You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


INTRODUCTION {#sec1-1}
============

Alveolar soft part sarcoma (ASPS) is an entity of sarcoma first described by Christopherson *et al*. in 1952.\[[@ref1]\] More commonly seen in children and young adults. ASPS represents \<1% of all soft-tissue sarcomas which is more common in females than males. In case of children, it affects the head-and-neck region with predilection to the tongue and orbit. In case of adults, it commonly affects the extremities,\[[@ref2][@ref3]\] genital tract, breasts, mediastinum, bladder and gastrointestinal tract.\[[@ref4][@ref5]\] ASPS in the forearm is a rare manifestation, only few cases are reported in India.\[[@ref6]\] Here, we present a case report of a young girl with ASPS of left forearm.

CASE REPORT {#sec1-2}
===========

An 18-year-old girl admitted in our department on February 2014 with the complaints of pain and swelling over medial aspect of upper one-third of the left forearm \[[Figure 1](#F1){ref-type="fig"}\] for the past 6 months, and the mass was gradually increasing in size, for which incisional biopsy was done outside and referred with biopsy report as glomangioma or epithelioid haemangioendothelioma. On examination, there was a palpable firm mass on the medial volar aspect of the left forearm measuring about 7 cm × 5 cm × 3 cm with surgical scar with few dilated veins over the swelling with no bruit. There was no distal neurovascular deficit. Hand functions were normal. Magnetic resonance imaging of the upper forearm showed the mass with high vascularity, involving mainly the muscular plane. The biopsy report showed the possibility of glomangioma or epithelioid haemangioendothelioma, which was a benign condition, and so excision biopsy was done.

![Swelling of left forearm](IJPS-50-310-g001){#F1}

A lazy \'S\' incision was made over the swelling. Highly vascular mass was found encapsulated within the flexor digitorum superficialis (FDS) muscle at the common flexor origin \[[Figure 2a](#F2){ref-type="fig"} and [b](#F2){ref-type="fig"}\]. The ulnar nerve was found closely adhered to the capsule of the mass and was dissected after dividing its muscular branches \[[Figure 3](#F3){ref-type="fig"}\]. Mass was excised along with part of FDS muscle up to the musculotendinous junction; the remaining tendinous part was attached to flexor digitorum profundus muscle with adequate tension.

![(a and b) Encapsulated mass with high vascularity](IJPS-50-310-g002){#F2}

![Preserved ulnar nerve](IJPS-50-310-g003){#F3}

Histopathology examination showed nests of large polygonal cells with abundant eosinophilic cytoplasm having pseudoalveolar pattern \[[Figure 4a](#F4){ref-type="fig"} and [b](#F4){ref-type="fig"}\], separated by delicate vascular structures. All the findings confirmed ASPS.

![(a and b) Histological view of alveolar soft part sarcoma](IJPS-50-310-g004){#F4}

The patient was screened for metastasis post-operatively. Computed tomography (CT) chest showed multiple coin-like opacities in both the lung fields, more in lower lobes \[[Figure 5](#F5){ref-type="fig"}\]. CT brain, CT abdomen and whole-body skeletal survey were normal.

![Computed tomography lung shows lung secondaries](IJPS-50-310-g005){#F5}

After discussion with oncology department (radiation oncology, medical oncology and surgical oncology), we decided to give cycles of chemotherapy and radiotherapy.

The patient received 6 cycles of chemotherapy with adriamycin, cyclophosphamide and vincristine as suggested by the oncologist. The patient was closely followed for 11 months. There was no locoregional recurrence or metastasis elsewhere. Full range of movements in the hand and elbow was possible.

After 11 months, the patient had good functional improvement \[[Figure 6a](#F6){ref-type="fig"} and [b](#F6){ref-type="fig"}\], due to financial constraints, PET scan and other investigations were not done on subsequent follow-up.

![(a and b) Functional status of the hand after 11 months](IJPS-50-310-g006){#F6}

DISCUSSION {#sec1-3}
==========

ASPS is one of the rarest forms of soft-tissue sarcoma. This tumour commonly occurs in females, with a male: female ratio of 1:2 and the mean age 22--25. Most common site of origin is lower extremity,\[[@ref7]\] then the trunk and the upper limbs. ASPS represents \<1% of all soft-tissue sarcomas, and they form one-third of all metastatic soft-tissue sarcomas (33%).\[[@ref8]\]

The genetic theory for ASPS\[[@ref1]\] is thought to be its origin in chromosomal rearrangement at t (X:17) (p11:Q25), resulting in the ASPL--TFE3 fusion gene.\[[@ref9]\] Since women have two X chromosomes, they are more prone for ASPS.

This tumour is slow-growing in nature, but the metastases are more common to the lung followed by bone and brain. Lymph node metastasis is rare.\[[@ref5]\] Prognosis of ASPS depends on patient\'s age, tumour size and the presence of metastasis at the time of diagnosis. Metastases are detected in 20%--25% of the patients at the time of diagnosis.

ASPS are more vascular in nature, because of these prominent vascular structure, the mass shows high-intensity signals in T1- and T2-weighed images\[[@ref3]\] and resembles those of haemangioma, but histologically, it shows typical features of ASPS.

Histologically, the tumour has peculiar, orderly arranged epithelioid-appearing tumour cells separated by delicate fibrovascular septae. ASPS can be easily differentiated from its histopathological mimics by demonstrating cytological uniformity, lack of nuclear atypia and paucity of mitotic figures in ASPS.\[[@ref6]\]

Treatment {#sec2-1}
---------

For primary tumour, extensive resection of the mass (R0 resection: Complete resection with no microscopic residual tumour) and adjuvant regional radiotherapy is considered as the most effective treatment of ASPS. The management algorithm for soft-tissue sarcoma \[[Flow chart 1](#FC1){ref-type="fig"}\] is shown below.\[[@ref10]\]

![Management algorithm for soft-tissue sarcoma](IJPS-50-310-g007){#FC1}

The local recurrence rate reportedly ranges from 10% to 30% after the removal of the mass and an adjunctive radiation treatment could be beneficial to prevent a relapse. Combination of surgery with radiotherapy and chemotherapy may prolong the mean survival time. There are reports regarding excision of pulmonary metastases providing a good prognosis along with radiotherapy or chemotherapy. In the literature, 5-year overall survival was reported as 83%. The presence of lung metastases is not a contraindication for surgery in patients with ASPS. The reason for favourable prognosis with this tumour can be explained by the slow-growing and indolent nature of this disease.

CONCLUSION {#sec1-4}
==========

ASPS are one of the rarest soft-tissue tumours, which rarely involve upper extremity. To the best of our knowledge, very few cases of ASPS has been reported from India. Characteristic histological features would facilitate an early diagnosis. Long-term follow-up is needed to find out the recurrence of a tumour or metastasis. Because of its rarity of occurrence in the upper extremity, this case has been reported.

Declaration of patient consent {#sec2-2}
------------------------------

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship {#sec2-3}
---------------------------------

Nil.

Conflicts of interest {#sec2-4}
---------------------

There are no conflicts of interest.