- Procedure: Wide local excision of right forearm soft tissue tumor - Size of specimen: 17x5.5x7cm - Size of tumors: Larger proximal tumor 7.5x3.5cm, smaller distal tumor nodule 1.5x1cm - Histology: Epithelioid sarcoma (high grade), deep margin involved - Previous biopsy: Outside biopsy confirmed epithelioid sarcoma - Median nerve not involved

1. Tumor Board
05/03/2019

2. Patient details
• Age/Sex : 53 Years / Female
• Hospital OP/ IP No: A18399814
• Biopsy no: 3021/18
• Date of Receiving Specimen : 06-12-2018
• Date of Report : 12-12-2018
• Clinical Diagnosis : Soft tissue sarcoma right forearm
• Previous Biopsy : USG guided right forearm mass biopsy
shows features of epithelioid sarcoma (reported outside
23/11/2018)
• Nature of Specimen : Outside block & slide
.

3. Gross Examination (Biopsy no: 3021/18)
Received outside one block and slide.

4. Microscopy (Biopsy no: 3021/18)
Sections studied shows tumor composed of lobules, sheets of pleomorphic
spindle shaped cells.
4x
40x

5. Microscopy (Biopsy no: 3021/18)
Section studied shows many round to ovoid cells with abundant cytoplasm with
hyperchromatic to vesicular nucleus and prominent nucleoli separated by
hyalinised stroma, infiltrating adjacent fat tissue.
40x

6. Microscopy (Biopsy no: 3021/18)
Immunohistochemistry (IHC)
Tumor cells showing Epithelial Membrane Antigen (EMA) positivity

7. Microscopy (Biopsy no: 3021/18)
Immunohistochemistry (IHC)
Tumor cells showing Cytokeratin (CK) positivity

8. Microscopy (Biopsy no: 3021/18)
Immunohistochemistry (IHC)
Tumor cells showing Vimentin (CK) positivity

9. Impression (Biopsy no: 3021/18)
• Biopsy from right forearm (outside block and slide) shows
features consistent with epitheloid sarcoma.
• Immunohistochemistry (IHC)
– Epithelial Membrane Antigen (EMA) and Cytokeratin (CK)
are strongly positive within tumor cells.
– Vimentin is also strongly positive suggestive of epitheloid
sarcoma.
– Smooth Muscle Actin (SMA) is negative within tumor cells.

10. Patient details
• Age/Sex : 53 Years / Female
• Hospital OP/ IP No: A18399814
• FNAC no: 304/18
• Site of FNAC : Right axillary lymph node (USG Guided)
• Date of FNA : 07-12-2018
• Date of Report : 10-12-2018
• Clinical Diagnosis : Soft tissue sarcoma right forearm
• Nature of aspirate : Blood mixed aspirate

11. Impression FNAC no: 304/18
USG guided FNAC right axillary lymph node showed features of
reactive lymphoid hyperplasia.

12. Patient details
• Age/Sex : 53 Years / Female
• Hospital OP/ IP No: A18399814
• FNAC no: 317/18
• Site of FNAC : Swelling on right palm
• Date of FNA : 31-12-2018
• Date of Report : 01-01-2019
• Clinical Diagnosis : Soft tissue sarcoma right forearm
• Previous FNAC - FNAC no: 304/18 :USG guided FNAC right axillary
lymph node shows features of reactive lymphoid hyperplasia.
• Nature of aspirate : Blood mixed aspirate

13. Microscopy (FNAC no: 317/18)
•Sparse to moderately cellular smears showing loose clusters and discrete cells
with anaplastic morphology.
•Individual cells have round to oval shaped hyperchromatic nuclei with
moderate amount of eosinophilic cytoplasm showing epithelioid morphology
in a hemorrhagic background.
40x

14. Impression (FNAC no: 317/18)
FNAC from right palm shows cytological features of a malignant
soft tissue sarcoma.

15. Patient details
• Age/Sex : 53 Years / Female
• Hospital OP/ IP No: A18399814
• Biopsy no: 74-75/18
• Date of Receiving Specimen : 09-012-2019
• Date of Report : 22-01-2019
• Clinical Diagnosis : Soft tissue sarcoma right forearm
• Previous Biopsy : Biopsy from right forearm mass shows
features of epithelioid sarcoma (reported outside)
• Nature of Specimen : Wide local Excision biopsy forearm
.

16. Gross Examination (Biopsy no:74/19)
Biopsy no: 74/19
Container labelled A as wide local
excision specimen
• Received skin with underlying
soft tissue, muscles and
tendons altogether measuring
17 x 5.5 x 4 cm.
• Elliptical skin piece attached
measures 12 x 4.5 cm.
• Attached linear tendon (distal
end) measures 5 cm in length.

17. Gross Examination (Biopsy no:74/19)
• The cut surface through the
skin revealed ill defined grey
white tumor with infiltrating
margins measuring
7.5 x 3.5cm.

18. Gross Examination
• Tumor is
– 8 cm away from distal
margin (tip of tendon)
– 2 cm away from proximal
margin
– 1 cm away from skin
(anterior margin)
– 3 cm from medial margin
– 2 cm from lateral margin.
• Grossly, the tumor
involves the deep resected
margin .

19. Gross Examination (Biopsy no:74/19)
• Also identified a solid nodule
measuring 1.5 x 1 cm, lying
within the tendon sheath, 2 cm
from the distal margin.
• Tumor nodule in the tendon
sheath is 5cms from the
proximal larger soft tissue
tumor.
Also noted median nerve (portion
of distal end of median nerve
with long suture) measuring
2.5cms from the soft tissue
tumor.

20. Microscopy (Biopsy no:74/19)
Sections studied shows lobules, nests and sheets of epithelioid cells with intervening
fibro-collagenous tissue and skeletal muscle fibres.
4x
40x
10x

21. Microscopy (Biopsy no:74/19)
Sections studied individual epithelioid cells with epithelioid cells with eosinophilic to
clear cytoplasm and high grade bizzare nuclear pleomorphism.
4x
40x

22. Microscopy (Biopsy no:74/19)
Sections studied shows areas of many congested blood vessels surrounded by tumor
cells, with wide areas of necrosis, atypical mitosis and dense lymphocytic infiltration.
4x
10x
40x
10x
10x

23. Microscopy (Biopsy no:74/19)
Sections studied shows tumor cells infiltrating the deep resected margin.
4x

24. Microscopy (Biopsy no:74/19)
Section studied shows adjacent another tumor nodule close to the distal margin
shows similar features with deep resected margin involvement.
10x 40x

25. Microscopy (Biopsy no:74/19)
Sections studied from
• proximal margin (includes skin, soft tissue and muscle) is
free of tumor.
• distal surgical margin (includes skin, underlying soft tissue,
muscle and tendon) is free of tumor.
• Section studied from distal resection margin (includes skin,
soft tissue, muscle and tendons) is free of tumor.
• medial and lateral surgical resected margins (including,
skin, muscle and tendon) are all free of tumor.
• skin, fibromuscular, neurovascular and collagenous tissues
are all free of tumor.
• attached median nerve is free of tumor.

26. Gross Examination (Biopsy no:75/19)
Container labelled B as median nerve
•Received single linear tissue bit measuring 2.5cm in length.
•Grossly - unremarkable
•All embedded in one block.

27. Final Impression
• Wide local excision from Right forearm shows
features consistent with high grade epithelioid
sarcoma (multi-centric).
• A differential diagnosis of epithelioid variant of
angiosarcoma has to be considered.
• Deep resected margin involved by the tumor.
• Proximal and distal fibromuscular and tendon
margins are free of tumor.
• Median nerve sent separately in another
container is free of tumor.

28. Summary
• PROCEDURE: Wide local excision.
• ANATOMIC SITE: Right forearm - flexor compartment.
• LOCALITY: Right side.
• Details of previous biopsy: Outside & 3021/18: Epithelioid sarcoma.
• Measurement of specimen: 17X5.5X7cms.
• Measurement of tumor : Proximal larger tumor measures 7.5x3.5 cms. Distal
smaller tumor nodule measures 1.5x1.0 cm.
• Distance from tumor to margin:- Proximal margin - 2 cms. Distal margin - 8 cms
.Medial margin- 3cms. Lateral margin - 2cms. Deep resected margin is involved
by tumor.
• Lymph nodes: Not submitted.
• tumor site : Soft tissue underlying the Right forearm flexor compartment.
• HISTOLOGICAL TYPE: Epithelioid sarcoma
• Vascular invasion- Not seen
• Bone invasion- Not seen
• Grade : High grade.

29. DISCUSSION

30. Salient Features
• Predilection for the distal extremities of young adults.
• Nodular growth pattern with central necrosis may superficially
mimic a granulomatous process.
• Uniform epithelioid cells with mild nuclear atypia and
eosinophilic cytoplasm.
• Proximal-type epithelioid sarcoma arises in the pelvis and
perineum and shows large cell morphology with marked
cytologic atypia.
• Diffusely positive for epithelial membrane antigen, keratins; 50%
CD34.
• Loss of INI1 expression is a characteristic finding.
• Protracted clinical course, with late recurrences and metastases.
• Proximal-type epithelioid sarcoma has a more aggressive course.

31. Differential Diagnosis

32. Prognostic Factors
Potential adverse prognostic factors in epithelioid sarcoma include
• Advanced age (>75 years)
• Male sex
• Large tumor size (>5 cm)
• Deep or proximal location
• Presence of tumor necrosis
• Nuclear pleomorphism
• High mitotic activity
• Vascular or nerve invasion
• Inadequate excision
• Multiple local recurrences
• Regional lymph node metastases at diagnosis