessment of soft tissue tumors. Sch J App Med Sci 2014;2:886-90.  Back to cited text no. 6
    
7.
Umarani MK, Lakra PS, Bharathi M. Histopathological spectrum of soft tissue tumors in a teaching hospital. IOSR J Dent Med Sci 2015;14:74-80.  Back to cited text no. 7
    
8.
Batra P, Gupta DO, Batra R, Kothari R, Bokariya P. Pattern of soft tissue tumors in rural population of central India. Innov J Med Health Sci 2013;3:124-6.  Back to cited text no. 8
    
9.
Myhre-Jensen O. A consecutive 7-year series of 1331 benign soft tissue tumors: clinico-pathologic data: comparison with sarcomas. Acta Orthop Scand 1981;52:287-93.  Back to cited text no. 9
[PUBMED]    
10.
Lazim AF, Bedoor AK.Al-Irhayim Soft tissue sarcomas in Mosul: a pathologic evaluation. Ann Coll Med Mosul 2008;34:152-60.  Back to cited text no. 10
    
11.
Petersen I, Gunther B, Mildner K, Subhi F, Knosel T, Altendorf-Hofmann A, et al. Update from the soft tissue tumor registry in Jena. Pathology 2011;32:40-6.  Back to cited text no. 11
    
12.
Makino Y. A clinico pathological study on soft tissue tumors of the head and neck. Acta Pathol Jpn 1979;29:389-408.  Back to cited text no. 12
[PUBMED]    
13.
Mandong BM, Kidmas AT, Manasseh AN, Echejoh GO, Tanko Madaki AJ. Epidemiology of soft tissue sarcomas in Jos, North Central Nigeria. Niger J Med 2007;16:246-9.  Back to cited text no. 13
    
14.
Zhi-wei F, Jing C, Sheng T, Yong C, Rui-feng X. Analysis of soft tissue sarcomas in 1118 cases. Chin Med J 2009;122:51-3.  Back to cited text no. 14
    

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Correspondence Address:
Sunil Y Swami
Bhagwanbaba Chowk, Shepwadi, Ambajogai, Beed, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.208703

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