Factors Associated With Survival in Patients With Synovial Cell Sarcoma of the Head and Neck: An Analysis of 167 Cases Using the SEER (Surveillance, Epidemiology, and End Results) Database

Synovial sarcoma in the prevertebral space can mimic malignant neurogenic neoplasm: Case report and literature review

Synovial sarcoma, a rare malignant neoplasm with a poor prognosis, accounts for approximately 5%-10% of all primary soft-tissue malignancies worldwide. Typically affecting adolescents and young adults, it primarily manifests near the joints of the lower extremities. This study aimed to demonstrate that this tumor can also affect the prevertebral space. A 32-year-old male patient presented at our outpatient clinic with a 2-month history of upper limb numbness and a 1-month complaint of palpable neck mass. Imaging studies revealed a bulky, lobulated, and heterogeneous mass exhibiting heterogeneous enhancement. Furthermore, the mass caused expansion of the neuroforamen in the neck, initially suggesting a diagnosis of malignant schwannoma. However, a histopathologic examination suggested synovial sarcoma. The article provided a comprehensive review of the clinical, pathological, and radiological features of this condition. Additionally, it explored current treatment options and prognoses by referencing relevant literature.

Small biopsies in the head and neck: Bone and soft tissue

Bone and soft tissue lesions in the head and neck encompass not only a broad morphologic spectrum but also significant inherent clinicopathologic overlap. Epidemiology, radiology, and location - similar to the diagnostic assessment in other sites - are especially important considerations in the context of an established mesenchymal proliferation. Herein, the approach towards diagnosis is stratified by morphology (spindle, sarcomatoid, epithelioid, round cell), cellular lineage (fibroblastic, nerve sheath, rhabdomyogenic), and tumor grade (benign, low- to high-grade malignant) as the basis of further immunohistochemical or molecular investigation.

Monophasic synovial sarcoma in the temporomandibular joint region: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Synovial sarcoma is a malignant neoplasm that arises from soft tissue and makes up 5 % to 10 % of all types of sarcoma. It is most common between the ages of 15 and 40; it typically develops in the lower extremities; just 3 % to 10 % of cases arise in the head and neck. The usual main areas in the head and neck are the parapharyngeal, hypopharyngeal, and paraspinal.

CASE PRESENTATION

An 18-year-old woman presented with a painful mass in the left pre-auricular area.

CLINICAL DISCUSSION

Magnetic resonance imaging showed a well-defined lobular mass localized superior and anterior to the left ear. Incisional biopsy showed spindle cell sarcoma. A preauricular incision was done to remove the tumor with the superficial lobe of the parotid gland during the procedure, and histological examination revealed a high-grade spindle cell sarcoma the differential diagnosis included a monophasic synovial sarcoma. Immunohistochemistry was done for a full evaluation and the panel supported diagnosing a monophasic synovial sarcoma.

CONCLUSION

Synovial sarcoma is a malignant tumor that is rare to develop in the temporomandibular region, which makes it a significant challenge to diagnose and differentiate it from other lesions, it should be considered in all patients with a mass in this region. The cornerstone to identify synovial sarcoma is Immunohistochemistry (IHC), and molecular genetic analyses. Total surgical excision, with or without radiation and chemotherapy, is currently the best option for treatment. We present a review of the literature after the case presentation.

The Role of Surgery for Primary Pulmonary Synovial Sarcoma: A Population-Based Study

INTRODUCTION

The rarity of primary pulmonary synovial sarcoma (PPSS) and the lack of prospective clinical trials resulted in poorly understood treatment modality and clinical outcomes. This study aimed to better understand PPSS based on patients from the Surveillance, Epidemiology, and End Results database.

MATERIALS AND METHODS

Clinical and survival data of PPSS patients who were diagnosed during 1989 through 2016 and retrieved from the Surveillance, Epidemiology, and End Results database were studied. Kaplan-Meier analyses and Cox proportional hazards model were applied to evaluate the overall survival (OS) and disease-specific survival (DSS) of PPSS patients.

RESULTS

A total of 122 patients with PPSS were included (median age: 50 y). PPSS accounted for 4.5% (122/2741) of total primary synovial sarcoma. Most of the patients were diagnosed as poor or undifferentiated grade (52.0% and 34.0%). Cancer-directed surgery was performed for 74.4% of PPSS patients and 28.2% of patients received radiotherapy. The 1-year, 3-year, 5-year, and 10-year OS rates of PPSS patients were 75.4%, 50.8%, 41.8%, and 39.3%, respectively. Cancer-directed surgery was shown to improve the survival of PPSS patients with localized or regional stage (P < 0.05), yet surgical resection did not prolong the OS and DSS of patients with distant stage (P > 0.1). Postoperational radiotherapy was associated with shortened survival time (P < 0.05). PPSS patients who received lobectomy had statistically prolonged OS and DSS than those with pneumonectomy (P < 0.001).

CONCLUSIONS

PPSS is a rare and special subtype of synovial sarcoma. Treatment with lobectomy or sublobar resection alone may contribute to a superior prognosis compared with other managements.

Primary pulmonary synovial sarcoma

Objective

Primary pulmonary synovial sarcoma (PPSS) is extremely rare. This study aims to identify the clinicopathologic and therapeutic factors determining survival in PPSS.

Methods

We performed a retrospective analysis of 121 patients from the Surveillance, Epidemiology, and End Results Database as well as 12 patients from our own institution diagnosed with PPSS. Patient survival was evaluated using the Kaplan-Meier method.

Results

The median survival time for 12 PPSS patients in our institution was 78 months. Postoperative chemotherapy (P = .027 for overall survival and P = .035 for disease-specific survival) was associated with superior survival, whereas pneumonectomy (P = .011 for overall survival and P = .006 for disease-specific survival) was associated with worse survival. Single lobe involvement (P = .022) and the absence of lymph node involvement (P = .045) were associated with improved disease-specific survival and overall survival, respectively. In the Surveillance, Epidemiology, and End Results Database, the median survival time was 23 months. Significantly superior survival was observed in patients with earlier American Joint Committee on Cancer stage (Ⅰ-Ⅱ) (P < .001 for both overall survival and disease-specific survival). Patients who were diagnosed within the recent decade did not achieve a better survival (P = .599 for overall survival and P = .596 for disease-specific survival).

Conclusions

PPSS was aggressive with a very poor prognosis. The seventh American Joint Committee on Cancer stage might aid in predicting survival. Pneumonectomy and lymph node involvement might be associated with worse survival, whereas single lobe involvement and postoperative chemotherapy might be associated with improved survival.

A case of a 22-year-old man with primary synovial sarcoma of the parapharyngeal space with an AR somatic mutation: A case report and review of the literature

This case report describes a 22-year-old man with a pharyngeal foreign body sensation arising from the left side of the postpharyngeal wall. Histological examination showed a biphasic pattern of epithelioid and spindle cells including glandular differentiation. The tumour was positive for vimentin and SS18-SSX, and the spindle cells were positive for bcl-2; in contrast, the epithelioid tumour cells were positive for pan-cytokeratin, epithelial membrane antigen and CD99. There was no INI-loss in tumour cells. Then, the presence of the SYT-SSX gene fusion was demonstrated by fluorescence in situ hybridization. In addition, androgen receptor gene somatic mutations were detected by next-generation sequencing. However, 6 months postoperatively, the patient had neither developed a recurrence nor received adjuvant radiotherapy and chemotherapy. Accurate diagnosis depends on morphological and immunohistochemical examination and a proper molecular analysis, and novel technologies can detect a wide variety of genetic alterations. Although androgen receptor somatic mutations cannot provide addition treatment at present, surgical resection with a clean margin and follow-up is an appropriate approach.

Synovial Sarcoma of Ethmoidal Sinus

Background  Synovial sarcoma is an aggressive soft tissue cancer of extremities mainly and rare in head and neck region, whereas rarest in ethmoidal sinus as only three cases have been reported till date. Case Reports  We managed two cases of synovial sarcoma who presented with nasal obstruction, epistaxis, and swelling around the nasofacial region. Endoscopic nasal biopsy and immunohistochemistry markers confirmed synovial sarcoma in both the cases. While one case was managed by surgery and chemoradiation, the second patient received two cycles of ifosfamide-based chemotherapy and succumbed after 6 weeks of diagnosis. Conclusion  Head and neck sarcomas are aggressive and carry a poor prognosis. Surgical resection with postoperative radiotherapy is the standard treatment. However, they have a high risk of recurrence and hence aggressive management and close follow-up is warranted for the optimal outcome.

Development and Validation of the Nomograms for Predicting Overall Survival and Cancer-Specific Survival in Patients With Synovial Sarcoma

BACKGROUND

The study aimed to build and validate practical nomograms to predict overall survival (OS) and cancer-specific survival (CSS) for patients with synovial sarcoma (SyS).

METHODS

A total of 893 eligible patients confirmed to have SyS between 2007 and 2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly divided into the training cohort (n = 448) and validation cohort (n = 445). Clinically independent prognostic and important factors were determined according to the Akaike information criterion in multivariate Cox regression models when developing the nomograms with the training cohort. The predictive accuracy of nomograms was bootstrapped validated internally and externally with the concordance index (C-index) and calibration curve. Decision curve analysis (DCA) was performed to compare the clinical usefulness between nomograms and American Joint Commission on Cancer (AJCC) staging system.

RESULTS

Two nomograms shared common indicators including age, insurance status, tumor site, tumor size, SEER stage, surgery, and radiation, while marital status and tumor site were only included into the OS nomogram. The C-index of nomograms for predicting OS and CSS was 0.819 (0.873-0.764) and 0.821 (0.876-0.766), respectively, suggesting satisfactory predictive performance. Internal and external calibration curves exhibited optimal agreement between the nomogram prediction and the actual survival. Additionally, DCA demonstrated that our nomograms had obvious superiority over the AJCC staging system with more clinical net benefits.

CONCLUSIONS

Two nomograms predicting 3- and 5-year OS and CSS of SyS patients were successfully constructed and validated for the first time, with higher predictive accuracy and clinical values than the AJCC staging system regarding OS and CSS.

Monophasic synovial sarcoma of the pyriform fossa

Head and neck synovial sarcoma is rare. We report the case of a 71-year-old man who presented with progressive dysphagia, odynophagia, shortness of breath on exertion and hoarseness of voice. Nasendoscopy revealed a smooth, non-fungating, non-ulcerative mass arising from the left lateral pharyngeal wall. CT showed a well-defined, heterogenous enhancing lesion arising from the left pyriform fossa. Initial biopsy taken was inconclusive and patient underwent a transcervical complete excision of the tumour, where histopathological analysis confirmed the diagnosis of monophasic synovial sarcoma of the left pyriform fossa. This patient also received adjuvant radiotherapy postoperatively and remained disease free 1 year after completion of treatment.

Tension Pneumothorax: Is it Sarcoma or Pazopanib?

Synovial sarcomas are rare malignant tumors that originate from primitive pluripotent mesenchymal stem cells that look similar to the developing synovium, but are histologically unrelated to it. Sarcomas commonly metastasize to the lungs and surrounding pleura, with a documented incidence as high as 85% for pleural-based metastases. The incidence of spontaneous pneumothorax in patients with sarcomas is only 1.9%, with synovial sarcoma being the third most common type of sarcoma associated with pneumothorax. While surgical resection is usually the treatment for localized primary synovial cell sarcoma, metastatic disease requires systemic therapy, mainly chemotherapy. Failure of chemotherapy calls for the use of targeted therapeutic agents such as pazopanib. Pazopanib has been linked to the incidence of spontaneous pneumothorax in previous case studies. However, primary research fails to establish a statistically significant causal association. Research shows that pneumothorax can result from lung metastases independent of therapeutic side effects. We report a case of synovial sarcoma of trapezius origin with secondary lung metastases, and development of pneumothorax after pazopanib treatment. We discuss the incidence of pneumothorax as a medication side effect versus independent effect of natural disease progression, and how this plays role in deciding when to continue using a medication in the face of complications.

The survival and prognosis analysis of synovial sarcoma subtypes: a Surveillance, Epidemiology, and End Results population-based analysis

PURPOSE

By comparing epidemiologic and prognostic data of synovial sarcoma subtypes, this study aims to clarify the difference in prognosis and risk factors among different synovial sarcoma subtypes.

METHODS

In total, 1692 patients with synovial sarcoma in the USA who were diagnosed during 1975 through 2016 and retrieved from the Surveillance, Epidemiology, and End Results (SEER) program were studied.

RESULTS

There were statistically significant differences in the distribution of age and race among three synovial sarcoma subtypes, while no major differences in the distribution of sex, tumor stage, and tumour size were found. The highest five and ten year survival rates were found in the biphasic subtype (69%, 60%), followed by the monophasic subtype (59%, 49%), and lowest in the epithelioid subtype (32%, 26%). Age and SEER historic stage were the two demographic factors that found to have statistically significant impact on survival in all subtypes. Radiation was found to be protective in the monophasic subtype (HR 0.61, p < 0.001).

CONCLUSION

Among different synovial sarcoma subtypes, the biphasic subtype favoured the best survival, while the epithelioid cell subtype was associated with the worst. Male and black race were independently associated with worse survival only in the monophasic subtype. Radiotherapy could provide significant benefit for patients with the monophasic synovial sarcoma.

Radiation therapy strategies for skull-base malignancies

INTRODUCTION

The management of skull base malignancies continues to evolve with improvements in surgical technique, advances in radiation delivery and novel systemic agents.

METHODS

In this review, we aim to discuss in detail the management of common skull base pathologies which typically require multimodality therapy, focusing on the radiotherapeutic aspects of care.

RESULTS

Technological advances in the administration of radiation therapy have led to a wide variety of different treatment strategies for the treatment of skull base malignances, with outcomes summarized herein.

CONCLUSION

Radiation treatment plays a key and critical role in the management of patients with skull base tumors. Recent advancements continue to improve the risk/benefit ratio for radiotherapy in this setting.

Synovial sarcoma disease characteristics and primary tumor sites differ between patient age groups: a report of the Cooperative Weichteilsarkom Studiengruppe (CWS)

BACKGROUND

Older age is associated with worse outcome in synovial sarcoma (SS) patients. Differences in disease presentation among distinct age groups, however, are currently unknown.

METHODS

SS patients < 21 years registered in consecutive CWS trials over the period of 1981-2018 were evaluated. Characteristics were analyzed according to age groups using the Fisher's exact test.

RESULTS

The study population included 432 SS patients. Disease characteristics differed according to age groups of children (0-12 years, n = 176), adolescents (13-16 years, n = 178), and young adults (17-21 years, n = 78). The proportion of invasive tumors (T2) was significantly higher in older patients: children 33%, adolescents 39% and young adults 54%, p = 0.009805. Similarly, the proportion of tumors > 10 cm was higher (13%, 21%, 31%; p = 0.005657) whereas conversely, the proportion of small tumors < 3 cm was lower in older patients (29%, 24%, 6%; p = 0.000104). The presence of metastases at first diagnosis was also highest in older patients (6%, 10%, 21%, p = 0.000963). Notably, the proportion of thigh tumors was higher in older patients (p = 0.04173), whereas the proportion of head-neck tumors was lower in older patients (p = 0.08896).

CONCLUSIONS

The rates of large, invasive tumors and the presence of metastases are significantly associated with older patient age. Localization to the thigh is more frequent in older patients.

DISCUSSION

The causes for these variations require further exploration.

Pediatric Tonsillar Synovial Sarcoma- Very Rare Localization: A Case Report and Review of the Literature

Tonsillar synovial sarcoma is an extremely rare entity and only 9 adult patients have been reported up to now. Here, we describe the first pediatric tonsillar synovial sarcoma of the literature in a patient who presented with a 2-month history of dysphagia and snoring. Clinical and radiological examinations showed that the tumor arose from the right palatine tonsil and narrowed the parapharyngeal space. An incisional biopsy from the palatine tonsil revealed the diagnosis of synovial sarcoma. The patient has underwent total tonsillectomy and received radiotherapy and chemotherapy because of the positive surgical margins. The patient is clinically in good condition and free of tumor 30 months after the initial diagnosis. We achieved a long-term complete remission with a combination of surgery, radiotherapy and chemotherapy in our case. Tonsillar synovial sarcoma should be kept in mind while dealing with tonsillar masses. We can conclude that a multidisciplinary approach is warranted while treating synovial sarcoma with this localization.

Synovial sarcoma of the supraclavicular region causing a hemorrhagic shock

A cystic mass that rapidly increases in volume in a dangerous anatomical region, notably the supraclavicular region, which contains important neurovascular elements, must be considered at high risk. A vascular study is mandatory before biopsy. Neoadjuvant chemotherapy can be a treatment option in high-risk synovial sarcoma.

Treatment Outcomes and Prognostic Factors of Adult Sinonasal Sarcomas: A Single-Institution Case Series

BACKGROUND The purpose of this study was to investigate the treatment outcomes and evaluate the prognostic factors of adult sinonasal sarcomas. MATERIAL AND METHODS A retrospective review was performed on consecutive patients with adult sinonasal sarcomas treated in our institution from 2005 to 2016. The Kaplan-Meier method was used to evaluate local recurrence-free survival (LRFS), distant metastases-free survival (DMFS), and overall survival (OS). Univariate and multivariate analyses using Cox proportional hazard models were performed to determine the prognostic factors associated with survival outcomes. RESULTS A total of 49 patients were followed up for 6-122 months, with a median time of 36 months. The 5-year LRFS, DMFS, and OS rates of all patients were 68.3%, 62.8%, and 43.2%, respectively. The results of univariate analysis revealed that patients with an advanced stage of primary tumor and those who received incomplete surgical resection had worse LRFS (p=0.013; p=0.026). Patients with the histological type rhabdomyosarcoma (RMS) and existing regional lymph node metastasis had worse DMFS (p=0.000; p=0.001). The histological type RMS, advanced stage of primary tumor, existing regional lymph node metastasis, and receiving incomplete surgical resection had an unfavorable effect on OS (p=0.001; p=0.002; p=0.008; p=0.011). The results of multivariate analysis showed that histological type and degree of surgical resection were the independent prognostic factors for OS. CONCLUSIONS Our results suggest that the histological type RMS and receiving incomplete surgical resection are independent prognostic factors for worse OS.

Survival changes in Patients with Synovial Sarcoma, 1983-2012

Background: Synovial sarcoma (SyS) is a rare malignancy that typically invades the extremities and occurs predominantly in adolescents. Studies on incidence and survival in SyS that were based on a large population had not been reported yet.

Methods: To evaluate changes in incidence and survival in SyS over three decades, we accessed data on SyS cases in each decade between 1983 and 2012 (1983-1992, 1993-2002, and 2003-2012) from the Surveillance, Epidemiology, and End Results (SEER) database. The survival difference between decades, age groups, sexes, race, pathologic types, sites, stages and socioeconomic status (SES) over three decades were accessed by comparing Kaplan-Meier curves.

Results: We located 2,070 SyS cases in 18 SEER registry regions between 1983 and 2012. Our study demonstrated that the incidence of SyS per 1,000,000 continued to increase from 0.906 to 1.348 to 1.548 in the total population and in most age groups and that the age of incidence peak was 15-29 years in three decades. But, the survival of patients with SyS did not significantly improve throughout the three decades, with 5-year survival rates of 69.4%, 61.1% and 60.5% respectively (p > 0.05). Interestingly, the widening survival gaps among races, sexes, pathological types and various SES over time were observed, with narrowing p values.

Conclusions: This study demonstrated the increasing incidence and unimproved survival rates across three decades in a large sample, indicating the urgency for further development of diagnosis, improving health care providers' awareness of SyS and lead to the development of novel treatments.

Synovial Sarcoma of the Head and Neck: A Single Institution Review

Background

The prognosis and clinical characteristics of head and neck synovial sarcomas (HNSS) are unclear. Herein, we present an update using a cohort of patients treated at our institution.

Methods

We performed a retrospective chart review of 44 patients diagnosed with primary HNSS between March 1990 and June 2012. Overall survival (OS) and progression-free survival (PFS) curves were estimated and hazard ratios (HRs) were calculated.

Results

The entire cohort's median PFS was 4.6 years, and 20 of the 44 (45%) patients developed either local or distant recurrence. Tumor size ≥ 5 cm (p = 0.008, HR = 4.69; 95% CI = 1.34–16.38) and a primary presentation in the soft tissues of the neck (p = 0.04, HR = 2.41; 95% CI = 1.003–5.82) were associated with significantly worse PFS. The OS and PFS of patients who received definitive local therapy versus those who received additional adjuvant systemic therapy did not differ significantly.

Conclusion

Despite the treatment challenges associated with HNSS, our cohort of patients had a better prognosis than one might expect in this unfavorable anatomical location. Our findings suggest that tumor size and site are predictive of PFS and that wide surgical excision is of vital importance, since traditional cytotoxic chemotherapy has limited efficacy at this site.

A clinicopathologic study on SS18 fusion positive head and neck synovial sarcomas

OBJECTIVE

To determine clinicopathologic factors on survival in patients with head and neck synovial sarcoma.

PATIENTS AND METHODS

We retrospectively identified patients with molecularly confirmed synovial sarcomas of the head and neck (SS-HN), either by the presence of SS18-SSX fusion transcript by RT-PCR or SS18 gene rearrangement by FISH, who were managed at our institution over a 20-year period (1996-2015). Kaplan-Meier survival analysis and log-rank test were performed to evaluate variables related to disease specific survival (DSS). Fisher exact test was performed to evaluate variables related to local recurrence.

RESULTS

Thirty-four patients (20 males and 14 females, mean of 31years) with SS18-SSX fusion-positive SS-HN were identified. The parapharyngeal region of the neck was the most common site. The mean tumor size was 4.8cm (0.8-10cm). Two-thirds (n=23) of cases had a monophasic histology. The 2, 5 and 10-year DSS rates were 97%, 79% and 68%. The 5-year DSS rates for the adult/pediatric cohort were 74%/88%. Recurrence showed significant effect on DSS (p=0.021). There was no significant effect on DSS with age, therapy modality, tumor site, surgical margin, tumor size (⩽5cm vs. >5cm) and histopathologic subtype. Tumor site (i.e. skull base/paranasal sinus region) was associated with local recurrence (p=0.003).

CONCLUSION

In our cohort DSS rate was associated with recurrence. Tumors located in the skull base/paranasal sinus region were associated with a higher rate of local recurrence. Thus appropriate selection of high risk patients who can benefit from multimodality therapies might improve survival.