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}
============

Spindle cell/pleomorphic lipoma is a relatively rare adipocytic neoplasm, which occurs predominantly in male patients aged 50-70 years.\[[@ref1]\] In most cases, it is detected in the subcutaneous tissues of the neck or shoulder. To the best of our knowledge, only five cases have been reported in which the lesion was intramuscular, the last one being a rare occurrence of spindle cell lipoma within an intramuscular lipoma.\[[@ref2][@ref3]\]

Case Report {#sec1-2}
===========

A 60-year-old lady presented with a large, slowly-growing mass over the posterior aspect of the neck and back. It was indolent and long-standing to start with, presenting with a spurt of growth in the recent past.

Fine-needle aspiration cytology (FNAC) was performed. The aspirate showed a cellular picture of spindle cells, pleomorphic multinucleated giant cells, and many bizarre cells. There was no necrosis or mitosis appreciated in the smears but the bizarre cells were alarming and the intramuscular location suggested a possible sinister pathology \[[Figure 1](#F1){ref-type="fig"}\]. A cautious diagnosis of a "mesenchymal tumor, rich in multinucleated giant cells of uncertain malignant potential" was offered and a wide excision was advised.

![Smears are cellular, showing scattered spindle-shaped cells admixed with giant cells (H and E, ×200)](JCytol-32-201-g001){#F1}

Gross {#sec2-1}
-----

A gross examination of the excised specimen showed a well-circumscribed intramuscular mass measuring 8 cm × 5 cm × 4 cm. The cut surface showed recognizable yellowish adipocytic areas admixed with streaks of gray white glistening areas. There were no areas of hemorrhage or necrosis. No infiltrating tongues of tissue or features to suggest invasion were identified. Muscle was seen all around the lesion and the resection margins were clear.

Microscopy {#sec2-2}
----------

The classical morphology of a pleomorphic lipoma was seen consisting of adipocytic cells admixed haphazardly with dispersed spindle cells and scattered pleomorphic cells \[[Figure 2](#F2){ref-type="fig"}\]. Floret giant cells were present. There was no mitosis or necrosis. No lipoblasts or plexiform capillary network was appreciated.

Immunohistochemistry with CD34 highlighted the spindly cells, further substantiating the diagnosis.

![Section from the excised mass showing mature adipocytes admixed with spindle cells and scattered bizarre-looking pleomorphic cells (H and E, ×100)](JCytol-32-201-g002){#F2}

Discussion {#sec1-3}
==========

Pleomorphic lipoma is a relatively uncommon benign adipocytic tumor that shows a variable lipomatous component, spindle-shaped cell component, and floret-like giant cells with nuclear pleomorphism, and was first described by Shmookler and Enzinger in 1981.\[[@ref4]\] It is reported to be four times more common in males, in the age group of 50-70 years.\[[@ref1]\] Only 10% of tumors occur in females. Our patient was an elderly lady.

The most typical location is the subcutaneous tissue in the head and neck region. However, few unusual sites have been reported such as the tonsillar fossa, orbit, and tongue\[[@ref1]\] and very few in the intramuscular compartment.\[[@ref2][@ref3]\] In our case, the site was the shoulder, which is typical; however, the intramuscular location was unusual. Most published cases have been described in the superficial compartment of the dermis. Typically, the lesion appears as a circumscribed, subcutaneous mass, which looks like the ubiquitous lipoma. However, microscopically, instead of the mature adipose tissue cells of the usual lipoma, it is characterized by an intimate admixture of variable-sized fat cells, spindle cells and bizarre, pleomorphic, multinucleated giant cells. Many of the giant cells show a distinctive floret-like arrangement of the nuclei and are associated with interlacing bundles of dense ropy collagen.\[[@ref4]\] In our case, the cells were more bizarre than usual with intranuclear inclusions, SR-like cells, and pleomorphic multinucleation.

While histology is well-documented in the literature, very few articles outline the cytological features of a pleomorphic lipoma.\[[@ref5][@ref6][@ref7][@ref8]\] The cytology shows a population of floret cells and pleomorphic cells admixed with adipocytes and spindle cells.\[[@ref8]\] The floret cells show multiple enlarged hyperchromatic nuclei arranged in a circle or semicircle in the cytoplasm. No atypical lipoblasts or arcuate capillary network is present. The diagnosis must be given with caution and with clinicoradiologic correlation because pleomorphic lipomas can mimic other benign and malignant soft tissue tumors such as giant cell fibroblastoma, myxoid liposarcomas, fibrosarcomas, or even anaplastic carcinomas.\[[@ref6][@ref7][@ref8]\] Giant cell fibroblastoma is a juvenile form of dermatofibrosarcoma protuberans, which is also CD34-positive and can have a similar giant cell-rich picture on cytology.\[[@ref9]\] However, it predominantly affects infants and children while pleomorphic lipoma mainly occurs in elderly men.

Myxoid liposarcoma involves the deep soft tissue of the extremities with a peak age incidence in the 4^th^ or 5^th^ decade. Cytologically, these tumors have myxoid background matrix with many univacuolated lipoblasts or multivacuolated lipoblasts and a characteristic rich plexiform vascular meshwork.

Myxoid fibrosarcoma is more common than pleomorphic lipoma in elderly males but the majority of these tumors occur in the extremities, and rarely on the trunk or head and neck area. Histologically, myxoid fibrosarcoma usually consists of spindle-shaped cells and multinucleate giant cells, and is characterized by prominent elongated, curvilinear, thin-walled blood vessels. Although the spectrum of myxoid fibrosarcoma is also variable, it tends to have more cellular atypia and mitotic activity. Moreover, myxoid fibrosarcoma usually lacks strong CD34 expression.\[[@ref1]\]

The rarity of intramuscular pleomorphic lipomas and the atypical cellular features of the aspirate can cause difficulty in diagnosing this entity.\[[@ref5]\] Even in our case, a malignant tumor was suspected because of the tumor location and the cytological picture. However, the classical histology of the excision specimen was reassuring. The differential diagnoses of a bizarre-looking but benign pleomorphic lipoma must always be kept in mind when evaluating the cytology of soft tissue tumors located at this anatomic site in the adult age group.

Conclusion {#sec1-4}
==========

Cytology serves as a guide to the reporting pathologist, in that it cautions us to rule out potentially malignant tumors because there is a growing awareness of the existence of a benign giant cell-rich tumor at this particular anatomic site. Pleomorphic lipomas are "clinicopathologic" entities, which necessitate attention to details such as the age and sex of the patient, the anatomic plane of the tumor, and this particular giant cell-rich morphology.

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

Nil.

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

There are no conflicts of interest.