Full download ebooks at ebooksecure.

com

(eBook PDF) Practical Soft Tissue Pathology: A

Diagnostic Approach: A Volume in the Pattern
Recognition Series 2nd Edition
For dowload this book click LINK or Button below

http://ebooksecure.com/product/ebook-pdf-
practical-soft-tissue-pathology-a-diagnostic-
approach-a-volume-in-the-pattern-recognition-
series-2nd-edition/
OR CLICK BUTTON

DOWLOAD EBOOK

Download More ebooks from https://ebooksecure.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Practical Pulmonary Pathology: A Diagnostic Approach: A

Volume in the Pattern Recognition Series 3rd Edition
Kevin O. Leslie Md - eBook PDF

https://ebooksecure.com/download/practical-pulmonary-pathology-a-
diagnostic-approach-a-volume-in-the-pattern-recognition-series-
ebook-pdf/

Practical Soft Tissue Pathology. A Diagnostic Approach

2nd Edition Jason L. Hornick - eBook PDF

https://ebooksecure.com/download/practical-soft-tissue-pathology-
a-diagnostic-approach-ebook-pdf/

Diagnostic Pathology. Soft Tissue Tumors - eBook PDF

https://ebooksecure.com/download/diagnostic-pathology-soft-
tissue-tumors-ebook-pdf/

(eBook PDF) Head and Neck Pathology: A Volume in the

Series: Foundations in Diagnostic Pathology 3rd Edition

http://ebooksecure.com/product/ebook-pdf-head-and-neck-pathology-
a-volume-in-the-series-foundations-in-diagnostic-pathology-3rd-
edition/
Practical Hepatic Pathology: A Diagnostic Approach 2nd
Edition Romil Saxena - eBook PDF

https://ebooksecure.com/download/practical-hepatic-pathology-a-
diagnostic-approach-ebook-pdf/

Gastrointestinal and Liver Pathology: A Volume in the

Series: Foundations in Diagnostic Pathology 3rd Edition
Amitabh Srivastava - eBook PDF

https://ebooksecure.com/download/gastrointestinal-and-liver-
pathology-a-volume-in-the-series-foundations-in-diagnostic-
pathology-ebook-pdf/

Head and Neck Pathology, A Volume in the Series:

Foundations in Diagnostic Pathology, 3ED 3rd Edition
Thompson - eBook PDF

https://ebooksecure.com/download/head-and-neck-pathology-a-
volume-in-the-series-foundations-in-diagnostic-pathology-3ed-
ebook-pdf/

Macrophages in the Human Body : A Tissue Level Approach

1st edition - eBook PDF

https://ebooksecure.com/download/macrophages-in-the-human-body-a-
tissue-level-approach-ebook-pdf/

Advantages and Pitfalls of Pattern Recognition:

Selected Cases in Geophysics: Volume 3 1st Edition
Horst Langer - eBook PDF

https://ebooksecure.com/download/advantages-and-pitfalls-of-
pattern-recognition-selected-cases-in-geophysics-volume-3-ebook-
pdf/
This page intentionally left blank
 Contributors

Rita Alaggio, MD Angelo Paolo Dei Tos, MD

Professor Professor of Pathology
University of Padua Department of Medicine
Institute of Pathologic Anatomy University of Padua School of Medicine
University of Padua Padua, Italy;
Padua, Italy Director, Department of Pathology
Azienda ULSS 2 Marca Trevigiana
Michele Biscuola, PhD Treviso, Italy
Institute of Biomedicine of Sevilla (IBiS)
Virgen del Rocio University Hospital/CSIC/University of Sevilla/ Leona A. Doyle, MD
CIBERONC Assistant Professor of Pathology
Seville, Spain Department of Pathology
Brigham and Women’s Hospital and Harvard Medical School
Thomas Brenn, MD, PhD, FRCPath Boston, Massachusetts
Department of Pathology
Western General Hospital and The University of Edinburgh Briana C. Gleason, MD
Edinburgh, Scotland Staff Pathologist
Covenant Surgical Partners
Jodi M. Carter, MD, PhD South San Francisco, California
Assistant Professor
Laboratory Medicine and Pathology J. Frans Graadt van Roggen, MB ChB, BSc Hons, PhD
Mayo Clinic Department of Pathology
Rochester, Minnesota Alrijne Zorggroep
Leiden, The Netherlands
Cheryl M. Coffin, MD
Professor Emerita Pancras C.W. Hogendoorn, MD, PhD
Pathology, Microbiology, and Immunology Professor of Pathology
Vanderbilt University Medical Center Leiden University Medical Center
Nashville, Tennessee Leiden, The Netherlands;
Visiting Professor in Sarcoma Pathology
Enrique de Alava, MD, PhD University of Oxford
Institute of Biomedicine of Sevilla (IBiS) Oxford, United Kingdom
Virgen del Rocio University Hospital/CSIC/University of Sevilla/
CIBERONC Jason L. Hornick, MD, PhD
Seville, Spain Director of Surgical Pathology and Immunohistochemistry
Department of Pathology
Brigham and Women’s Hospital
Professor of Pathology
Harvard Medical School
Boston, Massachusetts

vii
 Practical Soft Tissue Pathology: A Diagnostic Approach
Contributors

Vickie Y. Jo, MD Marisa R. Nucci, MD

Assistant Professor of Pathology Associate Pathologist
Department of Pathology Department of Pathology
Brigham and Women’s Hospital and Harvard Medical School Brigham and Women’s Hospital,
Boston, Massachusetts Professor of Pathology
Harvard Medical School
Alexander J. Lazar, MD, PhD Boston, Massachusetts
Professor
Departments of Pathology, Genomic Medicine, and Translational André M. Oliveira, MD, PhD
Molecular Pathology Professor of Laboratory Medicine and Pathology
The University of Texas M. D. Anderson Cancer Center Department of Laboratory Medicine and Pathology
Houston, Texas Mayo Clinic
Rochester, Minnesota
Bernadette Liegl-Atzwanger, MD
Head of Soft Tissue Pathology Service, Brian P. Rubin, MD, PhD
Associate Professor of Pathology Professor and Vice Chair of Research,
Institute of Pathology Medical University Graz Director, Soft Tissue Pathology,
Graz, Austria Director, Bone and Soft Tissue Fellowship Program
Robert J. Tomsich Pathology and Laboratory Medicine Institute
David Marcilla, MD Cleveland Clinic
Institute of Biomedicine of Sevilla (IBiS) Cleveland, Ohio
Virgen del Rocio University Hospital/CSIC/University of Sevilla/
CIBERONC Marta Sbaraglia, MD
Seville, Spain Department of Pathology
Azienda ULSS 2 Marca Trevigiana
Adrián Mariño-Enríquez, MD, PhD Treviso, Italy
Instructor
Department of Pathology Wei-Lien Wang, MD
Brigham and Women’s Hospital and Harvard Medical School Associate Professor
Boston, Massachusetts Departments of Pathology and Translational Molecular Pathology
The University of Texas MD Anderson Cancer Center
Houston, Texas

viii
 Series Preface

It is often stated that anatomic pathologists come from a practical perspective, we have asked our
in two forms: “Gestalt”-based individuals, who contributors to be complete and yet to discuss
recognize visual scenes as a whole, matching them only principal interpretative images. Our goal is
unconsciously with memorialized archives; and eventually to provide a series of monographs
criterion-oriented people, who work through that, in combination with one another, will allow
images systematically in segments, tabulating the trainees and practitioners in pathology to use
results—internally, mentally, and quickly—as they salient morphological patterns to reach with
go along in examining a visual target. These confidence final diagnoses in all organ systems.
approaches can be equally effective, and they are As stated in the introduction to the PPPDA
probably not as dissimilar as their descriptions text, the evaluation of dominant patterns is aided
would suggest. In reality, even “Gestaltists” secondarily by the analysis of cellular composition
subliminally examine details of an image, and, if asked specifically about and other distinctive findings. Therefore within the context of each
particular features of it, they are able to say whether one characteristic pattern, editors have been asked to use such data to refer the reader to
or another is important diagnostically. appropriate specific chapters in their respective texts.
In accordance with these concepts, in 2004 we published a textbook We have also stated previously that some overlap is expected between
entitled Practical Pulmonary Pathology: A Diagnostic Approach (PPPDA). pathologic patterns in any given anatomic site; in addition, specific
That monograph was designed around a pattern-based method, wherein disease states may potentially manifest themselves with more than one
diseases of the lung were divided into six categories on the basis of pattern. At first, those facts may seem to militate against the value of
their general image profiles. Using that technique, one can successfully pattern-based interpretation. However, pragmatically, they do not. One
segregate pathologic conditions into diagnostically and clinically useful often can narrow diagnostic possibilities to a very few entities using
groupings. the pattern method, and sometimes a single interpretation will be obvious.
The merits of such a procedure have been validated empirically by Both of those outcomes are useful to clinical physicians caring for a
the enthusiastic feedback we have received from users of our book. In given patient.
addition, following the old adage that “imitation is the sincerest form It is hoped that the expertise of our authors and editors, together
of flattery,” since our book came out, other publications and presentations with the high quality of morphologic images they present in this Elsevier
have appeared in our specialty with the same approach. series, will be beneficial to our reader-colleagues.
After publication of the PPPDA text, representatives at Elsevier,
most notably William Schmitt, were enthusiastic about building a series Kevin O. Leslie, MD
of texts around pattern-based diagnosis in pathology. To this end we Mark R. Wick, MD
have recruited a distinguished group of authors and editors to accomplish
that task. Because a panoply of patterns is difficult to approach mentally

ix
 Preface to the First Edition

With its diversity of histologic appearances and the rarity of many types osseous neoplasms is relatively straightforward on histologic grounds
of mesenchymal tumors, soft tissue tumor pathology can be intimidating alone, separate chapters are devoted to these groups of lesions. Cutane-
for pathologists in training and practicing pathologists alike. The current ous, gastrointestinal, and lower genital mesenchymal tumors are also
classification system informs the organization of the majority of soft presented in separate chapters, because many distinctive tumor types arise
tissue tumor textbooks, emphasizing the line of differentiation exhibited exclusively or predominantly in those anatomic compartments. Because
by the tumor cells. Pathologists can relatively easily recognize some many soft tissue tumors have more than one distinguishing feature (e.g.,
mesenchymal tumors as fibroblastic/myofibroblastic, “fibrohistiocytic,” epithelioid cytology and myxoid stroma, spindle cell morphology and
smooth muscle, skeletal muscle, vascular, or adipocytic, but for many prominent inflammatory cells), quite a few tumors are discussed in
other soft tissue tumors, the lineage is not intuitively obvious. Immu- multiple chapters to emphasize approaches to differential diagnosis.
nohistochemistry therefore plays a major role in demonstrating such Although molecular findings are included throughout the textbook when
lineages. However, for some mesenchymal neoplasms, there is no apparent relevant, the final chapter is devoted to molecular testing in soft tissue
normal cellular counterpart; such tumors (which are both histologically tumor pathology, both to provide an overview of the methods used (and
and clinically diverse) are often found in textbooks lumped together relative merits of the various techniques) and to give examples of how
in a separate chapter with tumors of uncertain lineage. Despite teaching the application of molecular testing can aid in differential diagnosis.
junior residents to describe tumors based on cytologic findings and The main patterns are included in table form in the front of the
histologic patterns, our specialty features surprisingly few pathology textbook. This section also includes additional distinguishing findings
textbooks wherein soft tissue tumors are presented in the same manner that can narrow down the differential diagnosis, specific diagnostic
in which pathologists approach them in daily practice—with tumor considerations within each category, and a reference to the chapter and
cell appearance, architectural arrangements, and stromal characteristics page number where the particular tumor type can be found. The reader
as organizing principles. may choose either to use these tables to identify specific tumors in the
This textbook addresses this gap in our literature by taking a pattern- book based on the dominant pattern and other particular features or
based approach to soft tissue tumor pathology, with chapters devoted to to go directly to the chapter or chapters containing tumors with the
the dominant cytology of the tumor cells (spindle cell tumors, epithelioid histologic features recognized. Although these tables are relatively
tumors, round cell tumors, pleomorphic sarcomas, biphasic tumors, comprehensive, they do not include most vascular, adipocytic, carti-
and tumors with mixed patterns), the quality of the extracellular matrix laginous, and osseous tumors, which can be studied in the chapters
(tumors with myxoid stroma), and other distinguishing features (giant devoted to those groups of neoplasms.
cell–rich tumors, soft tissue tumors with prominent inflammatory cells).
Because recognition of many adipocytic, vascular, cartilaginous, and Jason L. Hornick, MD, PhD

x
 Preface

In the 5 years since the publication of the first edition In sarcoma classification, among the most significant
of Practical Soft Tissue Pathology and the most recent recent advances is the emergence of discrete tumor
World Health Organization classification, we have types within the previous category of “undifferentiated
seen remarkable advances in diagnostic soft tissue round cell sarcomas” based on molecular genetics.
tumor pathology; the second edition of this book After Ewing sarcoma and other well-defined round
incorporates these changes. New defining molecular cell sarcomas were excluded by immunohistochemistry
genetic alterations continue to be discovered at an and fluorescence in situ hybridization (FISH), we had
astonishing rate. In turn, these findings lead (also no real options beyond this wastebasket category. Now,
with increasing speed) to new diagnostic tests, not round cell sarcomas with CIC gene rearrangements
only molecular assays but also using immunohisto- (most with CIC-DUX4) and BCOR genetic alterations
chemistry. In many cases, single-antibody immuno- (most often BCOR-CCNB3) are recognized diagnostic
histochemical tests serve as excellent surrogate markers for particular categories, with important prognostic implications and, we hope in the
molecular genetic alterations. These novel diagnostic markers have near term, distinct systemic therapies. In rapid succession, pathologists
proven to be extremely valuable tools for differential diagnosis, especially have introduced immunohistochemical markers that correlate with these
in limited biopsy material, such as core needle biopsies and fine needle rearrangements, some based on the gene fusions per se (e.g., CCNB3 and
aspirations, which we encounter every day in clinical practice. In the BCOR) and others reflecting downstream consequences of these fusions,
past, it could be challenging, if not impossible, to render a specific often discovered by gene expression profiling (such as ETV4).
diagnosis in such limited samples; now accurate diagnosis is often These genetic alterations and emerging diagnostic markers, which
possible with the aid of these powerful new markers. These markers have been integrated into the second edition, should improve the accuracy
have changed our diagnostic approach to both relatively common and and reproducibility of mesenchymal tumor diagnosis. I hope you find
rare tumor types, including major histologic categories of soft tissue this book useful in your daily clinical practice.
tumors, such as spindle cell tumors, epithelioid tumors, and round cell
sarcomas. Jason L. Hornick, MD, PhD

xi
This page intentionally left blank
 Acknowledgment

Many individuals have had a significant impact on my development as The residents, fellows, and my colleagues in the pathology department
a diagnostic pathologist and on the creation of this textbook. I would at Brigham and Women’s Hospital are an exceptional team of trainees
first like to acknowledge my colleague and friend Christopher Fletcher, and friends, and I am fortunate to share my passion for surgical pathology
without whom I would not have become a surgical pathologist. Without with them. My first introduction to monoclonal antibodies was during
his mentorship and support, this textbook would not exist. Chris gener- my doctoral work; I am grateful to Alan Epstein and Clive Taylor for
ously allowed me to photograph his consult cases, which have greatly this and for encouraging me to consider a pathology residency. Finally,
enhanced many of the chapters throughout the book. I would like to my wife, Harmony Wu, has provided support and insights during the
thank my colleagues and friends who devoted considerable time and long journey toward the completion of this textbook, and our children,
effort working on the excellent chapters that they contributed to this Hazel and Oscar, have been a source of inspiration and humility and
project. Their research, writing, and teaching in this field will continue have been (relatively) patient with me along the way.
to advance our understanding (and improve the diagnosis) of mesen-
chymal tumors for a new generation of pathologists and our clinical Jason L. Hornick, MD, PhD
collaborators.

xiii
This page intentionally left blank
 Contents

Pattern-Based Approach to Diagnosis xvii 10 Soft Tissue Tumors With Prominent Inflammatory
Cells 269
1 Introduction: Tumor Classification and Jason L. Hornick, MD, PhD
Immunohistochemistry 1
Jason L. Hornick, MD, PhD 11 Giant Cell–Rich Tumors 297
Bernadette Liegl-Atzwanger, MD, and Jason L. Hornick, MD, PhD
2 Biologic Potential, Grading, Staging, and
Reporting of Sarcomas 9 12 Adipocytic Tumors 311
Jason L. Hornick, MD, PhD Marta Sbaraglia, MD, and Angelo Paolo Dei Tos, MD

3 Spindle Cell Tumors of Adults 15 13 Vascular Tumors 341

Adrián Mariño-Enríquez, MD, PhD, and Jason L. Hornick, MD, Briana C. Gleason, MD, and Jason L. Hornick, MD, PhD
PhD
14 Cartilaginous and Osseous Soft Tissue
4 Pediatric Spindle Cell Tumors 101 Lesions 391
Cheryl M. Coffin, MD, and Rita Alaggio, MD Jodi M. Carter, MD, PhD, and André M. Oliveira, MD, PhD

5 Tumors With Myxoid Stroma 135 15 Cutaneous Mesenchymal Tumors 403

Vickie Y. Jo, MD, and Jason L. Hornick, MD, PhD Thomas Brenn, MD, PhD, FRCPath, and
Jason L. Hornick, MD, PhD
6 Epithelioid and Epithelial-Like Tumors 165
Leona A. Doyle, MD, and Jason L. Hornick, MD, PhD 16 Mesenchymal Tumors of the Gastrointestinal
Tract 459
7 Pleomorphic Sarcomas 209 Brian P. Rubin, MD, PhD, and Jason L. Hornick, MD, PhD
J. Frans Graadt van Roggen, MB ChB, BSc Hons, PhD, and
Pancras C.W. Hogendoorn, MD, PhD 17 Lower Genital Soft Tissue Tumors 499
Marisa R. Nucci, MD
8 Round Cell Tumors 233
Enrique de Alava, MD, PhD, David Marcilla, MD, 18 Applications of Molecular Testing to Differential
and Michele Biscuola, PhD Diagnosis 513
Wei-Lien Wang, MD, and Alexander J. Lazar, MD, PhD
9 Biphasic Tumors and Tumors With Mixed
Patterns 249
Jason L. Hornick, MD, PhD

xv
This page intentionally left blank
 Pattern-Based Approach to Diagnosis

Pattern Selected Diseases to Be Considered Pattern Selected Diseases to Be Considered

Spindle cell Nodular fasciitis Pleomorphic—cont'd Pleomorphic liposarcoma

Myofibroma/myopericytoma Pleomorphic leiomyosarcoma
Cellular benign fibrous histiocytoma Pleomorphic rhabdomyosarcoma
Dermatofibrosarcoma protuberans Myxofibrosarcoma
Superficial or desmoid fibromatosis Myxoinflammatory fibroblastic sarcoma
Neurofibroma Extraskeletal osteosarcoma
Schwannoma Undifferentiated pleomorphic sarcoma
Leiomyoma
Leiomyosarcoma Round cell Ewing sarcoma
Gastrointestinal stromal tumor Embryonal rhabdomyosarcoma
Solitary fibrous tumor Alveolar rhabdomyosarcoma
Spindle cell lipoma Round cell (high-grade myxoid) liposarcoma
Atypical spindle cell lipomatous tumor Poorly differentiated synovial sarcoma
Soft tissue perineurioma Desmoplastic small round cell tumor
Low-grade fibromyxoid sarcoma Mesenchymal chondrosarcoma
Monophasic synovial sarcoma CIC-rearranged sarcomas
Malignant peripheral nerve sheath tumor BCOR-rearranged sarcomas
Biphenotypic sinonasal sarcoma
Dedifferentiated liposarcoma Biphasic or mixed Biphasic synovial sarcoma
Clear cell sarcoma Mixed tumor
Nodular Kaposi sarcoma Glandular malignant peripheral nerve sheath tumor
Pseudomyogenic hemangioendothelioma Myoepithelioma/myoepithelial carcinoma
Gastrointestinal stromal tumor
Epithelioid Epithelioid hemangioma Ectopic hamartomatous thymoma
Epithelioid hemangioendothelioma Dedifferentiated liposarcoma
Epithelioid angiosarcoma
Glomus tumor Myxoid Intramuscular/cellular myxoma
Granular cell tumor Dermal nerve sheath myxoma
Cellular neurothekeoma Superficial acral fibromyxoma
Myoepithelioma/myoepithelial carcinoma Superficial angiomyxoma
Epithelioid schwannoma Deep angiomyxoma
Epithelioid malignant peripheral nerve sheath tumor Ossifying fibromyxoid tumor
Gastrointestinal stromal tumor Myoepithelioma/myoepithelial carcinoma
Perivascular epithelioid cell tumor (PEComa) Myxofibrosarcoma
Epithelioid sarcoma Pleomorphic liposarcoma
SMARCA4-deficient thoracic sarcoma Myxoid liposarcoma
Malignant rhabdoid tumor Extraskeletal myxoid chondrosarcoma
Alveolar soft part sarcoma Low-grade fibromyxoid sarcoma
Clear cell sarcoma Myxoinflammatory fibroblastic sarcoma
Sclerosing epithelioid fibrosarcoma Neurofibroma
Soft tissue or reticular perineurioma
Pleomorphic Atypical fibrous histiocytoma Malignant peripheral nerve sheath tumor
Atypical fibroxanthoma Spindle cell lipoma
“Ancient” schwannoma
Dedifferentiated liposarcoma

xvii
 Practical Soft Tissue
Pattern-Based Approach
Pathology:
to Diagnosis
A Diagnostic Approach

Pattern 1 Spindle Cell

Elements of the pattern: The tumor cells contain pointed or tapering ends.

xviii
 Pattern-Based Approach to Diagnosis

Pattern 1 Spindle Cell

Additional Findings Diagnostic Considerations Chapter:Page

Fascicular architecture Nodular fasciitis Ch. 3:20; Ch. 4:102; Ch. 5:158
Pseudosarcomatous myofibroblastic proliferation Ch. 3:25
Myofibroma/myofibromatosis/myopericytoma Ch. 3:27; Ch. 4:107
Fibrous hamartoma of infancy Ch. 4:114
Calcifying aponeurotic fibroma Ch. 4:114
Lipofibromatosis Ch. 4:115; Ch. 12:313
Mammary-type myofibroblastoma Ch. 3:31; Ch. 17:506
Intranodal palisaded myofibroblastoma Ch. 3:32
Cellular benign fibrous histiocytoma Ch. 15:410
Dermatomyofibroma Ch. 15:412
Superficial fibromatosis Ch. 3:46
Desmoid fibromatosis Ch. 3:47; Ch. 4:109; Ch. 16:481
Schwannoma Ch. 3:51; Ch. 16:475
Cellular schwannoma Ch. 3:53
Solitary circumscribed neuroma Ch. 15:415
Leiomyoma Ch. 3:64; Ch. 15:412; Ch. 16:471; Ch. 17:509
Angioleiomyoma Ch. 3:66
Leiomyosarcoma Ch. 3:66; Ch. 16:474
Epstein-Barr virus–associated smooth muscle neoplasm Ch. 3:68
Lymphangiomyoma Ch. 3:68
Inflammatory myofibroblastic tumor Ch. 4:118; Ch. 10:269; Ch. 16:479
Gastrointestinal stromal tumor Ch. 16:460
Monophasic synovial sarcoma Ch. 3:72
Malignant peripheral nerve sheath tumor Ch. 3:76
Biphenotypic sinonasal sarcoma Ch. 3:79
Atypical fibroxanthoma, spindle cell variant Ch. 15:449
Fibrosarcomatous dermatofibrosarcoma protuberans Ch. 15:418
Infantile fibrosarcoma Ch. 4:121
Infantile rhabdomyofibrosarcoma Ch. 4:126
Adult-type fibrosarcoma Ch. 3:81
Low-grade myofibroblastic sarcoma Ch. 3:84; Ch. 4:124
Cellular fetal rhabdomyoma Ch. 4:126
Spindle cell rhabdomyosarcoma Ch. 3:86; Ch. 4:127
Clear cell sarcoma Ch. 3:87
Nodular Kaposi sarcoma Ch. 13:382
Kaposiform hemangioendothelioma Ch. 13:380
Spindle cell angiosarcoma Ch. 13:384
Pseudomyogenic hemangioendothelioma Ch. 3:89; Ch. 15:425
Storiform/whorled architecture Cutaneous benign fibrous histiocytoma Ch. 15:410
Deep fibrous histiocytoma Ch. 3:39
Dermatofibrosarcoma protuberans Ch. 15:417
Storiform collagenoma Ch. 15:415
Soft tissue perineurioma Ch. 3:61; Ch. 15:422
Hybrid schwannoma/perineurioma Ch. 15:423
Low-grade fibromyxoid sarcoma Ch. 3:81; Ch. 4:124; Ch. 5:153
Follicular dendritic cell sarcoma Ch. 10:274
Dedifferentiated liposarcoma (subset) Ch. 7:225; Ch. 12:328
Lobulated architecture Dermal nerve sheath myxoma Ch. 5:139; Ch. 15:431
Superficial angiomyxoma Ch. 5:141; Ch. 15:428
Myxofibrosarcoma Ch. 5:148; Ch. 7:218
Extraskeletal myxoid chondrosarcoma Ch. 5:151
Plexiform architecture Plexiform schwannoma Ch. 3:54
Plexiform neurofibroma Ch. 3:59
Dendritic cell neurofibroma Ch. 15:424
Plexiform fibrohistiocytic tumor Ch. 11:303
Plexiform fibromyxoma Ch. 16:484

xix
 Practical Soft Tissue
Pattern-Based Approach
Pathology:
to Diagnosis
A Diagnostic Approach

Pattern 1 Spindle Cell—cont’d

Additional Findings Diagnostic Considerations Chapter:Page

Nuclear palisading Intranodal palisaded myofibroblastoma Ch. 3:32
Schwannoma Ch. 3:51
Monophasic synovial sarcoma (small subset) Ch. 3:72
Leiomyoma (subset) Ch. 3:64
Gastrointestinal stromal tumor (subset) Ch. 16:460
Nuclear pleomorphism “Ancient” schwannoma Ch. 3:51
Atypical neurofibroma Ch. 3:57
Malignant peripheral nerve sheath tumor Ch. 3:76
Pleomorphic lipoma Ch. 12:316
Dedifferentiated liposarcoma Ch. 7:225; Ch. 12:328
Myxofibrosarcoma Ch. 5:148; Ch. 7:218
Myxoinflammatory fibroblastic sarcoma Ch. 5:155; Ch. 7:217; Ch. 10:286
Pleomorphic fibroma Ch. 15:452
Atypical fibrous histiocytoma Ch. 15:411
Atypical fibroxanthoma Ch. 15:449
Myxoid stroma Nodular fasciitis (subset) Ch. 3:20; Ch. 4:102; Ch. 5:158
Soft tissue perineurioma (subset) Ch. 5:157
Reticular perineurioma Ch. 5:157
Microcystic/reticular schwannoma Ch. 5:158
Solitary fibrous tumor (small subset) Ch. 5:158
Monophasic synovial sarcoma (small subset) Ch. 5:158
Malignant peripheral nerve sheath tumor (subset) Ch. 3:76; Ch. 5:158
Low-grade fibromyxoid sarcoma Ch. 3:81; Ch. 4:124; Ch. 5:153
Primitive myxoid mesenchymal tumor of infancy Ch. 4:123
Fetal rhabdomyoma Ch. 4:126
Embryonal rhabdomyosarcoma (subset) Ch. 8:242
Dermal nerve sheath myxoma Ch. 5:139; Ch. 15:431
Dermatofibrosarcoma protuberans (small subset) Ch. 5:158
Superficial acral fibromyxoma Ch. 5:140; Ch. 15:427
Superficial angiomyxoma Ch. 5:141; Ch. 15:428
Deep angiomyxoma Ch. 5:141; Ch. 17:499
Lipoblastoma Ch. 12:319
Spindle cell lipoma (subset) Ch. 3:50; Ch. 15:405
Desmoid fibromatosis (subset) Ch. 3:47; Ch. 4:109; Ch. 16:481
Plexiform fibromyxoma Ch. 16:484
Myxoinflammatory fibroblastic sarcoma Ch. 5:155; Ch. 7:217; Ch. 10:286
Myxofibrosarcoma Ch. 5:148; Ch. 7:218
Myxoid liposarcoma Ch. 5:150; Ch. 12:332
Extraskeletal myxoid chondrosarcoma Ch. 5:151

xx
 Pattern-Based Approach to Diagnosis

Pattern 1 Spindle Cell—cont’d

Additional Findings Diagnostic Considerations Chapter:Page

Collagenous stroma Fibroma of tendon sheath Ch. 3:33
Desmoplastic fibroblastoma Ch. 3:34
Nuchal-type fibroma Ch. 3:35
Gardner fibroma Ch. 4:104
Fibromatosis colli Ch. 4:112
Infantile digital fibroma Ch. 4:112
Elastofibroma Ch. 3:36
Calcifying fibrous tumor Ch. 3:37
Solitary fibrous tumor Ch. 3:40
Mammary-type myofibroblastoma Ch. 3:31; Ch. 17:506
Hyaline fibromatosis Ch. 4:118
Storiform collagenoma Ch. 15:415
Superficial fibromatosis Ch. 3:46
Desmoid fibromatosis Ch. 3:47; Ch. 4:109; Ch. 16:481
Neurofibroma (subset) Ch. 3:57
Ganglioneuroma Ch. 3:63
Sclerosing perineurioma Ch. 3:63; Ch. 15:442
Monophasic synovial sarcoma (subset) Ch. 3:72
Low-grade fibromyxoid sarcoma Ch. 3:81; Ch. 4:124; Ch. 5:153
Low-grade myofibroblastic sarcoma Ch. 3:84; Ch. 4:125
Collagen bundles Intranodal palisaded myofibroblastoma Ch. 3:32
Spindle cell lipoma Ch. 3:50; Ch. 15:453
Neurofibroma (subset) Ch. 3:57
Gastrointestinal stromal tumor (subset) Ch. 16:460
Prominent inflammatory cells Calcifying fibrous tumor (lymphocytes) Ch. 3:37
Inflammatory myofibroblastic tumor (plasma cells, lymphocytes) Ch. 4:118; Ch. 10:269; Ch. 16:479
Leiomyosarcoma (lymphocytes, histiocytes; small subset) Ch. 10:273
Epstein-Barr virus–associated smooth muscle neoplasm (lymphocytes) Ch. 3:68
Myxoinflammatory fibroblastic sarcoma (neutrophils, lymphocytes) Ch. 5:155; Ch. 7:217; Ch. 10:286
Follicular dendritic cell sarcoma (lymphocytes) Ch. 10:274
Interdigitating dendritic cell sarcoma (lymphocytes) Ch. 10:277
Fibroblastic reticular cell sarcoma (lymphocytes) Ch. 10:277
Angiomatoid fibrous histiocytoma (lymphocytes, including germinal Ch. 3:68; Ch. 10:285
centers)
Gastrointestinal schwannoma (lymphocytes, including germinal Ch. 16:477
centers)
Inflammatory fibroid polyp (eosinophils) Ch. 16:482
Prominent or distinctive giant cells Nodular fasciitis (osteoclast-like; subset) Ch. 3:20; Ch. 4:102; Ch. 5:158
Phosphaturic mesenchymal tumor (osteoclast-like) Ch. 3:30
Solitary fibrous tumor (floret-type; small subset) Ch. 3:44
Pleomorphic lipoma (wreath-like) Ch. 12:316
Leiomyosarcoma (osteoclast-like; small subset) Ch. 11:309
Clear cell sarcoma (wreath-like) Ch. 3:87
Plexiform fibrohistiocytic tumor (osteoclast-like) Ch. 11:303
Giant cell fibroblastoma (floret-type) Ch. 15:421
Benign fibrous histiocytoma (Touton) Ch. 15:405
Soft tissue aneurysmal bone cyst (osteoclast-like) Ch. 14:397

xxi
 Practical Soft Tissue
Pattern-Based Approach
Pathology:
to Diagnosis
A Diagnostic Approach

Pattern 1 Spindle Cell—cont’d

Additional Findings Diagnostic Considerations Chapter:Page

Adipocytic component Spindle cell lipoma Ch. 3:50; Ch. 12:316
Atypical spindle cell lipomatous tumor Ch. 3:50; Ch. 12:324
Lipofibromatosis Ch. 4:115; Ch. 12:313
Lipoblastoma Ch. 12:319
Myxoid liposarcoma Ch. 5:150; Ch. 12:332
Myolipoma Ch. 3:64; Ch. 12:321
Mammary-type myofibroblastoma (subset) Ch. 3:31; Ch. 17:506
Hemosiderotic fibrolipomatous tumor Ch. 12:319
Solitary fibrous tumor (subset) Ch. 3:44
Calcifications, cartilage, and/or bone/osteoid Phosphaturic mesenchymal tumor (calcifications, osteoid) Ch. 3:30
Calcifying fibrous tumor (calcifications) Ch. 3:37
Melanotic schwannoma (calcifications; subset) Ch. 3:55
Calcifying aponeurotic fibroma (calcifications) Ch. 4:114
Myositis ossificans (bone/osteoid) Ch. 14:391
Fasciitis ossificans (bone/osteoid) Ch. 3:23
Fibro-osseous pseudotumor (bone/osteoid) Ch. 14:392
Soft tissue aneurysmal bone cyst (bone/osteoid; subset) Ch. 14:397
Malignant peripheral nerve sheath tumor (cartilage and/or bone; Ch. 3:76
subset)
Dedifferentiated liposarcoma (cartilage and/or bone; subset) Ch. 7:225; Ch. 12:328
Extraskeletal osteosarcoma (bone/osteoid) Ch. 14:400
Prominent or distinctive blood vessels Nodular fasciitis (plexiform) Ch. 3:20; Ch. 4:102; Ch. 5:158
Myofibroma/myofibromatosis/myopericytoma (dilated, branching) Ch. 3:27; Ch. 4:107
Fibroma of tendon sheath (slit-like) Ch. 3:33
Nasopharyngeal angiofibroma (dilated, irregular, thin-walled) Ch. 4:117
Angiofibroma of soft tissue (small, branching) Ch. 3:37
Spindle cell hemangioma (dilated) Ch. 13:379
Solitary fibrous tumor (rounded, hyalinized; dilated, branching) Ch. 3:40
Monophasic synovial sarcoma (dilated, branching; subset) Ch. 3:72
Schwannoma (rounded, hyalinized) Ch. 3:51
Angioleiomyoma (thick-walled) Ch. 3:66
Lymphangiomyoma (dilated lymphatics) Ch. 3:68
Superficial angiomyxoma (elongated) Ch. 5:141; Ch. 15:428
Deep angiomyxoma (rounded, medium-sized) Ch. 5:141; Ch. 17:499
Cellular angiofibroma (thick-walled, hyalinized, medium-sized) Ch. 17:504
Low-grade fibromyxoid sarcoma (elongated) Ch. 3:81; Ch. 4:124; Ch. 5:153
Myxoid liposarcoma (plexiform) Ch. 5:148; Ch. 12:332
Myxofibrosarcoma (curvilinear) Ch. 5:148; Ch. 7:218
Inflammatory fibroid polyp (rounded, small) Ch. 16:482
Plexiform fibromyxoma (branching, small) Ch. 16:484

xxii
 Pattern-Based Approach to Diagnosis

Pattern 2 Epithelioid

Elements of the pattern: The tumor cells resemble epithelial cells with a rounded or
polygonal appearance and at least moderate amounts of cytoplasm.

xxiii
Another random document with
no related content on Scribd:
cut to heaven one of these days, if you go on using that road,” the
officer said, whereat the man grinned broadly.
The relationship between courage and discretion is always a
difficult thing in war. Many lives have been lost, I fear, in this war
because officers, particularly those new to the game, would not take
cover when a shell came over, lest they might appear “rattled.” In
point of fact, a man may often escape a wound, or perhaps even
save his life, by taking refuge in a dug-out or seeking refuge behind
a tree or a wall, when he hears by the diminishing speed of a shell
that it is about to burst in his neighbourhood.
A very few weeks in the field, however, makes most men fatalistic
about shell-fire—a man sees so often that life and death hang on a
fraction of a second, on a foot this way or that. Going up to trenches
one afternoon with two companions in a particularly lively part of our
line, we had to cross a little bridge over a ditch. Twenty yards from
this bridge was a dug-out in which the headquarters of the battalion I
had come to visit was situated. I had just reached the dug-out, when
I heard the slow drone of a shell. As I turned towards the direction
from which the sound came the shell burst square over the bridge
we had crossed less than a minute before, and two other shells fell
close by within a few seconds. With the utmost satisfaction, I must
admit, I dwelt on the thought that, if I had delayed for a minute to
fasten a boot-lace or to light a cigarette, I should in all probability
have been on that bridge just when those three shells burst there.
Two officers were following one another in cars through a ruined
village close behind our lines. At the end of the village they were
stopped by a military policeman, who warned them that the road was
being shelled. The officer in the leading car decided that he would
wait for the “strafing” to cease; the other, who was in a hurry,
proceeded to his destination by another route. On arriving he found a
telephone message to say that the first car had been struck square
by a shell a few minutes after he had left, and that the officer and his
chauffeur had been killed on the spot.
The rivet that holds the regimental officers together, their common
solicitude as their common pride, are the men. The officer in the
trenches is thinking continually of the men, of their safety, of their
comfort, of their health, of their behaviour under fire. Get an officer
talking about a “show,” and he will never tire of telling you how well
the men behaved, how Private This is a most “gallant feller,” and
Private That, “my best bomber,” died. “The men did d—— well,” “The
men were splendid.” How often have I heard phrases like these!
Pride in their officers, pride in their regiment, flashes out quaintly in
the men’s talk. Listen to a group of soldiers describing a fight.
“The Captain ’e says....” “Lieutenant Blank ups with his rifle quick-
like....” “The Major? ’E’s a fair nut, ’e is. First over the parapet ’e was,
and going that fast that, what with the bombs you ’ave round you,
and them you carry in a box, we couldn’t ’ardly keep up with ’im!”
This is a sergeant-major on the death of his Colonel:
“Yes, sir,” he says in his deep, slow voice, “our Colonel was hit, the
best soldier that ever commanded this battalion. He was a grand
man. ‘Sergeant-major,’ he says to me, ‘sergeant-major, I’m just going
up to have a look round.’ Well, he didn’t come back. Then a man
coming down, wounded, says in a great fuss: ‘Sergeant-major, it’s
something awful up there. The Colonel’s killed,’ he says, ‘and the
Adjutant, too!’ ‘You’ve got the wind up, my man,’ I said to the chap,
not believing him. ‘You run along to the dressing-station and get your
head bound up. You haven’t any brains to spare, remember.’ But, all
the same, I went up to see for myself what was happening. It was
true, sure enough. There was the Colonel, mortal bad he was, and
the Adjutant killed. Ah, he was a grand gentleman, our Colonel!
There were not many like him, sir! We could ill spare him!”
When you have seen officers and men together in the trenches
you understand Francis Grenfell’s dying words: “Tell them I died
happy. I loved my squadron.” Those noble words are the epitome of
the lifework of the Regimental Officer.
Out of this close friendship between officer and man springs a
great spirit of camaraderie between officers in the trenches. It is no
small test of character for a group of men of different stations, ages,
and dispositions to live in the closest possible association, as men
do in the trenches, for days at a time, and never to fail to display that
mutual forbearance and readiness to serve which help men over the
rough paths of life. During the months I have been at the front I have
been privileged, at different times, to see a great deal of officers
together in the trenches. I have spent nights with them in their dug-
outs; I have had various meals with them at their messes; I have
accompanied them on their rounds. What has struck me more than
anything has been the real spirit of co-operation existing between
them. This takes the form not only of the sharing of the minor
comforts of life, such as the pooling of gifts sent out from home—
which was only to be expected—but of a continual striving to help
one another, to render one another small services in their duties, to
cover up, if needs be, one another’s shortcomings, and, above all, to
make things smooth for the new man.
On the other hand, active service appears to accentuate inter-
regimental rivalry. Trenches are a great theme for criticism. There
may be a battalion in our army in the field to-day that has given a
written testimony to the troops from which it has “taken over” of the
splendid condition in which the trenches were left. If there is, I have
not found it. The relieving battalion always roundly abuses its
predecessor for the state of the trenches. In every trench I have
been in I have been shown with pride the improvements made by the
actual tenants: “You should have seen the state of things those
bloody fellows in the Blankshires left behind!...” I once heard the
Commander of the Second Army get in a sly dig at a brigade on
parade regarding this inevitable trench criticism. It was a very human
touch in a formal address, and evoked broad smiles from the
audience, both officers and men.
Nothing could be more charming than the atmosphere of a trench
mess. The Colonel is back at the battalion headquarters with the
Adjutant, so that the senior officer present is the Captain in
command of the company holding the particular section of trench, or
at most a Major. The rest of the company at table will consist of two
or three subalterns, the machine-gun officer, possibly the doctor, and
sometimes the Chaplain. The “Padre” is, properly speaking, attached
to the Field Ambulance, but one often meets these gallant men in the
firing-line, making their tour of the men under their charge as
conscientiously as the Captain makes his round of his trenches.
You must picture the company seated on rough benches or
ammunition-boxes (here and there one finds a chair salved from a
wrecked farm) round a makeshift table, knocked together by the
orderlies, with sheets of newspaper in lieu of a tablecloth. Most of
the food is put on the table at once—sardines in an enamel soup-
plate, cold tongue ditto, ration bread (rather mouldy if we are in an
isolated post), some kind of hot meat on an enamel dish, and
enamel cups for drinks. The conversation is sprightly, mostly of the
events of the day. The presence of the “Padre” curbs the freedom of
the language to some extent, though, Heaven knows, he, poor man,
has already discovered that the army swears terribly in Flanders. “I
can stand a good deal,” a “Padre” said to me one day, “but I draw the
line firmly at some words.”
This imperturbable young man with the shaven head and the
yellow moustache, whose dinner is being continually interrupted by
gruff voices issuing from the darkness at the door of the dug-out,
“Can I speak to the Captain?” “A message for the Captain!” “About
those blankets for the men, sir ...” is responsible for the safety of this
stretch of trench and its tenants. He transacts his business through
the door of the dug-out and eats his dinner at the same time, always
tranquilly. The hole in the back of his tunic is a souvenir of a piece of
high-explosive shell in the shoulder, and the cut in the knee of his
trousers is due to the same cause. A boy with yellow hair and pink
cheeks, who is talking telescopic rifles with the doctor, is Lord of the
Hate Squad—in other words, in charge of the snipers. Only that
afternoon I had seen him, with a companion, amid bullets snapping
viciously against a ruined wall, patiently waiting for a certain sniping
Hun whose habitat was in a tree. He had not got him that day, but
the Hate Squad had their eye on the sniper, and sooner or later his
number would go up.
A burst of laughter from the other end of the table greets a story
told with infinite gusto by the machine-gun officer, a phlegmatic
young man with the ribbon of the Military Cross on his tunic. He
knows German well, and one of his amusements is to revile the
Germans in their own tongue. He is recounting some of the epithets
he applies to them.
Our army in the field has managed to scrape together a whole
vocabulary of trench slang. It is a strange medley of English, French,
and German. That immortal phrase “Gott strafe England” has given
to trench slang “strafing” as a substantive, and “to straf” as a verb.
As you have probably already gathered from reading soldiers’ letters
in the newspapers, to be “strafed” is to be bombarded by the enemy
—in short, to suffer in any way at the hands of the Hun. The morning
and evening “straf” is equivalent to the morning and evening
“frightfulness” or “hate,” the liveliness with which the German guns
issue in the day and march it out at its close. The Germans apply the
words “Morgengruss” (morning greeting) and “Abendsegen” (evening
benediction) to these periodical outbursts from our side. “Hate,” used
in this sense, undoubtedly owes its origin to that amusing sketch in
Punch, showing a German family indulging in its “morning hate.” This
clever cartoon had an immense vogue at the front, and I have seen it
frequently hanging up on the walls of dug-outs and billets.
To be “crumped”—another expression often heard in the trenches
—is to be bombarded with heavy howitzer shells, an onomatopœic
word. To be “archied”—a Royal Flying Corps phrase—is to be
shelled by anti-aircraft guns, which are universally known as
“Archibalds” or “Archies.”
A whole vocabulary has grown up about the guns which are
playing such a rôle in this war. “Gunning” is freely used as a
synonym for “shelling”; the heavy guns are, tout court, “the heavies”;
the howitzers are the “hows.” There is a wild and picturesque crop of
nicknames to denote the different kinds of guns and shells. Thus, our
heaviest howitzer is known as “Grandmother” or “Grandma,” while
the next below it in size is “Mother.” A certain German long-range
naval gun, whose shells have the peculiarity of bursting before you
hear them arrive, is known as “Percy.” German high-explosive
shrapnel shells are “white hopes” or “white swans.” “Jack Johnsons,”
“Black Marias,” and “coal-boxes” are used rather indiscriminately for
different kinds of heavy shells, while “whizz-bangs,” the small 15-
pounder shell thrown by a mountain-gun, are also called “pip-
squeaks.” The men in the firing-line got so free with their nicknames
for shells in official reports at one time that a list of officially
recognized and distinctive nicknames for German shells was drawn
up and issued for use by some divisions.
From the French trench slang derives one or two expressions. “To
function” (fonctionner) is one. A man “functions” as liaison officer, a
trench-pump will not “function.” “Dégommer” is often used to denote
the action of relieving an officer of his command. It is, of course, pure
French slang, and is invariably used in this sense in the French
Army. This word has a curious derivation. It was, I believe, first
applied by the Humanité in its old sledgehammer days under the late
Jean Jaures, to denote Aristide Briand, most fiercely hated of all
French Ministers because, at the outset of his career, he was in the
ranks of those revolutionary Socialists whom he had to combat so
fiercely when in office. All public men who came under the ban of the
Humanité had their nicknames, and were never referred to by
anything else. Thus M. Lépine, the late Prefect of Police of Paris,
was spoken of as le sinistre gnome, M. Clemenceau as Le Tigre,
and M. Briand, after his fall from power as the result of his
suppression of the railway strike, as Le Dégommé—“the ungummed
one,” the innuendo being that he had clung to office until he was
forcibly torn from power.
Talk at the trench mess, of course, principally turns round such
trench topics as the men and their caprices, the date of relief, leave.
There is “grousing” about the slowness of promotion, about the
Mentions in Despatches. But there is no gloom. It is an eternal
wonder to me that the officers in the trenches are so consistently
cheerful. Neither death nor danger depresses their spirits; the
monotony does not make them despondent. They do not hide the
fact that they hate shell-fire, or that they could contemplate a more
agreeable existence than living in a ditch in Flanders. Only they
realize that they have a job to do, and they do it. And they will go on
doing it until their work is done.
The Germans have realized too late what they have lost by
sacrificing the respect of their enemies. Our soldiers in the trenches
make no concealment of their admiration of the efficiency and
bravery of the Germans as fighters, but as men they loathe and
despise them. The British soldier is an easy-going fellow, and the
Germans, had they only regarded the conventions of soldiering,
might have prevented much of the bitterness which this war has
engendered. Even as it is, though the anger of our men against their
treacherous enemy makes them a formidable and pitiless foe in the
assault with the bayonet, they are gentle and paternal with their
prisoners.
I have actually seen the British escort giving German prisoners
cigarettes. I have read letters written by German prisoners waiting in
our lines in France to be sent with a convoy to England, dwelling on
the good treatment they were receiving, and describing how they
were given the same rations as their escort, including cigarettes, and
were being taught football by their captors. The extraordinary agapes
that took place during the Christmas truce, when British and
Germans, for a few brief hours, fraternized between the lines, could
not, I believe, occur again, except possibly with the Saxons, who
have behaved decently in this war, and for whom our men have a
soft corner in their hearts. Since Christmas the hideous crime of the
asphyxiating gas has drifted in a foul miasma between us and our
enemy. No man who fought in the second battle of Ypres and saw
the sufferings of the gas victims would give his hand to a German to-
day. But the psychology of the British soldier is so enigmatic that the
prophet would run grave risk of coming to grief who ventured to
predict what the British soldier will do where his heart is concerned.
Nevertheless, this much I would say—that to-day the British soldier
neither fears nor trusts the German. He knows that, man for man, he
is his superior; he looks forward to the time when, gun for gun and
shell for shell, the same will be true.
 “Daily Mail” phot.
German Prisoners.
With the British and German lines in places only forty yards or less
apart, there is always a certain amount of communication between
ourselves and the enemy. The Germans generally contrive to find
out which of our battalions is holding the trenches opposite, and
often greet the reliefs with the name of their regiment. When a
famous Highland battalion was going away, after a long stay in one
portion of the line, the Germans played them out of the trenches with
“Mary of Argyll,” very well rendered on the cornet. The Jocks were
hugely amused, and gave the performer a round of applause to
reward his efforts.
A large sheet of water which had formed about some shell-holes
outside the trenches of the Rifle Brigade in the winter afforded both
sides a great deal of amusement. One night a patrol found a rough
wooden model of a German submarine floating in the pond, flying a
paper flag on which were inscribed the words: “Deutschland,
Deutschland über alles!” The submarine was “captured,” and for the
next few days several handy fellows in the battalion of the R.B.’s
holding the front line spent all their spare time in constructing a
model battleship. This was subsequently launched at night flying a
pennant with the words: “Why don’t you come out and fight?” A night
or two after our patrols found that the pennant had been removed
from the battleship, and replaced by a flag bearing the words:
“Germania rules the waves!” In the meantime the battle of Heligoland
was fought. The model was accordingly rescued from the pond,
suitably disfigured to represent a sinking ship, “Bluecher” painted in
large letters on its side, and the flag replaced by one bearing these
words: “Has your Government told you about this ship?” The blow
told: the model disappeared, and the jest ended.
The exchange of news is very popular. I was in the front line one
afternoon when a message arrived from the division announcing the
surrender of German South-West Africa, and adding: “Perhaps the
enemy might like to know this.”
The suggestion was immediately acted upon. The news was
translated into German, “Gott strafe England!” was added to give it a
proper German ring, and when I went down the men were painting
the message in white on a large blackboard, which was going to be
hoisted on the parapet facing the German trench. The Germans
attacked this part of the line the next day, whether as the result of
our message I am unable to say.
The high comradeship of our trenches is enhanced by many little
touches redolent of home. The British soldier is a homing-bird, and
he loves to perpetuate the memory of places that are dear to him in
his surroundings in the trenches. The troops in the Ploegsteert lines
—“Plug Street” of wide renown—who inaugurated the custom of
giving street names to trenches with their “Strand” and “Fleet Street”
and “Hyde Park Corner,” in reality hit upon a very practical solution of
the great difficulty of providing suitable identification for the network
of trenches which was growing up all along our lines. Now the
custom is general, and the neatly inscribed sign-boards which meet
your eyes in so many parts of the line evoke recollections of busy
streets and squares in London and provincial towns, and of gallant
commanders, some of whom have “gone west,” whose names are
perpetuated in countless “houses” and “corners” and “farms” along
our line.
Since I came to France I have made it my business to visit the
trenches in almost every part of the line. There are those who say:
“When you have seen one trench, you have seen them all.” Of a
truth, outwardly there is little enough difference between them all—
the same swarm of dust-coloured figures, the same sandbags, the
same timber-work, the same mud, the same strip of No Man’s Land
ahead, the same devastation behind, the same noises echoing
hollow all about. But to me each strip of trench is another corner of
the great heart of Britain, where Britons of all stamps—the fair-haired
Saxon, the darker Norman, the Scot, the Celt, from many climes, of
many races—are playing the part in the work of Empire which is
every Briton’s birthright to-day. The bond uniting them in the steel
line which the German hordes have vainly tried to break is the
companionship of the Table Round of the Empire, the bulwark of the
world’s civilization against the most formidable menace ever
launched by the powers of darkness.
 CHAPTER XI
THE PRINCE OF WALES

One evening, a few years ago, I stood on the platform of the Gare
du Nord, and saw the arrival of the London train that was bringing
the young Prince of Wales to Paris for a stay of a few months before
going to Magdalen College, Oxford. The arrival was quite informal.
There was no red carpet, no guard of honour, only a few old friends
of King Edward, like the Marquis de Breteuil, with whom the Prince
was going to live, and M. Louis Lépine, most Parisian of police
prefects. “Comme tout ça fait penser à son grand-père!” one of those
present said to me as the train steamed in. “Il aimait Paris, celui-là!”
Because of his grandfather, Paris from the first opened her heart
wide to the young Prince, a fair-haired slip of a boy, as I saw him that
day at the Gare du Nord, acknowledging with just a trace of
embarrassment the cordial welcome of the friends of that other
“Prince de Galles.” The newspapers very chivalrously acceded to his
wish that his movements should be ignored, and for a few brief
months the Prince of Wales enjoyed that magic experience which
everyone would give the best years of his life to be able to taste
again, the first acquaintanceship with Paris. From the windows of the
Breteuil mansion in the Avenue du Bois he saw spring creeping into
the trees of the Bois de Boulogne, while in London winter still drearily
held sway. Many a time I met him swinging along the paths of the
Bois with his tutor, the tall Mr. Hansell, or caught a glimpse of him
driving out with one of the young Breteuils.
During his stay in Paris the young Prince went to the theatre, and
visited the museums, and played tennis at the courts of the Bois de
Boulogne or the Ile de Puteaux. M. Georges Cain, Curator of the
Carnavalet Museum, and the greatest living authority on antiquarian
Paris, led him into all the historic nooks and corners; M. Lépine took
him round the Halles and the queer cabarets and lodging-houses
surrounding the markets; while with Mr. Hansell he made excursions
into the wider France—to Reims, and Amiens, and Tours, of
cathedral fame; to the château country of the Loire; to Avignon and
the Palace of the Popes; to Brest and Toulon, where M. Delcassé,
another faithful friend of Edouard Sept, showed him the French Navy
at work.
In the months he spent amongst the French I know the Prince
learnt to love and admire France—eternal France, in President
Poincaré’s noble phrase. In a conversation which I was privileged to
have with the Prince in London before he went out to the front, he
spoke with affectionate remembrance of his days in Paris, with
indignation at the German air-raids on the city. Now, by a strange
dispensation of Providence, the Prince of Wales is in France again,
but the France he finds to-day is not the France he left a year or two
ago.
He finds Paris tranquil, but sobered—digne, in the phrase of a
Parisian. He finds France vibrating with a passion she has not known
since the cry, “La Patrie en danger!” brought the tatterdemalions of
the Revolution flocking in their thousands to take service under the
Tricouleur. He finds in France England’s stanch and helpful Ally,
finds the entente cordiale which his grandfather built up with such
infinite tact and inexhaustible patience welded into a firm alliance by
the blood of Frenchman and Briton spilled in defence of a common
ideal of liberty. When, in the fulness of time, Edward, Prince of
Wales, shall succeed, by the grace of God, to the throne of his
fathers, History shall count it a wise and far-seeing decision that sent
the Heir-Apparent into the field to play his part in those great events
which shall throw their shadow over his reign and the reign of his
sons and grandsons.
Directly the war broke out the Prince of Wales, like every other
Englishman of spirit, was burning to play his part; but the sending of
the Prince to the front was undoubtedly something in the nature of
an experiment. History and precedent were against such a course—
an argument often adduced by authorities when there is a question
of checking the ardour of youth.
 Yet if there were those who doubted the wisdom of exposing the
Prince of Wales to the perils and hardships of campaigning, there
was one person thoroughly and completely convinced as to the
propriety of his going to the front. That person was the Prince
himself; and to objectors his rejoinder, eminently practical and
modest, was something to the effect that he had brothers at home if
anything happened to him.
It speaks volumes for the energy of the young Prince that,
although he only joined the Grenadier Guards at the beginning of the
war, he should have rapidly passed through the necessary
preliminary training, and then have succeeded in overcoming any
opposition to his dearest wish.
In the earliest days of the war the Prince was seen taking his turn
on the guard at St. James’s, and performing the ordinary routine duty
of a Guards Subaltern.
This, however, was not to last long, and soon the happy day came
when the London Gazette announced the appointment of Lieutenant
the Prince of Wales, K.G., Grenadier Guards, to be A.D.C. to Field-
Marshal Sir John French, Commander-in-Chief of the British Army in
the Field; and the Prince left for General Headquarters.
Then for a long time we heard no more of the Prince of Wales.
Now and again a soldier’s letter from the front contained a brief
mention of his doings—that the Prince had been in the trenches or
had visited a hospital—and an occasional paragraph in the French
newspapers revealed the fact that he had been in the French or
Belgian lines. But it was the Commander-in-Chief himself who first
broke the silence anent the Prince’s doings. In his despatch dealing
with the battle of Neuve Chapelle he mentioned that the Prince of
Wales had acted as liaison officer with the First Army during that
engagement, and paid a tribute to the zeal and quickness with which
the Prince had discharged his duties, and the deep interest he took
in the comfort and general welfare of the men. It was the Prince of
Wales himself who brought that despatch to London, and Londoners
were able to see for themselves how he had filled out and hardened
during the months he had spent with the army in the field. His eyes
shone with the light of health, his face was tanned with exposure to
the rain and wind of winter and the pale sunshine of spring in
Flanders, and his whole being exuded that bodily fitness and mental
vigour which are the symptoms of a man whose heart is in his work.
This was my impression of the Prince when I saw him in the field
myself one wet afternoon in March. It was when the Second Army,
with whom I was on that particular occasion, was carrying out a local
attack against the Germans in the northern part of our line. The
valley was heavy with mist, and reverberating with the sound of our
guns carrying out the artillery preparation, our shrapnel bursting with
a gleam of orange-coloured fire against the white haze enveloping
the ridge we were going to attack.
As I stood and watched the fascinating spectacle—I find there is
no sight which holds the attention more than the play of bursting
shells—I noticed two young officers ascending the road leading to
the point where a group of Generals and Staff Officers was posted.
The new-comers stalked up the steep path at a good pace, and as
they passed I saw that the one who was leading was the Prince of
Wales. He was in field kit, with long trousers and putties, after the
manner of the Guards, and was wearing his accoutrements strapped
on over his “British warm.” He appeared to be soaked through, and
his walk through the steamy air had made him very hot. He saluted
punctiliously as he passed the group of Generals, then took up his
position with his companion and, unstrapping his glasses, began to
survey the scene that unfolded itself in the valley.
As darkness was falling I saw him again, walking along a road
where soldiers were standing to, preparatory to marching away to
take their turn in the trenches. As the men came running out of the
roadside hovels where they had been billeted, hoisting their packs
on their backs or tugging at their strappings, they recognized the
Prince, who acknowledged their salutes with a smile. He stopped for
a minute and talked to one or two of the men, then walked on
through the gathering shadows to a neat little racing-car standing by
the roadside, in which he was going to drive himself and his
companion back to G.H.Q.
 For many months the Prince lived at G.H.Q. He shared quarters
with Lieutenant-Colonel S. L. Barry and Lord Claud Hamilton, and
was a member of the Commander-in-Chief’s mess. Colonel Barry, a
distinguished cavalry officer and a delightful companion, arranges
the details of the Prince’s plans at the front, and his visits to different
parts of our lines and to the French and Belgian Armies; while in
Lord Claud Hamilton, the youngest brother of the Duke of Abercorn,
who won the D.S.O. for gallantry while serving with his regiment, the
Grenadier Guards, in the trenches, the Prince has a comrade of his
own age.
With that gift of easy self-effacement which our Public Schools and
’Varsity inculcate, the Prince slipped without any apparent difficulty
into his place in Sir John French’s small and intimate household at
G.H.Q. All ceremonial was waived as far as the Prince was
concerned, to his own great relief, and he was treated like any other
officer of the personal Staff. Perfectly natural as he is, the Prince has
small liking for the elaborations of Court etiquette in private life. He
has shown that, at State functions, he can acquit himself with dignity,
but excessive demonstrations of respect in private life embarrass
him, for, first and last, he is English, as English in mind and manner
as he is in appearance.
The Prince is English in his love of fresh air and hard exercise and
bodily fitness. Anything gross and unwieldy and fat and slothful is
repugnant to him. He takes a tremendous amount of exercise at the
front. He is always in training. He eats and drinks very little. He
thinks nothing of going for a run before breakfast, riding until
luncheon, then walking ten miles or so, with a three-mile run home to
finish up with. No doubt his intense mental alertness and energy, a
positively Celtic quickness of temperament, have something to do
with this love of physical exercise; but I believe it mainly springs from
pride of body, the clean and sane and English desire to be perfectly
healthy.
But the Prince of Wales is nothing of a prig or a faddist. He has
arranged his life in this healthful way of his own initiative entirely,
with a quiet decision that is rather surprising in a young man who
has the world at his feet. But then the Prince of Wales knows his own
mind, and acts, as far as he can, according to his own ideas. His
manners are charming, he is quite unaffected and absolutely
unspoilt, and he talks freely in a manner that betrays a strongly
marked sense of humour.
Of fear, I think, he knows nothing. If he had had his way, he would
be permanently in the firing-line. He has been with his Grenadiers in
the trenches. He has been under shell-fire. But the experience did
not suffice him. He wants to savour in person the perils and
hardships which so many of his friends in the army (whom he
regards with unconcealed and frankly expressed envy) are
experiencing day after day. “I want to see a shell burst really close,”
he said on one occasion. “I want to see what it is like.” Someone
pointed out that a shell had burst over the headquarters in which he
had been lunching that day. “I know,” he exclaimed quite wrathfully,
“but I didn’t see it!”
When an engagement is on, as he cannot obviously be allowed to
go to the firing-line (in the Flanders flats there is no chance of a
close view of a battle with even a reasonable chance of safety from
shell-fire), he sometimes visits a casualty clearing-station, where the
wounded are being brought in. He goes round the stretchers while
the doctors are examining the wounds, and talks freely with the men
about their experiences. Many a wounded man sent down from the
front has been taken to hospital in the Prince’s own car, with the
Prince himself at the steering-wheel. Infinitely good-natured as he is,
he is always doing good turns like this to casual people he meets on
the road as he motors about between the armies in the execution of
his duties.
The Prince is no shirker. Nor is he content with being given merely
nominal tasks which he could scramble through anyhow if he
pleased. Everything he does he does with all his heart, for he wants
to play his part in this war, not from ostentation or personal ambition,
but a sheer sense of duty. He follows the operations of the armies,
both the French and the British, and makes his own maps. He keeps
a diary of all he sees. If he cannot be present in person with the men
in the front line, he is with them in spirit night and day, and follows
their movements, their successes, and their mishaps, as closely as
any officer of the General Staff.
His thoughts are often with the Fleet, in which he began his career.
I believe the Prince had once hoped that he might have put to sea
with Sir John Jellicoe, as his younger brother was privileged to do.
His friends in the navy send him long letters full of the most amusing
gossip about the “shows” they have been in, about their life at sea,
about the adventures of old shipmates of the Prince. The Prince,
who, like all real naval men, will talk naval “shop” for hours without
ever being bored, devours these letters, and sometimes reads out
extracts to his friends at G.H.Q.
When he was at G.H.Q. the Prince of Wales learnt all there was to
know about the organization of the army. He visited in person all the
different services at G.H.Q., the bathing-stations behind the front, the
railheads, the ammunition-parks, the R.E. stores. He went down the
lines of communication, and saw for himself the unloading and
distribution of supplies. He inspected the hospitals at the base. He
has been to see the French Army at work. He has paid many visits to
the Belgian lines. In everything he has seen he has displayed the
same intense interest, the same absorbing thirst for information.
He has done service with his own regiment, the Grenadier Guards,
has lived with them in the trenches and in billets. If there is an officer
with the British in the field to-day who knows what the army has
accomplished, not only in the way of organized efficiency, but of
uncomplaining endurance of hardships and danger, it is the Prince of
Wales.
In the summer the Prince of Wales left G.H.Q., and was attached
to the First Army, with which he went through a regular course of
training as a Staff Officer. For some time he was on the Intelligence.
Here his work was to read through the German newspapers, and the
letters and documents taken from prisoners or the dead, and
translate any passages that appeared to furnish useful information.
When I was going down to visit a portion of our line towards the
south in June, it was the Prince of Wales, who was then serving in
the Q.M.G. branch of the First Army, who handed over our passes.
 It is the fate of all writers who would describe the lives of Princes
to be exposed to the charge of sycophancy. Yet there is no life for a
plant of this growth in the perfectly natural and wholesome
atmosphere surrounding the Prince of Wales at the front. He is not
playing at soldiering. His periods of leave are few and far between.
His life must often be very monotonous by reason of the restrictions
which considerations of State must necessarily place upon his young
and ardent temperament. Nevertheless, he sticks to his work,
because he feels that his place is with our army in France. In after
years, when the land over which the young Prince will one day rule is
reaping the harvest of that peace for which our men in Flanders
endured and died, the months which Edward, Prince of Wales,
spent, of his own wish, with the army in the field will surely form
another and a closer tie between him and the Empire.
 CHAPTER XII
THE GUARDS IN FLANDERS.

“... They (the 3rd French Chasseurs) had neared the cross-
road, when Wellingtons’s voice was heard clear above the
storm, ‘Stand up, Guards!’ Then from the shelter of the
wayside banks rose the line of Maitland’s brigade of Guards,
four deep and fifteen hundred strong, which poured a
withering volley into the square, and charging, swept them out
of the combat.”
(“The Guards at Waterloo.” From The Life of Wellington, by
the Right Hon. Sir Herbert Maxwell, Bart., M.P.)
“Tangier,” “Namur,” “Gibraltar,” “Blenheim,” “Malplaquet,”
“Dettingen,” “Talavera,” “Fuentes d’Onor,” “Waterloo,” “Alma,”
“Inkerman,” “Tel-el-Kebir,” “South Africa”—what a host of gallant
memories these battle honours of the Guards call forth, what a
glorious procession of heroic figures defiling through history amid the
fire and smoke of a hundred deathless fights! Men come and go in
war. The regiment remains. Its battle honours are the symbol of what
it was, the promise of what it will be.
No body of troops in the British Army has redeemed the promise
of its battle honours more illustriously in this war than the Guards.
Marlborough, Wellington, Raglan, who saw in their careers, each in
his turn, that the Guards were true to the promise of their colours,
must look down from the Elysian Fields in proud admiration of the
way in which the Guards in this war have once more maintained the
untarnished splendour of their name. It will be with rightful
satisfaction that the historian of the future will record how, in an
unmilitary age, the British Army proved itself not unmindful of its
great traditions, but he will be able to add that no regiments showed
themselves more highly imbued with respect for the noblest qualities
of the soldier than the Guards.
It is this same respect for soldierly attributes that is the outstanding
feature of the Guards on active service. It is not a pose. It is not an
affectation of the officers. It is not an individual whim. It is an attitude
of mind that pervades the Guards as a whole, from their most senior
officer down to the youngest drummer-boy. It is not a creation of this
war, for then surely it would have withered for lack of fertile soil, by
reason of the number of original Guardsmen who have died. On the
contrary, it is seen as strong and as virile as ever, even in men who
abandoned their civilian pursuits to take service with the Guards.
The young men of good birth who have received commissions in the
Guards after the outbreak of war, and the recruits who come out with
drafts—novices all, not only to the war, but also to the Guards—are
saturated with this manly respect for soldierly virtues.
In what do these soldierly virtues consist? First and foremost, in
courage. Courage, indeed, is their alpha and omega, for it is the
basis of all merit in the soldier. The standard that the Guards set, the
standard that they most emulate and most admire, is the courage
that recks not of danger, the courage that thinks first of the common
cause, then of the fellow-man, and of self last; the courage that leads
the forlorn hope as blithely as the storm, that is uncomplaining in
hardships and humane after victory; the courage that hides itself
beneath a bushel when the ordeal is past.
Then there is discipline. The strictest discipline on duty, a certain
friendly good-fellowship off duty—these are the relations between
officers and men of the Guards, as, of course, they are between
officers and men right through the British Army. In the field the
Guards officer is a guardian to his men. He is eternally preoccupied
with their comfort in the trenches and in the billets; he furthers their
sports and games, often out of his own pocket; he takes a general
interest in their welfare. He is debonair and democratic in his
dealings with them off duty, and they respect the familiarity thus
allowed them, and in time of need repay their leaders’ generous
solicitude by a loyalty and a devotion that are beyond all praise.