Diagnosis and management of synovial sarcoma

A 63-year-old woman presenting with a synovial sarcoma of the hand: a case report

Introduction

Synovial sarcoma is a high-grade, soft-tissue sarcoma that most frequently is located in the vicinity of joints, tendons or bursae, although it can also be found in extra-articular locations. Most patients with synovial sarcoma of the hand are young and have a poor prognosis, as these tumors are locally aggressive and are associated with a relatively high metastasis rate. According to the literature, local recurrence and/or metastatic disease is found in nearly 80% of patients. Current therapy comprises surgery, systemic and limb perfusion chemotherapy, and radiotherapy. However, the 5-year survival rate is estimated to be only around 27% to 55%. Moreover, most authors agree that synovial sarcoma is one of the most commonly misdiagnosed malignancies of soft tissues because of their slow growing pattern, benign radiographic appearance, ability to change size, and the fact that they may elicit pain similar to that caused by common trauma.

Case presentation

We describe an unusual case of a large synovial sarcoma of the hand in a 63-year-old Caucasian woman followed for 12 years by a multidisciplinary team. In addition, a literature review of the most pertinent aspects of the epidemiology, diagnosis, treatment and prognosis of these patients is presented.

Conclusion

Awareness of this rare tumor by anyone dealing with hand pathology can hasten diagnosis, and this, in turn, can potentially increase survival. Therefore, a high index of suspicion for this disease should be kept in mind, particularly when evaluating young people, as they are the most commonly affected group.

Synovial sarcoma: imaging features of common and uncommon primary sites, metastatic patterns, and treatment response

OBJECTIVE

The purpose of this review is to describe the imaging features, common and uncommon sites, metastatic pattern, and treatment response of synovial sarcoma.

CONCLUSION

Synovial sarcoma primarily occurs in young adults, most commonly in the lower extremities; presents as a large, noninfiltrative, well-circumscribed mass adjacent to joints, often with punctuate calcifications; and may exhibit a triple signal pattern on T2-weighted images. Small synovial sarcomas can mimic benign lesions. This tumor has a propensity for late local recurrence and metastasis, most commonly to lung.

SYT-SSX breakpoint peptide vaccines in patients with synovial sarcoma: a study from the Japanese Musculoskeletal Oncology Group

In the present study, we evaluated the safety and effectiveness of SYT-SSX-derived peptide vaccines in patients with advanced synovial sarcoma. A 9-mer peptide spanning the SYT-SSX fusion region (B peptide) and its HLA-A*2402 anchor substitute (K9I) were synthesized. In Protocols A1 and A2, vaccines with peptide alone were administered subcutaneously six times at 14-day intervals. The B peptide was used in Protocol A1, whereas the K9I peptide was used in Protocol A2. In Protocols B1 and B2, the peptide was mixed with incomplete Freund's adjuvant and then administered subcutaneously six times at 14-day intervals. In addition, interferon-α was injected subcutaneously on the same day and again 3 days after the vaccination. The B peptide and K9I peptide were used in Protocols B1 and B2, respectively. In total, 21 patients (12 men, nine women; mean age 43.6 years) were enrolled in the present study. Each patient had multiple metastatic lesions of the lung. Thirteen patients completed the six-injection vaccination schedule. One patient developed intracerebral hemorrhage after the second vaccination. Delayed-type hypersensitivity skin tests were negative in all patients. Nine patients showed a greater than twofold increase in the frequency of CTLs in tetramer analysis. Recognized disease progression occurred in all but one of the nine patients in Protocols A1 and A2. In contrast, half the 12 patients had stable disease during the vaccination period in Protocols B1 and B2. Of note, one patient showed transient shrinkage of a metastatic lesion. The response of the patients to the B protocols is encouraging and warrants further investigation.

Synovial sarcoma leading to a paraesophageal abscess in a child

Background:

Synovial sarcoma (SS) is an uncommon malignant neoplasm arising from primitive pluripotential mesenchyme primarily affecting the soft tissues of the extremities. Rarely other locations are involved, including the mediastinum.

Case Report:

After treatment for mediastinal SS by surgical resection, radiation therapy, and chemotherapy, an 11-year-old boy developed an esophageal stricture and fistula, the latter resulting in a paraesophageal abscess. Management of the esophageal stricture and fistula required a multi-disciplinary approach. We report our experience with the management of this difficult complication, as well as a brief review of the literature on SS.

Conclusions:

Rare conditions, particularly those with unusual complications, present therapeutic challenges requiring a multi-disciplinary team approach. Reporting experiences with difficult cases can benefit providers faced with similar problems in the future.

Small blue round cell tumor: an unusual case presentation in the foot

Small blue round cell tumors of childhood rarely present in the foot or ankle. The following is a case presentation of an 18-year-old male with a large soft-tissue mass of the foot with associated lung metastasis. A definitive diagnosis could not be fully made, even with immunohistochemical and genetic testing. Diagnosis favored poorly differentiated synovial sarcoma.

Synovial sarcoma involving skull base--a retrospective analysis of diagnosis and treatment of 21 cases in one institution

To retrospectively review the diagnosis and treatment outcomes of 21 diagnosed with synovial sarcoma (SS) extending to skull base region and identify prognostic factors for local recurrence and distant metastasis. The clinical and pathological records of 21 synovial sarcoma cases involving skull base treated at Department of Oral and Maxillofacial Surgery, Affiliated to Ninth People's Hospital, Shanghai Jiao Tong University, from 2003 to 2008 were reviewed. Parameters including clinical, radiographic, histological findings, and treatment modalities were analyzed. Prognostic factors influencing overall survival, local recurrence, and metastasis were identified. Categorical variables were compared between groups for local recurrence and distant metastasis by using 2-tailed Fisher exact test. The sample consisted of 8 males and 13 females with a median age of 23. 42.9% of cases showed skull base bone erosion with 9.5% of cases presenting intracranial tumor extension. 52.4% of cases died from recurrence or metastasis with a median survival time of 11 months. Orbital involvement, perineural and cranial invasion along with other factors were statistically significant for their impact on overall survival. Local recurrence was associated with tumors located in the infratemporal space (p=0.01), perineural invasion (p=0.001), pathological grade 3 (p=0.005), and tumor size >5 cm (p=0.008). The aggressive behavior of skull base SS and its close proximity to vital structures make the diagnosis and management a challenge. The study reported high local recurrence rates despite surgical and postoperative radiotherapy. Adjuvant chemotherapy did not seem to affect distant metastasis rates.

Mycetoma or synovial sarcoma? A case report with review of the literature

Mycetoma, also commonly referred to as Madura foot, is statistically rare in the United States. However, it is endemic to other parts of the world. It is a pseudotumor characterized by a triad of tumefaction, draining sinuses, and grains. Two types exist, with each caused by different groups of organisms that require different treatment approaches. Therefore, the exact diagnosis and culture of the organism is vital to successful treatment outcomes. Synovial sarcoma, in contrast, is a malignancy much more commonly seen in the United States. It is characterized by a well-circumscribed, often palpable, mass that is usually well delineated on magnetic resonance imaging. It has characteristic histologic and genetic features that help distinguish it from other soft tissue masses. We present a case of a soft tissue mass diagnosed in the United States. The patient had several clinical and radiographic features of synovial sarcoma but the histologic outcome was mycetoma. The case is followed by a review of the published data.

[Rare primary chest wall sarcoma: the synovialosarcoma]

INTRODUCTION

Malignant primary tumours occurring in the thorax encompass a large group of tumours which may arise from the lung, mediastinal structures, the pleura or the chest wall.

OBSERVATION

We report the case of a 37 year old patient, who presented with left sided chest pain. On clinical examination a right sided chest wall mass was identified. Chest X Ray showed a left sided upper mediastinal opacity, associated with a left sided pleural opacity. Thoracic CT scan revealed a large mass arising from the chest wall and infiltrating the mediastinum associated with a second chest wall mass at the level of the 8(th) and 9(th) right ribs. The biopsy of the chest wall mass revealed it to be a parietal synovialosarcoma. The patient responded to chemotherapy based on ifosfamid and doxorubicin as well as mediastino-pulmonary radiotherapy. There was an improvement in the patient's clinical and radiological state but the patient died by pulmonary embolism after the 3(rd) cause of treatment.

CONCLUSION

Chest wall synovialosarcoma has a poor prognosis, however, its chemosensitivity means that treatment may initially be effective.

Management of monophasic synovial sarcoma of the small intestine

Although prognosis for patients with intraabdominal synovial sarcoma is poor, laparoscopic wide regional excision may allow for a more prolonged disease-free survival.

Background:

Reports of primary intraabdominal synovial sarcomas are extremely rare.

Methods:

A literature review using PubMed was performed. A retrospective review of the one known case at our institution was completed.

Results:

Even the most experienced pathologists report that synovial sarcomas can be very difficult to diagnose correctly. One cytogenic abnormality that is common (>90%) and pathognomonic for synovial sarcoma is a characteristic chromosomal translocation resulting in the SYT/SSX fusion gene. Wide regional excision has been performed for intraabdominal sarcoma, with improved results. Our patient is more than 24 months with no evidence of recurrent or metastatic disease.

Conclusions:

The prognosis for patients with intraabdominal synovial sarcoma remains poor. However, wide regional excision may allow for prolonged disease-free survival.

Malignant inguinal monophasic synovial sarcoma: report of a case and review of the literature

Background

A synovial sarcoma (SS) is an aggressive soft tissue tumor that classically occurs in the extremities near, but rarely within large joints, in young adults. Variable symptoms and clinical manifestations may be encountered and a definite diagnosis should depend on pathological results. This poses certain difficulties in arriving at a prompt diagnosis and appropriate treatment.

Case presentation

We report the case of a 68-year-old woman patient who presented an inguinal mass with swelling and pain in the right lower limb. She underwent surgery, and later received systematic intravenous chemotherapy. The pathological studies, especially the specific chromosomal translocation of a t(X;18) (p11.2;q11.2), confirmed the diagnosis as a synovial sarcoma. To the best of our knowledge, this is the first report of a monophasic synovial sarcoma in the inguinal region.

Conclusion

Besides making the readership aware of the rarity of location and age of this present case, this report distinctly highlights the great value of a molecular analysis of an SYT associated genetic alteration in the diagnosis of synovial sarcoma occurring at rare sites especially when immunochemical results are equivocal.

High-grade prostatic sarcoma seen in a catheterized urine specimen: case report and differential diagnosis

Urine cytology has been effectively used in the diagnosis and management of epithelial bladder tumors, particularly high-grade urothelial carcinoma. Indeed it is the gold standard for bladder cancer screening. Although urothelial carcinoma is the most frequently identified bladder tumor by urine cytology, metastatic carcinomas from the kidney, colon, and a variety of other regional organs have been detected. Stromal lesions such as inflammatory myofibroblastic tumor, gastrointestinal stromal tumor, and leiomyosarcoma are other much rarer entities occurring within the bladder. Few to no case reports exist documenting their identification within urine cytology specimens. Herein we report the detection of a high-grade prostatic sarcoma within a catheterized urine specimen of a young male having a diffusely enlarged prostate. The specimen consisted of numerous fragments of relatively uniform spindle cells having ovoid nuclei with rounded ends and finely dispersed chromatin. Cytoplasmic borders were indistinct. No mitoses or significant atypia was present. The background consisted of numerous red blood cells, cellular debris, and a few clusters of unremarkable urothelial cells. Followup surgical biopsy of the patient's prostate revealed a high-grade spindle-cell sarcoma. Further immunohistochemical and molecular delineation of the tumor was not informative for a more definitive diagnosis. Although rare, sarcomas and other mesenchymal tumors involving the bladder are unique entities with a broad differential diagnosis.

Pediatric synovial sarcoma of the sacrum: a case report

We reported a rare synovial sarcoma arising within sacrum of a 12-year-old boy. A plain radiograph, magnetic resonance imaging performed before surgery, and the intraoperative findings showed that the tumor was S2 and below. Immunohistochemically, desmin and CD34 were negative. CK, CK7, CK1, CK3, CK8, CK19, Bcl-2, E-cadherin, ki-67, P53, SMA, CD99, CD56, S-100, vimentin, and epithelial membrane antigen were positive. Some were focal positively reactive to S-100, P53, and ki-67. The spindle cells were strongly positive for vimentin and CK3. The immunohistochemical findings confirmed its diagnosis of synovial sarcoma.

Metastatic synovial sarcoma with cervical spinal cord compression treated with posterior ventral resection: case report

CONTEXT

Synovial sarcomas, which represent 5% to 10% of all adult soft-tissue sarcomas, usually metastasize to the lungs. Metastasis to the spine is rare. Spinal cord compression due to spinal metastasis occurs in approximately 3% of patients with extraspinal soft-tissue sarcomas.

METHOD

Case report.

FINDINGS

A 26-year-old woman presented with neck pain, arm weakness, and a history of metastatic synovial sarcoma originating at the right knee. Computed tomography revealed destruction of the odontoid and C2 body. Magnetic resonance imaging revealed tumor in the posterior elements of C2 and in the ventral epidural space from C2-C5. She was treated with C2-C3 laminectomy, posterior C2 corpectomy with occipital-C7 fixation, and fusion. Postoperatively, her neck pain resolved and left upper extremity strength returned to normal.

CONCLUSION AND CLINICAL RELEVANCE

Metastatic spinal cord compression from synovial sarcoma is rare. Surgical resection can lead to neurologic improvement.

Synovial Sarcoma: A Clinicopathological and Radiological Study of 12 Cases Seen Over 18 Years

Background

Synovial sarcoma is a rare malignant soft tissue tumor characterized by a poor outcome. We report herein our experience concerning synovial sarcoma and review its diagnosis, histology, treatment and prognosis.

Methods

This is a retrospective review, from 1990 to 2007, of cases of synovial sarcoma diagnosed at the Department of Pathology, Farhat Hached hospital, Sousse, Tunisia. The clinical, radiological and pathological features as well as treatment modalities and patient's outcome were recorded.

Results

From 1990 to 2007, 12 cases of synovial sarcoma have been diagnosed in our department. Patients' mean age at the time of diagnosis was 21 years. There was no sex predominance and the lower extremity was the most commonly involved. A painful tumefaction was the most common presenting symptom. The duration of symptoms ranged from 6 months to 6 years. Malignancy was suspected on radiological findings in only 2 cases. Ten patients underwent surgery, in association with adjuvant chemotherapy in 4 cases, one of whom underwent post-operative radiotherapy. Histological subtypes included monophasic synovial sarcoma in 8 cases, biphasic synovial sarcoma in 3 cases and poorly differentiated synovial sarcoma in one case. At the time of analysis, 6 patients were dead with an average follow-up of 18 months.

Conclusions

Synovial sarcoma is a rare malignancy with a propensity for young adults and a poor prognosis. Its symptomatology is non-specific and it is characterized by histopathological diversity. Diagnosis can be suggested by radiology and definitive diagnosis is achieved after pathological analysis.

Childhood pancreatic tumors: a single institution experience

PURPOSE

The rarity and histopathologic diversity of primary pancreatic neoplasms in children have made it difficult to predict prognosis and to develop optimal management protocols.

METHODS

A 90-year (1918-2007), single institution, retrospective review of all patients with neoplastic pancreatic masses was performed.

RESULTS

Eighteen patients were identified with 7 distinct histopathologic subtypes. The most common were gastroenteropancreatic neuroendocrine, solid pseudopapillary, and acinar tumors. There were 6 benign and 12 malignant tumors. Six patients had disease outside the pancreas at their initial operation. There were 7 deaths (41%), 2 related to the initial operation, 3 from disease progression, 1 from a small bowel obstruction, and 1 from necrotizing pancreatitis. Five deaths were in patients with extrapancreatic disease found at initial operation. The median duration of follow-up for the 10 survivors was 41 months.

CONCLUSION

In adults, pancreatic ductal adenocarcinoma is by far the most common histopathologic subtype, with other subtypes more common in children. Stage is an important prognostic factor. Long-term disease-free survival in childhood pancreatic malignancies is achievable with complete surgical resection, prognosis, and adjuvant treatment, depending on the histopathologic type.

Synovial sarcoma of the thoracic spine

BACKGROUND CONTEXT

Synovial sarcoma is an uncommon malignant neoplasm occurring chiefly in young adults. It often presents as a solid well-circumscribed soft-tissue mass in the extremities of young adults. Despite its proximity to joints, it has been well established that the tumor cells do not display features of synovial differentiation but instead appear to have a primitive epithelial phenotype. There is no report of a lower thoracic paravertebral synovial sarcoma in an adult male.

PURPOSE

To describe our management in a patient with a synovial sarcoma of the thoracic spine and to review previously published cases.

STUDY DESIGN

Case report.

METHODS

A 60-year-old man presented with a 5-month history of right upper quadrant abdominal pain radiating to his back in a band-like fashion; shortness of breath on exertion; and increasing pain when standing, sitting, or walking. Magnetic resonance imaging (MRI) demonstrated a large right-sided paraspinal mass sitting on the eighth and ninth ribs, pressing on the T9 vertebrae and abutting the T7 and T8 vertebral level exhibiting "Triple Intensity." Plain films demonstrated a right-sided paraspinal mass extending from the T7-T8 level to T10. Bone scintigraphy showed increased uptake on the right thoracic spine at T7-T8 to T10. Computed tomography (CT) imaging revealed a right paraspinal mass with lytic changes in the T9 vertebral bodies. A right-sided thoracotomy was performed, and the patient underwent subsequent radiation therapy. Absence of the tumor was shown by an MRI scan after the operation.

RESULTS

Complete resolution of the patient's complaints was achieved. The diagnosis is supported by plain radiographs, bone scintigraphy, magnetic resonance and CT imaging studies, and histologic and immunohistochemical evidence.

CONCLUSIONS

Synovial sarcomas are rarely present in the paravertebral region of the thoracic spine. A careful radiographic study of the tumor permitted early preliminary diagnosis, confirmed upon histopathologic analysis. Despite lytic changes, removal of a periosteal layer permitted sparing of the vertebral bodies.

[Assessment of prognostic factors of thoracic synovial sarcoma]

INTRODUCTION

Synovial sarcoma is an uncommon tumour and thoracic involvement is rare and of varying location. Clinical characteristics are dominated by pain, with a slow progression over years. Pathological and immuno-histochemical characteristics are helpful in the diagnosis but a specific translocation between chromosomes X and 18 is crucial for confirmation. Extensive surgical resection is required for cure, combined with adjuvant radiotherapy in the presence of adverse prognostic factors.

CASE REPORT

We report a case of synovial sarcoma of the chest wall, responsible for chronic local pain for several years, presenting as an acute pleuropneumonitis in a 21-year-old patient. In view of the large size of the tumour, associated with a high proliferation index (Ki-67), a surgical resection was performed, together with local adjuvant radiotherapy.

CONCLUSION

This case report reviews synovial sarcoma and underlines the difficulties and requirements of both diagnostic strategy and therapeutic management. Among them, an initial systematic review of prognostic factors (tumour size, mitotic activity, proliferation index, SYT-SSX type fusion, histological grade) is crucial to determine the therapeutic options.

[Synovial sarcomas in Lugo between 2002-2006]

OBJECTIVE

To study the clinical and epidemiological characteristics of all adults patients as having synovial sarcoma in the Hospital Xeral-Calde (Lugo) between 2002 and 2006.

PATIENTS AND METHOD

We conducted a retrospective study of the case records of all adults patients diagnosed with synovial sarcoma from January 2002 through December 2006. Patients were considered to be adults if they were more than 18. In all cases a tissue-biopsy sample showing synovial sarcoma was required. The Hospital Xeral-Calde is the only referral center for a population of almost 250.000 people.

RESULTS

Four cases (3 women) met the classification criteria for this study. The mean age was 35 years old (range, 22-41). The most common presentation was a palpable mass (mean 6.7cm.) associated with pain in lower extremities. The mean delay for the diagnosis was 17 months, but in one case has been noted as long as 2.5 years. Unlike the neck synovial sarcoma case, a long delay in the diagnosis implied a major tumor size and a higher histologic grade. The mean follow-up was 25.5 months; one patient died 1.5 years after the diagnosis.

CONCLUSIONS

The overall annual incidence rate of synovial sarcoma in the Lugo region between January 2002 and 2006 for the population older than 18 years was a minimum estimate 0.32/10(5). Better physician awareness may contribute to the progressive increase in the recognition of this condition, especially in young people presenting with palpable mass. A long delay at the diagnosis implied a poor prognosis.

Gene expression profiling for the investigation of soft tissue sarcoma pathogenesis and the identification of diagnostic, prognostic, and predictive biomarkers

Soft tissue sarcomas are malignant neoplasms derived from mesenchymal tissues. Their pathogenesis is poorly understood and there are few effective treatment options for advanced disease. In the past decade, gene expression profiling has been applied to sarcomas to facilitate understanding of sarcoma pathogenesis and to identify diagnostic, prognostic, and predictive markers. In this paper, we review this body of work and discuss how gene expression profiling has led to advancements in the understanding of sarcoma pathobiology, the identification of clinically useful biomarkers, and the refinement of sarcoma classification schemes. Lastly, we conclude with a discussion of strategies to further optimize the translation of gene expression data into a greater understanding of sarcoma pathogenesis and improved clinical outcomes for sarcoma patients.