Case Report: What may the right forearm swelling be?

Case information:, female, 63, right forearm to remove the swellingWhat can be seen in surgery: The swelling originates from tendonsGeneral view: Specimens by 10% neutral Folmarin solution fixed gray-yellow tissue piece, size 10X6X5cm, also see gray-yellow broken tissue, size 7X7X3cm, part of the production(Wax block note: 1 sash-yellow crushed tissue 2-4 sash-yellow tissue)heimmunohisic chemistry (pathological diagnosis) (right forearm) malignant interleaf-derived tumor/ sarcoma, combined with immunohiscitisresult results and morphology, the lesions are in line with the slide of sarcoma, recommended in combination with clinical lyson if necessary to do genetic testing SS18 to assist in further diagnosisYC1201429-3 immune grouping results: Vim (plus), EMA (part plus), TLE (s) bcl-2 (part plus), STAT6 (scattered in the plasma weak plus), CD34 blood vessels (plus), CK (-), Desmin (-), SMA (-), S-100 (-), Ki-67 (30 percent)Case discussion:-slip sarcoma (synovial sarcoma, SS) is a malignant tumor with interlocutor and epithelial bipolar differentiation, a cytogeneticly specific t (X;18) (p11;q11) and the generation of SS18 (SYT)-SSX fusion geneAlthough the vast majority of sliding membrane sarcoma occurs near large joints, but its tissue occurrence is not related to the slip membrane, and some tumors can also occur in the body without a slip membrane, such as the heart-packed lung, pleural, celiac, kidney and prostate, so strictly speaking, the slide membrane sarcoma is not a slip membrane tumor, the slide sarcoma is a misnoname (mismer)Tumor cells in sliding sarcoma may start from unknown polypotted stem cells, which can differentiate into the interlobite and epithelialSome scholars have suggested the use of "soft tissue cancer" or "connective tissue cancer sarcoma" instead of slide-film sarcoma, but because in the daily work of the membrane sarcoma has become a habitual use and widely accepted, if the new diagnostic name is bound to cause misunderstanding or confusionSlide-membrane sarcoma is less common, accounting for about 5% to 10% of soft tissue sarcoma, in MDIn more than 6000 cases of Soft Tissue Sarcoma in Anderson, sliding sarcoma accounted for 6%The domestic case pool accounts for about 7.5% of soft tissue sarcoma ICD-O coding s skating carnivorous 9040/3 slide-film sarcoma, shuttle cell type 9041/3 slide-membrane sarcoma, biphase 9043/3 .Clinical performance 1 Age and gender slide sarcoma are better in 15-35 years of age, Cad-man and other reported series, 83.6% of patients aged 10 to 50 years old The carctor sarcoma can occur in children under 10 years of age, and there are also reports in the literature that it can occur in newborns Slip-film sarcoma is less common in people over 60 years of age, accounting for less than 10%, and histologically mostly poorly differentiated, and occurs in - less common areas such as the lungs, pleural, torso and head and neck Sliding sarcoma is slightly more common in men, male: about 1.2:1 for women Between 2008 and 2016, a total of 782 cases of sliding membrane sarcoma were diagnosed at Fudan University's affiliated oncology hospital, of which 414 were male, 368 were female, male were 1.13:1, the age range was 2 to 81 years old, the average age and The median age is 36.5 years and 36 years old, 59% between the ages of 10 and 40, 80% between the ages of 10 and 50, and 2.4% and 6.9% respectively 2 80% to 95% of the cases occur in the limb, of which about 50% to 60% occur in the lower limbs, especially around the thighs and knees, followed by the foot, calves and ankles, as well as the hip, hip and groin areas; In the limb, tumors are mostly found in soft tissue next to the joint and are closely linked to tendon membranes, tendons and sac structures In rare cases, attached to the fascia, ligament, and interbone membranes, and actually occurs in the joint cavity (intraartcular SS) very rarely (5%) In addition to the limbs, about 5% to 12% of the cases occur in the head and neck, mostly located next to the vertebrae, the form of isolated lumps of the pharynx and throat, other rare areas include cheeks, ear back, jaws, soft palate, tongue, chin den, upper jaw sinus, tonsils, scalp and salivary glands, located in these special areas of the slide caricomoma is easy to be misdiagnosed other tumors such as sarcoma or malignant malignant cancer Between 5% and 10% of the cases are located in the torso, including chest wall, pleural, heart bag, septum, abdominal wall, abdominal cavity, pelvic cavity and peritoneal membrane, some of which can have cystic changes The carbapenems located in these areas often need to be confirmed by molecular genetics, and 5% of cases can occur in substance organs, such as the heart, lungs, kidneys, prostate, esophagus, stomach and small intestine, etc., which can even occur in the skin, vulva, penis, blood vessels (intravascular SS), peripheral nerve (intranerual SS), intra-bone and nervous system centers, etc., and often need to be confirmed by molecular genetics Although neurofibromatosis occurred in type I neurofibromatosis abominable become malignant peripheral neuropathy, but the slide sarcoma can also occur in patients with type I neurofibromatosis (NF1), that is, the shuttle cell sarcoma occurred in type I neurofibromatosis disease is not necessarily all malignant peripheral neuroblastoma Of the 782 cases of sliding membrane sarcoma diagnosed at Fudan University's affiliated oncology hospital, 509 cases, or 65%, were found in limbs or limbbelts Those located in the lower/lower limb belt and upper limb/upper limb belt accounted for 49% and 16% of the total, respectively, followed by the head, neck and lung chest 3 Symptoms and signs on the clinical stage of the disease hidden, mostly showed as a slow growth of the deep soft tissue in the lump, preoperative disease for more than 2 to 4 years, there are up to 20 years, can be accompanied or not accompanied by pain or pain Some cases located in special areas can show corresponding symptoms, such as those located in the throat, which can manifest as swallowing and breathing difficulties or hoarseness Cases with a longer course of progress are often misdiagnosed as benign disorders, such as arthritis, glioscosis, or cysticitis Cases located in the hand, foot or wrist, if the tumor is small, can be misdiagnosed as tendon cysts or benign lesions A small number of cases of cystic change can also be misdiagnosed as sliding membrane cysts, lymphomas or cysts of the tongue These conditions can delay diagnosis and treatment Some patients may have varying degrees of trauma, while others have a history of metal implants or have received radiation therapy imaging is not characteristic, mainly manifested in the soft tissue lump shadow near the large joint, can also be distributed in the pharynx, pleural and heart envelope CT shows that the lumps are circular, round, or varying degrees of leafy ness, medium density or soft tissue density About 15% to 30% of cases can show calcification, in most cases are in a delicate color, some cases can be significantly calcified Clinically, for a soft tissue tumor located near a large joint with calcification, consider the possibility of a sliding sarcoma MRI helps to determine the specific location and scope of the tumor, is of great help to clinical stages, and helps to detect many nodule lesions or some heterogeneous changes within the tumor, such as bleeding, necrosis, fluid plane or spacing Smaller tumors T1WI are often shown as homogeneous, the signal strength is similar to those of adjacent muscles, and larger tumors are shown as heterogeneous and medium signal strength due to bleeding and necrosis The sliding sarcoma is high on the T2WI image, similar to or higher than adipose tissue About one-third of the glioblastoma on T2WI shows a high, medium and low mixed three-signal pattern (triple signal pattern) :(1) high signal, which can have a liquid plane due to the fluid contained in the tumor and with cystic variation; Because the caroblastoma can grow slowly, tumor volume may be small (e.g 5cm), and some cases can have a clear perimeter, so imaging can be misdiagnosed as benign lesions In cases of clinically slow growth, the tumor perimeter is more clear and can be covered with fibrous pseudo-envelope, while others are in-the-form During the operation, it was seen that the tumor was closely attached to the outer wall of the adjacent tendon, tendon or joint sac, and was solid nodules, and a few cases were sac-like Located at the end of the limb (hand and foot) is smaller in size, its diameter may be less than 1cm, located in the limb near the end (e.g thighs, hips, knees, shoulders and elbows), the diameter is usually 3 to 10 cm, the larger up to 15cm or 20cm The cut surface is gray-white or gray-red, fish-like, less differentiated people can see necrosis Cases accompanied by calcification or osteosome can have a gravel sensation when taken The tissue form is divided into four subtypes, biphasie type, spindle cell type, monophase epithelial type (nmonoophasie epithelial type) and differential differentiation type, with shuttle cell type being the most common, followed by bipolar Differential differentiation and monophase epithelial types are rare, both of which need to be confirmed by molecular genetics testing 1 Biphase-sliding membrane sarcoma accounts for about 20% to 30% of the caroblastoma, consisting of varying proportions of epithelial-like cells and shuttle-shaped cells, which can be metamorphic between epithelial cells and shuttle cells Epithelial-like cells are rectangular or high column,larger, round or egg-round, fine lymatter or empty-bubble-like, rich cytoplasm, can be ie-red, light-stained or bright, the cell boundary is clear Epithelial-like cells often form adenoid structures, the adenoid cavity can be seen in the ie-red secretion-like substance, PAS staining can be positive, the cavity can also be free of secretions Epithelial-like cells are also arranged in the form of solid bar beams or nest clumps The boundary between epithelial-like cells and shuttle-shaped cells can be clearly divided, or it can be divided or moved In a few cases, epithelial-like cells also appear transparent Mesh fiber staining can clearly show the epithelial composition of the tumor Epithelial-like cells can also form nipple-like structures with a clump cell instead of fibrous connective tissue In about 1% of cases, epithelial-like cells can be associated with scaly and keratosis In other cases, especially at the edge of the lesions, it is visible that the cystic cavity-like structure, the sac wall lining square or flat epithelial-like cells, can be mistaken for a sac structure, and then determine that the tumor started from the slip membrane Shuttle-shaped cells are basically the same in shape, shuttle-shaped or fat shuttle-shaped, the nucleus is shuttle-shaped or egg-shaped, the nucleus is deeply dyed nuclear kernels are not obvious, or the chromatin is carefully visible small kernels, cell matter is small but not clear Shuttle cells are arranged in a striped, interwoven or swirling order, and can also be strip-like, and nuclear division is generally less common, except in a less differentiated tumor, where the nuclear division is often more than 2/10HPF The density of shuttle cells can be uneven, and can be a dense alternating distribution of interstitial systromes can also contain a variety of collagen fibers Calcification or osteosome in 20% to 30% of cases can also be seen, which has a suggestive effect on the diagnosis of carucoma sarcoma When calcification is more widespread, also known as calcified caricoma (eal-eifying synovial sarcoma), suggests a better prognosis It is important to note that sometimes large areas of calcification can mask tumorous tissue, leading to missed or misdiagnosis Sliding cartilage can even have cartilage, but more close to calcification or osteosome In some cases, fat cells can also be seen, which can be shown by Giemsa staining or CD117 markers, which have a certain indicative effect on the diagnosis of caruride sarcoma Biphase glioblastoma can contain more primitive areas of differentiation, similar to extraogenous especially sarcoma 2 Shuttle-shaped cell-type sliding membrane sarcoma, also known as monophasic tumor (monophasicus tpe), is the most common type of sliding membrane sarcoma, is also the most likely to be misdiagnosed one type, about 50% to 60% of the slide-film sarcoma Barracuda-shaped glioblastoma is mainly composed of amperes with short-striped or vortex-like arrangement of barracuda-like cell-like cells, tumor cells can also be long-striped, fish bone-like or humanoid arrangement, similar to fibroids Nuclear division can be rarely seen depending on the case, in general, in less differentiated tumors, nuclear division is easy to see, can be more than 15/ 10HPF In the shuttle-shaped tumor cells are sometimes visible scattered in the fat cells, Giemsa staining or CD117 markers can be clearly displayed, for the diagnosis of sliding membrane sarcoma is indicative In some cases, there are many neusupposed collagen fibers that can be seen between shuttle cells, mainly in carbide carifying carcinoma with glass-like degeneration and recurrent cases after radiation therapy The density of shuttle cells can be uneven, can be a dense alternating distribution, easy to be misdiagnosed as malignant peripheral neurocyma In a few cases, the mesomersy is accompanied by significant mucus-like degeneration, also known as mucus-like carctor sarcoma Vascular syllaves vary from case to case, and in some cases it can be an octozoma-like, especially in tumors with poor differentiation, which has a certain suggestive effect on the diagnosis of carucoma sarcoma A few cases can be cystic-like, tumor cells are located in the thickening of the sac wall, easy to be missed or misdiagnosed as a sliding membrane cyst or lymphoma and other benign lesions Most of the shuttle-shaped cell-type slide-membrane sarcoma after extensive extraction can be found in the upper skin-like area of the stove, as a small nest-like or small block-like epithelial-like cells, cytoplasmic light dye or eosinophilion, the nucleus and adjacent shuttle-shaped cells similar to the nucleus, this part of the cell can often express epithelial markers, strictly belong to the bipolar glider sarcoma Cases consisting entirely of shuttle cells and other types of shuttle-shaped cell sarcoma (e.g fibroids, malignant peripheral neurocymas, or malignant isolated fibroblasts, etc.) are difficult to identify in the photoscopy In addition, shuttle-shaped cell-type slide-membrane sarcoma can also contain areas with poor differentiation, often with the help of immunohiscitis markers and molecular genetics testing 3 Single-phase epithelial type is rare, the proportion of carulomated sarcoma , mainly composed of adenoid-arranged epithelial-like cells, morphologically similar to adenocarcinoma, after extensive extraction and slicing, often can be seen in the local area of the cell composition of the shuttle, but there are pure epithelial and not see the transverse cell components This type is also often confirmed by molecular genetics 4 The area with poor differentiation can occur in about 62% of the glioblastoma The proportion of differential regions in the tumor varies, can be the bureau, but also can account for more than 20% of the tumor, some cases can reach 90%, the latter is relatively rare, about 10% to 15% of the cession sarcoma Because differential differentiation of glioblastoma has a higher invasive and metastasis rate, it is of practical significance to identify this type of slip-film sarcoma Histology, differential-differentiated sliding-film sarcoma also consists of three morphological subtypes, consisting of small circular cells with poor differentiation, large round cells and highly malignant fat shuttle cells, and in a few cases, tumor cells can also be in a horizontal muscle-like (rhabdoid-like) form The three subtypes of tumor cells are significantly different.