Approach to Diagnosis of Spindle Soft tissue Neoplasms

[KeratinPearls]

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Anyone know any good sources for how to approach soft tissue spindle cell neoplasms? I looked at Dr. Wicks site and there was a nice powerpoint in there. Any others? Jerad any recommendations?

Thanks.

 

[yaah]

1) Look at it
2) Decide what it is
3) Review the gross and the clinical history to make sure you aren't calling something that should be benign malignant or something that is obviously cancer benign.
4) Submit more sections if necessary.
5) Re-review.

Sounds trite but that's how it is in a sense. A lot of times clinicians just want to know whether something is benign or malignant. If it is malignant, is it high grade or low grade. After that, the rest is just fine points which most clinicians don't care as much about. Textbooks are good for confirming your suspicions and providing checks to make sure you're not making a diagnosis that should not generally be made (i.e. spindle cell lipoma in the thigh).

 

[KCShaw]

Pray to the Gods of Spindle, and bring thine sacrifices.

I do like Yaah's approach, though. I think it's very easy to get lost if you don't back off and think about the basics again -- what's the patient demographic, where is it, what did it look like radiographically/surgically/grossly, what's the 2x impression, then are there a bunch of mitoses/crazy cells or not.. as with other things don't get caught up in the trees. One of the soft tissue folk may have specific good resources -- I kept getting pointed at reference texts, which have their place but generally aren't that good for getting a holistic grip on a subject.

 

[zao275]

yaah and KCShaw: you guys sure you aren't soft tissue pathologists at heart?

I agree completely that the clinical info/demographics can be very helpful in guiding your thinking (and if something doesn't make sense, get a consult). Soft tissue can be tricky because of the vast array of patterns, numerous odd/long names, and the fact that bland things can be malignant (e.g. - low grade fibromyxoid sarcoma) and ugly things can be benign (e.g. - pleomorphic lipoma).

One of the tough things is that you often have difficulty figuring out the lineage of the tumor (unlike a carcinoma in the lung or skin, where things are a bit more clear...usually). Once you figure out that it is smooth muscle, you can look up that chapter in the book. But there are loads of tumors with unknown cell type/line of differentiation, and that makes looking them up more difficult.

Wick's stuff is really good for learning the approach by pattern. John Goldblum has given talks on this, as well (have not yet had a chance to attend one but I hear they are fantastic). Overall, the best thing is to look at a bunch of unknowns and learn the most common patterns (and the most common entities). Obvious, I know, but most people don't have access to that kind of collection. This is why I have been whole slide scanning and posting as many good soft tissue cases as I can on pathxchange. You can study and ask questions as well. If you really want to learn some soft tissue path, check it out: http://www.pathxchange.org/user/2587/cases. I have about 60 or so cases, with another 30 or so on the way soon. I am adding them as fast as they can scan and upload them!

Jerad

 

[pathstudent]

Soft Tissue can be a real bitch.

I had a case that I called a dedifferentiated chondrosarcoma with the help of colleagues.

The patient had their slides sent to an elite sarcoma place and it was reviewed by an internationally recognized expert in sarcoma pathology, like one that writes text books and edits journals, and it was called a chondromyxofibroma. I **** my pants because that's benign. The patient hadn't had any treatment yet, so no harm had come to the patient but it was professionally embarrassing for me. The patient died a few months later of metastatic dedifferentiated chondrosarcoma and we had the same expert review the metastatic material and this time the diagnosis was the same as ours. There was no harm done to the patient as there was no curative therapy.

This expert is 100 times better than me at soft tissue pathology but it shows to go you that soft tissue pathology can be a real bitch.

 

[KeratinPearls]

Soft Tissue can be a real bitch.

I had a case that I called a dedifferentiated chondrosarcoma with the help of colleagues.

The patient had their slides sent to an elite sarcoma place and it was reviewed by an internationally recognized expert in sarcoma pathology, like one that writes text books and edits journals, and it was called a chondromyxofibroma. I **** my pants because that's benign. The patient hadn't had any treatment yet, so no harm had come to the patient but it was professionally embarrassing for me. The patient died a few months later of metastatic dedifferentiated chondrosarcoma and we had the same expert review the metastatic material and this time the diagnosis was the same as ours. There was no harm done to the patient as there was no curative therapy.

This expert is 100 times better than me at soft tissue pathology but it shows to go you that soft tissue pathology can be a real bitch.

Im not familiar with this entity. So a chondromyxofibroma progressed to a dediff chrondosarcoma and metastasized?

 

[pathstudent]

Im not familiar with this entity. So a chondromyxofibroma progressed to a dediff chrondosarcoma and metastasized?

NO the expert was wrong in this one instance, or at least his interpretation underestimated the biologic potential of the lesion. and I meant chondromyxoid fibroma.

But like I said, no harm was done to the patient. The patient was ****ed either way.

But I remember totally panicking when something I called a high grade malignancy was reinterpreted as a benign neoplasm by an expert.

 

[zao275]

pathstudent: Agree. Soft tissue cases (like any field) can be missed by even the most elite soft tissue pathologists. I have seen varying opinions between top people in the field, as well. Good for you getting the dx right. As you mentioned, dediff chondrosarc is almost uniformly fatal (and quite uncommon), regardless of therapy. But, yes, there is a BIG difference between that and chondromyoid fibroma.

 

[Parts Unknown]

Soft Tissue can be a real bitch.

True. Just look in your trousers.

 

[KeratinPearls]

true. Just look in your trousers.

lol.