Synovial sarcoma with a large hematoma in the inguinal region

Femoral Vein Intravascular Synovial Sarcoma Mimicking Primary Deep Vein Thrombosis-A Rare Cause of Deep Vein Thrombosis

Synovial sarcomas are rare malignant mesenchymal soft tissue tumors. We presented the case of a 53-year-old woman patient presenting with acute deep vein thrombosis, later diagnosed as a deep synovial sarcoma of the femoral vein wall. The tumor was identified through cross-sectional magnetic resonance angiography and computed tomography, followed by ultrasound-guided core biopsy. The case report emphasized the importance of considering the possibility of an intravascular neoplasm mimicking thrombus, particularly if calcifications, vein expansion with intravascular cystic spaces, fluid-fluid levels, and septations within a thrombosed vein are seen in imaging.

An infected chronic expanding haematoma treated with hip disarticulation

This is a report of an anticoagulated patient with septic shock caused by an infected chronic expanding haematoma (CEH) that required hip disarticulation as a means of definitive surgical source control. As far as we know, we did not find any report of an infected giant CEH in the lower extremity as large as in the present patient.

Large intraosseous chronic expanding hematoma after total hip arthroplasty presenting with chronic disseminated intravascular coagulation: a case report and literature review

Background

A chronic expanding hematoma (CEH) is a rare complication caused by surgery or trauma; it mostly affects the soft tissues, such as those in the trunk or extremities. We present the first case of a large intraosseous CEH presenting with chronic disseminated intravascular coagulation (DIC), 22 years after total hip arthroplasty (THA); the CEH was treated with a single-stage excision and revision THA.

Case presentation

A 67-year-old man presented to our hospital with left thigh pain and an enlarging mass. He had no history of trauma, anticoagulant use, or a collagen vascular disorder. The patient initially declined surgery. Two years later, radiographs and computed tomography images revealed progressive osteolysis, marginal sclerosis, and calcification in the left femur, in addition to loosening of the femoral component. Laboratory data revealed anemia and chronic DIC of unknown causes. Magnetic resonance imaging revealed a “mosaic sign” on the mass, indicating a mix of low- and high-signal intensities on T2-weighted images. Needle biopsy prior to surgery revealed no infection or malignant findings. An intraosseous CEH was suspected due to extensive osteolysis and loosening of the femoral component. No other factors that could induce chronic DIC were identified, such as sepsis, leukemia, cancer, trauma, liver disease, aneurysms, or hemangiomas. Therefore, we speculated that the anemia and chronic DIC were caused by the large intraosseous CEH. A single-stage revision THA with surgical excision was performed to preserve the hip function and improve the chronic DIC. The postoperative histopathological findings were consistent with an intraosseous CEH. The anemia and chronic DIC improved after 7 days. There was no recurrence of intraosseous CEH or chronic DIC at the 6-month follow-up. The left thigh pain improved, and the patient could ambulate with the assistance of a walking frame.

Conclusions

The loosening of the femoral component caused persistent movement, which may have caused intraosseous CEH growth, anemia, and chronic DIC. It is important to differentiate CEHs from malignant tumors with hematomas. Furthermore, the “mosaic sign” noted in this case has also been observed on magnetic resonance images in other cases of CEH.

Large inguinal synovial sarcoma mimics a vascular lesion: A case report and literature review

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Synovial sarcomas mostly affect adolescents and young adults with slight male predominance.

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The cellular origin of SS is disordered mesenchymal stem cells that have undergone self-renewal dysregulation mediated by the SS18-SSX fusion protein.

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Novel therapies targeting molecular and genetic pathways of SS are under research, including SYT-SSX-derived peptide vaccine, retinoic acid and its derivatives.

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Various manifestations and rarity of SS could mimic vascular lesion which mislead the diagnosis.

Introduction

Synovial sarcoma (SS) is one of soft tissue sarcomas (STS), characterized by t(X;18)(p11;q11) chromosomal translocation. Clinical diagnosis of SS in groin is difficult owing to rarity and various manifestations. We reported a rare and interesting case of inguinal biphasic SS with initial impression of a vascular lesion.

Presentation of case

We reported a 72-year-old man who presented with a right inguinal progressively enlarged mass for 5 years. The mass became ulcerative with active bleeding after blunt trauma. Computed tomography (CT) showed a large heterogeneous tumor with focal vivid enhanced area, and an inguinal vascular lesion was impressed. Angiography revealed faint tumor stain without contrast extravasation or aneurysm lesion. Surgical resection of the tumor was performed. Final pathology and fluorescence in situ examination (FISH) demonstrated biphasic SS with SS18 gene rearrangement. No evidence of recurrence after one-year follow-up.

Discussion

SS constitutes 5%–10% of STS. The most primary sites are extremities (68.7%) and trunk (15.7%). Treatment options for SS include surgery, chemotherapy, radiotherapy, targeted therapy, and novel therapies. In our case, the initial impressions of large inguinal tumor were hematoma or pseudoaneurysm. Preoperative angiography assisted in differentiating the lesion, evaluating tumor vessels, and preventing bleeding by embolization. Our patient recovered satisfactorily after surgical excision without major complications.

Conclusion

Primary inguinal SS is an extremely rare tumor which can present as a vascular lesion. Diagnosis is confirmed by pathology and FISH exam. Further studies are required to determine the manifestation and management of SS.

Extracellular matrix composition modulates angiosarcoma cell attachment and proliferation

Angiosarcoma is a rare and generally fatal tumor composed of aberrant cells of endothelial origin. Because of its infrequency in humans, very little is known about the growth requirements of this vascular sarcoma. Unlike the rapidly proliferating solid tumors from which they are isolated from, many of the established angiosarcoma cell lines exhibit less than robust growth in culture and often fail to form tumors in xenograft models. In order to better understand angiosarcoma in vitro growth conditions, we focused on a singular aspect of their culture—adhesion to the extracellular matrix—in order to identify attachment substrates that may facilitate and/or enhance their growth in tissue culture. Our data indicates that the extracellular matrix of angiosarcomas contains similar protein compositions to that of non-diseased endothelial cells. Moreover, angiosarcoma cell lines exhibited strong attachment preference to substrates such as collagen I or fibronectin, and less preference to collagen IV, laminin, or tropoelastin. Growth on preferred extracellular matrix substrates promoted mitogenic signaling and increased proliferation of angiosarcoma cell lines. These findings provide insight that may lead to more successful in vitro growth of angiosarcoma cell lines.

Clinical features of soft tissue sarcoma presenting intra-tumour haematoma: case series and review of the literature

INTRODUCTION

Intra-tumour haematoma is an uncommon clinical presentation in malignant soft tissue tumours. This study aimed to highlight the clinical features of patients with soft tissue sarcomas with intra-tumour haematoma.

METHODS

The patient group was composed of eight men and one woman aged between 29 and 83 years (mean 44.0 ± 20.8). The average follow-up was 29.8 months. Clinical information, including clinical features, radiological information and treatment course, was retrospectively investigated.

RESULTS

Tumours were predominantly located in the chest wall and thigh, and average diameter was 10.3 cm. Six patients underwent needle biopsy with ultrasound sonography, and three underwent an open biopsy. Histological diagnoses indicated that all tumours were high grade, three of which were undifferentiated pleomorphic sarcomas, three synovial sarcomas, two pleomorphic liposarcomas, one a leiomyosarcoma and one a malignant peripheral nerve sheath tumour. The median diagnostic delay time was 3.0 months. Magnetic resonance imaging (MRI) indicated a haematoma area <25 % in three, 25-50 % in four and 50 % two. A wide resection was performed in eight patients, and radiotherapy was administered to one patient for the initial local treatment of a primary tumour. Local recurrence was detected in four patients, whilst five developed lung metastases. The five-year survival rate was 57.1 % and median survival 34.0 months.

CONCLUSIONS

Soft tissue sarcomas with intra-tumour haematoma presented with locally aggressive and highly metastatic behavior, consistent with high-grade tumours.

Synovial sarcoma mimicking haemophilic pseudotumour

This is a case of a 36-year-old gentleman with haemophilia A who was presented with an acute atraumatic soft tissue swelling in the right thigh. Open biopsy was performed with the resultant diagnosis of a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudotumour. The findings reported on MRI scan initially were highly consistent with those present in patients with mild haemophilia. An important part of orthopaedic management in haemophilia is concerned with intraarticular and intramuscular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clinician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophilic patient.

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.

Extremity soft tissue sarcomas presented as hematomas

INTRODUCTION

Soft tissue sarcoma (STS) with extensive intra-tumoral hemorrhage is an infrequently described entity, usually misdiagnosed as intra-muscular hematoma. The outcomes in this group of patients have not been previously described.

MATERIALS AND METHODS

We retrospectively identified 15 patients, with initial clinical or imaging diagnosis of hematoma, or hematoma versus hemorrhagic sarcoma, although final diagnosis of high-grade STS was established in all cases.

RESULTS

The most common location was the thigh. Three patients had a bleeding predisposition. Ten patients were referred for further evaluation with the initial diagnosis of muscle strain/hematoma, hematoma versus abscess in one, whereas four were referred for soft tissue mass evaluation. Final diagnosis was made by one biopsy in only 53% of patients. Mean time to diagnosis for patients with two biopsies was 7 months from initial presentation. Histologic diagnosis was malignant fibrous histiocytoma in ten patients. Surgical treatment included tumor resection in eleven and amputation in three patients. One patient had lung metastatic disease at presentation and eight developed lung metastases within a median time of 7 months.

CONCLUSION

We suggest that an STS masquerading as hematoma should be suspected when the mechanism and the energy of the trauma do not justify the clinically detected severity of the injury, or the lesion does not follow the expected clinical course of resolution after initial conservative management. Bleeding predisposition does not exclude malignancy. The evacuation of hematomas should include pathologic examination of tissue. Prognosis is dismal due to early metastatic disease.

Soft-tissue sarcoma mimicking large haematoma: a report of two cases and review of the literature

We report on 2 patients with soft-tissue sarcomas mimicking large haematomas. Neither patient had a medical history of trauma or bleeding tendency. In a patient with a large leiomyosarcoma in the buttock, insufficient biopsy material from initial surgeries precluded a correct diagnosis. In the second patient with epithelioid sarcoma of the forearm, fasciotomy was repeatedly performed for compartment syndrome arising from the tumour. It is important to reconfirm prior trauma and investigate the clinical course and images of patients with an unusual history of haematoma in the extremities. The possibility of a malignant tumour should be suspected, and repeated biopsies should be performed if necessary.

A case of monophasic synovial sarcoma presenting as a vulvar mass

BACKGROUND

Synovial sarcoma is the fourth most commonly occurring sarcoma, accounting for 8-10% of all sarcomas. They arise from unknown pleuripotent stem cells that are capable of differentiating into mesenchymal and/or epithelial structures. Synovial sarcoma is characterized by specific chromosomal translocation t (X; 18)(p11, q11).

CASE

We report the first case of monophasic synovial sarcoma arising in soft tissues of the vulva in a 33-year-old female. Complete excision of the mass was possible with tumor-free margins.

CONCLUSION

Only four previous cases of biphasic synovial sarcoma arising in the vulva have been reported. The finding of the SYT-SSX2 translocation is generally associated with a better prognosis, besides tumor negative margins after excision offer the possibility of a better outlook for this patient.

Soft tissue sarcoma mimicking chronic hematoma: value of magnetic resonance imaging in differential diagnosis

We report six patients with soft tissue sarcoma mimicking traumatic hematoma. The lesions in these patients, showed huge hematomas and were characterized by rapid growth. Cytology of percutaneous; aspiration biopsy samples was performed in all six patients; however, in five patients, findings for malignant cells were negative. Consequently, they were misdiagnosed, resulting in a poor prognosis. We conducted a retrospective study in which we evaluated the clinical findings, the magnetic resonance (MR) images, and computed tomography (CT) scans of the soft tissue sarcomas forming huge hematomas in the lesion. MR imaging revealed the fine tumor mass with enhancement and characterized the hematoma in the lesion in a more precise fashion than did CT. We conclude that MR imaging is a suitable method for differentiating these soft tissue sarcomas from chronic traumatic hematoma.