Soft tissue pathology for the radiologist: a tumor board primer with 2020 WHO classification update


Radiologists serve an important role in the diagnosis and staging of soft tissue tumors, often through participation in multidisciplinary tumor board teams. While an important function of the radiologist is to review pertinent imaging and assist in the differential diagnosis, a critical role is to ensure that there is concordance between the imaging and the pathologic diagnosis. This requires a basic understanding of the pathology of soft tissue tumors, particularly in the case of diagnostic dilemmas or incongruent imaging and histologic features. This work is intended to provide an overview of soft tissue pathology for the radiologist to optimize participation in multidisciplinary orthopedic oncology tumor boards, allowing for contribution to management decisions with expertise beyond image interpretation.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9


  1. 1.

    Goldblum J, Weiss S, Folpe AL, editors. Enzinger and Weiss’s soft tissue tumors. 7th ed. Philadelphia: Elsevier; 2020. p. 1–14.

  2. 2.

    Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin. 2004;54(1):8–29.

    Article  Google Scholar 

  3. 3.

    WHO Classification of Tumours Editorial Board. Soft tissue and bone tumours. Lyon (France): International Agency for Research on Cancer; 2020. (WHO classification of tumours series, 5th; vol. 3).

  4. 4.

    Clark MA, Thomas JM. Delay in referral to a specialist soft-tissue sarcoma unit. Eur J Surg Onc. 2005;31:443–8.

    CAS  Article  Google Scholar 

  5. 5.

    Ray-Coquard I, Thiesse P, Ranchere-Vince D, et al. Conformity to clinical practice guideline, multidisciplinary management and outcomes of treatment for soft tissue sarcomas. Ann Oncol. 2004;15:307–15.

    CAS  Article  Google Scholar 

  6. 6.

    Clasby R, Tilling K, Smith MA, Fletcher CD. Variable management of soft tissue sarcoma: regional audit with implications for specialist care. Br J Surg. 1997;84(12):1692–6.

    CAS  Article  Google Scholar 

  7. 7.

    Blay JY, Soibinet P, Penel N, et al. Improved survival using specialized multidisciplinary board in sarcoma patients. Ann Oncol. 2017;28(11):2852–9.

    Article  Google Scholar 

  8. 8.

    Kransdorf MJ, Murphey MD, Wessell DE, et al. ACR appropriateness criteria soft-tissue masses. J Am Coll Radiol. 2018;15(5S):S189–97.

    Article  Google Scholar 

  9. 9.

    Kransdorf MJ, Murphey MD. Imaging of soft tissue tumors. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 39–41.

    Google Scholar 

  10. 10.

    Gielen JL, De Schepper AM, Vanhoenacker F, et al. Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients. Eur Radiol. 2004;14(12):2320–30.

    Article  Google Scholar 

  11. 11.

    Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM. Value of MR imaging in differentiating benign from malignant soft-tissue masses: study of 95 lesions. AJR. 1990;155(6):1251–5.

    CAS  Article  Google Scholar 

  12. 12.

    Sundaram M, McGuire MH, Herbold DR. Magnetic resonance imaging of soft tissue masses: an evaluation of fifty-three histologically proven tumors. Magn Reson Imaging. 1988;6:237–48.

    CAS  Article  Google Scholar 

  13. 13.

    Kransdorf MJ, Jelinek JS, Moser RP, Utz JA, Brower AC, Hudson TM, et al. Soft-tissue masses: diagnosis using MR imaging. Am J Roentgenol. 1989;153:541–7.

    CAS  Article  Google Scholar 

  14. 14.

    Crim JR, Seeger LL, Yao L, Chandnani V, Eckardt JJ. Diagnosis of soft-tissue masses with MR imaging: can benign masses be differentiated from malignant ones? Radiology. 1992;185(2):581–6.

    CAS  Article  Google Scholar 

  15. 15.

    Kransdorf MJ, Murphey MD. Imaging of soft tissue masses. In: Kransdorf MJ, Murphey MD, editors. Imaging of soft tissue tumors: Lippincott Williams & Wilkins; 2014. p. 46–8.

  16. 16.

    Hoeber I, Spillane AJ, Fisher C, Thomas JM. Accuracy of biopsy techniques for limb and limb girdle soft tissue tumors. Ann Surg Oncol. 2001;8(1):80–7.

    CAS  Article  Google Scholar 

  17. 17.

    Fisher C, Montgomery EA, Thway K. Biopsy interpretation series: biopsy interpretation of soft tissue tumors. 2nd ed. Philadelphia: Wolters Kluwer; 2016. p. 1–20.

  18. 18.

    Singer S, Tap WD, Kirsch DG, Crago AM. Soft tissue sarcoma. In: DeVita VT, Lawrence TS, Rosenberg SA, editors. Hellman, and Rosenberg’s principles and practice of oncology. 11th ed: Lippincott Williams & Wilkins; 2019. p. 1401–50.

  19. 19.

    Gamboa AC, Gronchi A, Cardona K. Soft-tissue sarcoma in adults: an update on the current state of histiotype-specific management in an era of personalized medicine. CA Cancer J Clin. 2020;70(3):200–29.

    Article  Google Scholar 

  20. 20.

    Salah S, Lewin J, Amir E, Abdul RA. Tumor necrosis and clinical outcomes following neoadjuvant therapy in soft tissue sarcoma: a systematic review and meta-analysis. Cancer Treat Rev. 2018;69:1–10.

    Article  Google Scholar 

  21. 21.

    Berg W, Hruban R, Kumar D, Singh H, Brem R, Gatewood O. Lessons from mammographic-histopathologic correlation of large-core needle breast biopsy. Radiographics. 1996;16:1111–30.

    CAS  Article  Google Scholar 

  22. 22.

    Mihalik JE, Krupka L, Davenport R, Tucker L, Toevs C, Smith RS. The rate of imaging-histologic discordance of benign breast disease: a multidisciplinary approach to the management of discordance at a large university-based hospital. Am J Surg. 2010;199:319–23.

    Article  Google Scholar 

  23. 23.

    Office of the Assistant Secretary for Planning and Evaluation; US Department of Health and Human Services. The importance of radiology and pathology communication in the diagnosis and staging of cancer: mammography as a case study. Washington, DC; 2010. Available from: [Accessed July 20, 2020].

  24. 24.

    van Vilet M, Kliffen M, Krestin GP, van Dijke CF. Soft tissue sarcomas at a glance: clinical, histological, and MR imaging features of malignant extremity soft tissue tumors. Eur Radiol. 2009;19(6):1499–511.

    Article  Google Scholar 

  25. 25.

    Murphey MD, Kransdorf MJ. Radiologic evaluation of soft tissue tumors. In: Miettinen M, editor. Modern Soft Tissue Pathology: Tumors and Non-Neoplastic Conditions: Cambridge University Press; 2016. p. 11–40.

  26. 26.

    Baheti AD, O’Malley RB, Kim S, Keraliya AR, Tirumani SH, Ramaiya NH, et al. Soft-tissue sarcomas: an update for radiologists based on the revised 2013 World Health Organization classification. Am J Roentgenol. 2016;206(5):924–32.

    Article  Google Scholar 

  27. 27.

    Khoo M, Pressney I, Hargunani R, Saifuddin A. Small, superficial, indeterminate soft-tissue lesions as suspected sarcomas: is primary excision biopsy suitable? Skelet Radiol. 2017;46(7):919–24.

    Article  Google Scholar 

  28. 28.

    Sung KS, Seo SW, Shon MS. The diagnostic value of needle biopsy for musculoskeletal lesions. Int Orthop. 2009;33(6):1701–6.

    Article  Google Scholar 

  29. 29.

    Meek RD, Mills MK, Hanrahan CJ, Beckett BR, Leake RL, Allen H, et al. Pearls and pitfalls for soft-tissue and bone biopsies: a cross-institutional review. Radiographics. 2020;40(1):266–90.

    Article  Google Scholar 

  30. 30.

    Kransdorf MJ, Murphey MD. Compartmental anatomy and biopsy planning. In: Kransdorf MJ, Murphey MD, editors. Imaging of soft tissue tumors: Lippincott Williams & Wilkins; 2014. p. 745–68.

  31. 31.

    Graham DS, Russell TA, Eckardt MA, Motamedi K, Seeger LL, Singh AS, et al. Oncologic accuracy of image-guided percutaneous core-needle biopsy of peripheral nerve sheath tumors at a high-volume sarcoma center. Am J Clin Oncol. 2019;42(10):739–43.

    CAS  Article  Google Scholar 

  32. 32.

    Dabbs D, editor. Diagnostic immunohistochemistry: theranostic and genomic applications. 5th ed. Philadelphia: Elsevier Saunders; 2019. p. 1–12.

    Google Scholar 

  33. 33.

    Oliner JD, Saiki AY, Caenepeel S. The role of MDM2 amplification and overexpression in tumorigenesis. Cold Spring Harb Perspect Med. 2016;6:a026336.

    Article  Google Scholar 

  34. 34.

    Perry K. Soft tissue pathology for clinicians. Gewerbestrasse: Springer International Publishing; 2017. p. 15–8.

    Google Scholar 

  35. 35.

    Hanson KF, Birinyi P, Walker R, Raptis C, Chenock R, Coppens J, et al. Melanoma mimicking malignant peripheral nerve sheath tumor with spread to the cerebellopontine angle: utility of next-generation sequencing in diagnosis. Case Rep Pathol. 2018;9410465.

  36. 36.

    ISSVA Classification of Vascular Anomalies ©2018 International Society of the Study of Vascular Anomalies. Available at “” Accessed March 23, 2020.

  37. 37.

    Drilon A, Laetsch T, Kummar S, et al. Efficacy of Larotrectinib in TRK fusion-positive cancers in adults and children. N Engl J Med. 2018;378(8):731–9.

    CAS  Article  Google Scholar 

  38. 38.

    Pierron G, Tirode F, Lucchesi C, et al. A new subtype of bone sarcoma defined by BCOR-CCNB3 gene fusion. Nat Genet. 2012;44(4):461–6.

    CAS  Article  Google Scholar 

  39. 39.

    Singer S, Tap W, Schaefer IM, Fletcher CD. Sarcomas with CIC-rearrangements are a distinct pathologic entity with aggressive outcome: a clinicopathologic and molecular study of 115 cases. Am J Surg Pathol. 2017;41(7):941–9.

    Article  Google Scholar 

  40. 40.

    Capper D, Jones DT, Sill M, et al. DNA methylation-based classification of central nervous system tumours. Nature. 2018;555(7697):469–74.

    CAS  Article  Google Scholar 

  41. 41.

    Coudray N, Ocampo PS, Sakellaropoulos T, et al. Classification and mutation prediction from non-small cell lung cancer histopathology images using deep learning. Nat Med. 2018;24(10):1559–67.

    CAS  Article  Google Scholar 

Download references


The authors thank Norm Cyr for expert photographic and graphic design assistance.

Author information



Corresponding author

Correspondence to Karin J. Kuhn.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kuhn, K.J., Cloutier, J.M., Boutin, R.D. et al. Soft tissue pathology for the radiologist: a tumor board primer with 2020 WHO classification update. Skeletal Radiol (2020).

Download citation


  • Soft tissue neoplasms
  • Sarcoma
  • Differential diagnosis
  • Musculoskeletal system/diagnosis
  • Musculoskeletal system/pathology
  • Patient care team