Primary cardiac synovial sarcoma: A review correlating outcomes with surgery and adjuvant therapy

Comment on Manole et al. Primary Pericardial Synovial Sarcoma: A Case Report and Literature Review. Diagnostics 2022, 12, 158

With great interest, we read the article by Manole et al [...].

Complete resection of a giant intrapericardial cardiac synovial sarcoma

Synovial sarcoma of the heart is a rare tumor. Herein we would like to report a case of giant intrapericardial cardiac synovial sarcoma that originated from the right ventricle and grew outward near the diaphragm. After making adequate preoperative preparation, we performed the surgery as quickly as possible and resected the tumor completely. Based on the identification of the translocation on chromosome 18 rearrangement, the tumor can be diagnosed as a primary cardiac synovial sarcoma. Through this study, we aim to afford more information about cardiac synovial sarcomas as well as a reference for similar cases.

Case report: Characteristics and nature of primary cardiac synovial sarcoma

Primary malignant cardiac tumors rarely occur, and cardiac synovial sarcoma (SS) is especially rare among such tumors. Herein, we present the case of a 35-year-old female with primary cardiac SS treated with surgery, chemotherapy, and radiotherapy. She presented with chest symptoms and underwent imaging examinations. A cardiac tumor was suspected, and an open biopsy was performed. The pathological findings suggested cardiac SS. Next, we performed a resection, and the tumors persisted at a macroscopic level. Immunohistochemistry was negative for SS18-SSX and positive for the SSX C-terminus and cytokeratin CAM5.2, a reduction of SMARCB1/INI1 was observed, and fluorescence in situ hybridization showed positive SS18 split staining. Owing to the FNCLCC grade 3 tumor and R2 margins, adjuvant chemotherapy with ifosfamide, doxorubicin, and radiotherapy was initiated, and the patient was diagnosed with cardiac SS. The differences in patients with cardiac SS compared with general SS include male predominance, larger tumor size, and poorer prognosis. Pathological findings of immunohistochemistry and fluorescence in situ hybridization were found to be more reliable than imaging findings for a correct diagnosis. Additionally, because incomplete resection is frequently performed, adjuvant therapy, including chemotherapy and radiation therapy, may be performed. The findings indicate that multiple therapies, including surgery, chemotherapy, and radiotherapy, are essential treatment strategies for improving the prognosis of patients with cardiac SS.

Multimodal imaging features of primary pericardial synovial sarcoma: a case report

Background

Primary pericardial synovial sarcoma is an extremely rare malignant tumor, and affected patients have a poor prognosis. Only a few cases have been reported in the literature.

Case summary

A 34-year-old man was admitted to our hospital with chest tightness and a cough. An echocardiogram revealed a heterogeneous mass with a large pericardial effusion. Further computed tomography (CT) of the chest and cardiac magnetic resonance imaging (CMRI) demonstrated an irregular pericardial mass abutting the left atrium and left ventricle and invading the mediastinal structures. Pathology results showed that the tumor was a monophasic synovial sarcoma. The patient underwent chemotherapy and survived for 17 months.

Discussion

Many cardiac tumors are clinically asymptomatic or nonspecific, and they are frequently detected or diagnosed at an advanced stage of the disease. Multimodal cardiac imaging facilitates the detection and assessment of cardiac tumors. In particular, CMRI is considered as a superior imaging tool, because it provides high tissue contrast and can detect invasion of the myocardium. We describe the clinical details and multimodal imaging features of a rare primary pericardial synovial sarcoma, hoping to provide guidance for the diagnosis of similar cases in the future.

Cardiac synovial sarcoma masquerading as effusive constrictive pericarditis

Primary cardiac synovial sarcoma is a rare entity, arising from the pericardium or the chambers of the heart. It presents in the 4th decade of life with a striking male predisposition. We describe an unusual case of a 22-year-old female who presented with complaints of dyspnoea on exertion, palpitations, and chest pain. Trans-thoracic echocardiography was suggestive of a cystic pericardial mass with pericardial effusion anterior and lateral to the right ventricle. Computed tomography scan (CT scan) revealed thick-walled predominantly cystic lesion over the left ventricle with gross pericardial effusion with internal septations. These findings were suggestive of an infected pericardial cyst. Upon surgery, an adherent mass in the pericardial cavity was found which was not separable from the right heart structures, the great vessels, and the left ventricle. Biopsy was taken, histopathology was suggestive of spindle cell neoplasm, and an immunohistochemistry analysis revealed Transducin-like enhancer of split 1 (TLE 1)-positive malignant spindle cell tumour likely synovial sarcoma. After surgery, the patient received serial adjuvant chemo-radiation therapy. The synovial sarcoma masqueraded as effusive constrictive pericarditis, due to which it eluded preoperative diagnosis.

Massive primary cardiac synovial sarcoma of the left atrium: a case report

Background

Synovial sarcomas are tumors typically located in the extremities and characterized by a t(X;18)(p11.2;q11.2) chromosomal translocation. With only around 100 cases reported in the literature, cardiac synovial sarcomas are extremely rare.

Case presentation

We describe a case of a 59-year-old male who presented to his primary care physician with chest pain, palpitations, and dyspnea and was diagnosed with atrial flutter. Following atrial ablation, a transthoracic echocardiogram incidentally revealed a 5.5 × 5.0 cm heterogeneous mass. Further workup found a heterogeneous mass with mild fluorodeoxyglucose uptake that was abutting the left atrium, left ventricle, and left pulmonary veins. The tumor was resected and confirmed to be a monophasic synovial sarcoma with a SS18-SSX gene fusion. Four months post-operative, the patient had recovered well from surgery. He is currently undergoing concurrent radiation and chemotherapy.

Conclusions

Due to the rarity of this tumor, guidelines on diagnosis and treatment come only from case reports. Our case describes a primary cardiac synovial sarcoma arising from the left atrium in the atrioventricular groove in which diagnosis of atrial flutter preceded detection of the mass.

Case Report: A Young Man With Giant Pericardial Synovial Sarcoma

Pericardial synovial sarcomas are sporadic tumors. Herein, we report a case of primary pericardial synovial sarcoma originating from the right pericardium. Missed diagnosis delayed surgical treatment. Eventually, the tumor occupied the almost entire pericardial cavity. The pericardial tumor was surgically removed as soon as possible after admission. In this paper, we aim to provide details that can help further understand the differing symptoms and presentations of pericardial synovial sarcoma and highlight the importance of consideration of this disease in similar cases where the etiology of pericardial effusion is unknown.

Diagnostic approach to a cardiac mass: a case report of misdiagnosed cardiac synovial sarcoma

Background

Cardiac synovial sarcoma (CSS) is an extremely rare malignant tumour with a poor prognosis. We report the case of a 31-year-old woman who presented with a CSS in the right atrium and was initially misdiagnosed with a tuberculoma. The aim of this article is to focus on the importance of having broad differential diagnoses including rare entities.

Case summary

A 31-year-old White woman, with a close contact with a relative having pulmonary tuberculosis, presented to the emergency unit with severe dyspnoea. Chest radiography and echocardiography showed a large pericardial effusion with a mass in the right atrium. Pericardiocentesis removed bloody exudative fluid with adenosine desaminase at 17 UI/L and no malignant cells in the cytological study. Cardiac magnetic resonance revealed a tuberculoma of the right atrium. Intraoperatively, the mass was only biopsied because of the local invasion. Histological study concluded to a CSS. The patient died 3 days later.

Discussion

This case highlights the importance of having broad differential diagnoses including rare entities. Histology was the key investigation for the diagnosis of CSS which has no clinical nor laboratory or imaging pathognomonic signs.