Primary pleuropulmonary synovial sarcoma

Recurrent Metastatic Pulmonary Synovial Sarcoma during Pregnancy: A Case Report and Literature Review

Primary pulmonary synovial sarcoma is a rare type of soft tissue tumor. Exceptionally it can occur during pregnancy, representing a challenge in management and treatment given its notable aggressiveness and the not infrequent incidence of maternal death. We report our case of metastatic recurrence of pulmonary synovial sarcoma during pregnancy, with the aim to emphasize the decision-making, diagnostic, and therapeutic multidisciplinary processes and the evolution of the pathology. Besides, we focused on the analysis of the limited literature data available on the topic.

Pleural Neoplasms-What Could MRI Change?

The primary pleural neoplasms constitute around 10% of the pleural tumors. The currently recommended method for their imaging is CT which has been shown to have certain limitations. Strong development of the MRI within the last two decades has provided us with a number of sequences that could potentially be superior to CT when it comes to the pleural malignancies' detection and characterization. This literature review discusses the possible applications of the MRI as a diagnostic tool in patients with pleural neoplasms. Although selected MRI techniques have been shown to have a number of advantages over CT, further research is required in order to confirm the obtained results, broaden our knowledge on the topic, and pinpoint the sequences most optimal for pleural imaging, as well as the best methods for reading and analysis of the obtained data.

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.

Mediastinal Primary Synovial Sarcoma With Postoperative Pericardial Recurrence in a Previously Treated Angiofibroma

Synovial sarcoma is a malignant soft tissue tumor that often occurs near the limb joints. Here, we report a case of a patient with a synovial sarcoma that occurred in the mediastinum. The initial pathological diagnosis was suspected angiofibroma after surgical resection. After surgery, the tumor recurred in the pericardium and caused cardiac tamponade. Pericardial fenestration was performed and the patient was diagnosed with synovial sarcoma. The final diagnosis was the postoperative pericardial recurrence of the mediastinal synovial sarcoma. It is important to consider follow-up on the basis of the malignant tumor, especially if the disease is rare.

Primary Pleuropulmonary Synovial Sarcoma: Report of Two Cases and a Comprehensive Review of the Literature

Primary sarcomas of the lung represent less than 0.5% of all primary lung tumors and comprise a heterogeneous group of malignancies including synovial sarcoma (SS). Primary pleuropulmonary SS has non-specific presentations, such as chest pain, shortness of breath and cough, and its associated imaging features resemble those of other intrathoracic malignancies. The diagnosis of these tumors needs to be confirmed by cytogenetic and molecular studies. Here, we describe two rare cases of primary pleuropulmonary SS who were admitted to our hospital. We also provide a concise review of clinical, radiological, and histopathological characteristics of pleuropulmonary SS after exploring 168 studies (415 corresponding patients) that were identified through a literature search.

Pediatric thoracic mass lesions: Beyond the common

Thoracic mass lesions can be categorized as originating in one of the three major compartments: a) chest wall and pleura, b) lung parenchyma and airways, c) mediastinum. While some of these, such as lymphoma, are common in both children and adults, others are rare and unique to childhood. The goal of this review is to familiarize radiologists with unusual but distinctive mass lesions of the pediatric thorax.

An unusual endobronchial lesion: expanding the differential diagnosis

Synovial sarcoma is a rare tumour, accounting for approximately 2.5-10% of all soft tissue sarcomas. In the thorax, it most often presents as a large, homogenous mass and, most commonly, is the result of extrathoracic tumour metastasis. Here, we report a case of a 73-year-old male who presented to the hospital after a motor vehicle collision. Chest computed tomography demonstrated a 2.0 × 2.4 cm left lower lobe pulmonary nodule with endobronchial extension and a 2.5 × 2.1 cm right-sided kidney mass. He was eventually diagnosed with monophasic synovial sarcoma. To date, only seven other cases of primary pulmonary synovial sarcoma with endobronchial extension have been reported. A review of the cases and literature is discussed.

Primary Synovial Sarcoma of the Mediastinum with Long-term Follow-up

Chest radiography showed a right posterior mass on the mediastinum of an 84-year-old woman. The mass had been growing gradually for four years. Surgical excision was performed, and a pathological examination found the mass to be consistent with primary synovial sarcoma (SS) of the mediastinum. To our knowledge, this is a rare case in which follow-up imaging was able to be performed over a period of four years. This disease is aggressive, and its early diagnosis is key to achieving a cure. It is important to consider primary SS in the differential diagnosis of a primary intra-thoracic tumor, even if the tumor grows slowly.

Primary monophasic synovial sarcoma of the pleura: Neoadjuvant chemotherapy followed by complete resection

We describe a rare case of primary pleural synovial sarcoma in a 27-year-old man with a 4-month history of dry cough and left-sided chest pain. A CT scan showed a large cystic mass in the left pleural cavity. The patient underwent two video-assisted thoracoscopic biopsies and the diagnosis of synovial sarcoma of the pleura was established. After neoadjuvant chemotherapy, which resulted in a partial response, the tumor was completely resected with extrapleural pneumonectomy. Pathological findings showed less than 5% of viable cancer and free surgical margins. The patient is clinically well 24 months after surgery, with no evidence of recurrent disease.

Primary Cystic Pleuropulmonary Synovial Sarcoma Presenting as Recurrent Pneumothorax

Primary pleuropulmonary synovial sarcomas are quite rare, representing 0.1-0.5% of all pulmonary malignancies. We report an entirely cystic monophasic synovial sarcoma in a 25-year-old male who presented with recurrent pneumothorax and no evidence of a mass lesion on imaging. The purpose of this case report is to increase awareness of neoplasms clinically presenting as a pneumothorax with no imagining evidence of a mass-forming lesion and emphasize the significance of fluorescent in situ hybridization testing in nontypical synovial sarcoma cases.

Primary pleuropulmonary and mediastinal synovial sarcoma: a clinicopathologic and molecular study of 26 genetically confirmed cases in the largest institution of southwest China

BACKGROUND

Primary pleuropulmonary and mediastinal synovial sarcomas (PPMSSs) are extremely rare. The authors present the largest series in an Asian population.

METHODS

Between 2000 and 2015, 26 genetically confirmed PPMSSs were included. The clinicopathologic features of all of the cases were reviewed. Immunohistochemical staining was carried out using the following antibodies: TLE1, cytokeratin (AE1/AE3), EMA, CD99, Bcl-2, CK7, CD34, S-100 protein, and Ki-67. The chromosomal translocation t(X;18)(p11.2;q11.2) was detected by fluorescence in situ hybridization (FISH) and reverse transcription polymerase chain reaction (RT-PCR). We compared the clinical, pathologic, immunohistochemical, and molecular features of this series with that of the previous series and soft tissue synovial sarcomas.

RESULTS

This series included 17 males and nine females. The median age was 36.5 years (range, 16-72 years). The tumors involved the lung (76.9 %), pleura (15.4 %), and mediastinum (7.7 %). The median tumor size was 6 cm (range 2.3 ~ 24 cm). The majority of the tumors were well-circumscribed. The tumors were classified as monophasic (84.6 %), biphasic (3.8 %), and poorly differentiated (11.5 %) types. The tumors were graded as French Federation of Cancer Centers (FNCLCC) grade 2 (62.5 %) and FNCLCC 3 (37.5 %). Diffuse immunostaining for TLE1, BCL-2, and CD99 was identified in 91.7, 95.7, and 56.0 % of the tumors, respectively. Focal positivity was seen with EMA (84.6 %), CK7 (55.6 %), cytokeratin (AE1/AE3) (68.0 %), CD34 (5.0 %), and S-100 protein (21.7 %). A high Ki-67 index (≥10 %) was observed in 91.3 % of the tumors. The fusion transcripts included SS18-SSX1 (15/22, 68.2 %), SS18-SSX2 including variants (6/22, 27.3 %), and SS18-SSX4 (1/22, 4.5 %) fusions. The remaining four cases showed positivity for SS18 rearrangement by FISH. Surgical excision of tumors or lobectomy were performed in 20 patients, and seven of the patients underwent adjuvant therapy. Clinical follow-up was available in 73.1 % cases, with a median follow-up of 12.0 months. The median survival time was 14.5 months. Tumor resection (p = 0.024) and no residual tumor (p = 0.004) were associated with an improved overall survival time.

CONCLUSIONS

PPMSS is a highly aggressive neoplasm. Extensive surgical resection of the tumor and more effective adjuvant therapy should be advocated. PPMSS must be differentiated from similar diseases.

Novel MR Imaging Applications for Pleural evaluation

Computed tomography is the first-line modality for evaluation of chest diseases primarily because of its spatial resolution. Magnetic resonance (MR) imaging is used as a problem-solving tool to answer key questions that are vital to optimal patient management. MR has the potential to provide qualitative, quantitative, anatomic, and functional information without the use of ionizing radiation or nephrotoxic contrast administration. With new advances in proton MR techniques, MR imaging can overcome some of the inherent problems associated with imaging the lung. This article describes novel MR applications for evaluation of the pleura and pleural diseases.

Synovial sarcoma presenting as a lung mass and diagnosed by cytology

Synovial sarcoma is a common soft tissue sarcoma with variable fibrous and epithelial differentiation that rarely arises from other body sites, such as within the lung. A case of a 68-year-old male with an extensive smoking history who presented with chest pain and a primary, central, metabolically active lung mass was reported. The mass was biopsied by bronchial brushing, bronchoalveolar lavage (BAL), and transbronchial fine-needle aspiration (FNA). Cytologic analysis of bronchial brushing, BAL, and FNA revealed single and clusters of atypical spindle cells, oval, or spindle-shaped nuclei with smooth nuclear membranes, hyperchromatic and granular chromatin, scant to moderate and delicate cytoplasm, a high degree of mitotic figures, and a lack of necrosis. Immunohistochemical studies showed that the tumor cells were positive for CD99, BCL2, and CK7. A diagnosis of synovial sarcoma was rendered. The differential diagnosis of primary pulmonary synovial sarcoma is discussed, including neuroendocrine tumors, squamous cell carcinoma, and various sarcomatous tumors.

Primary Pleural Synovial Sarcoma Treated with Pazopanib

A 42-year-old woman presented with chest pain and breathlessness with a nodule measuring 2×2 cm in size at the base of the right lung. A bronchoscopic examination did not reveal any malignancy. However, the patient developed difficulty in breathing, enlargement of the nodule, and right pleural effusion 14 days later. A video-assisted thoracic surgical biopsy specimen revealed the presence of pleural synovial sarcoma. The patient was treated with doxorubicin-ifosfamide combination chemotherapy because of metastasis to the pelvis. However, after a transient partial clinical response, there was a relapse of refractory disease. Although treated with pazopanib as second-line chemotherapy, the patient died eight months after the initial presentation.

Primary pulmonary synovial sarcoma requiring differentiation from pulmonary metastasis of tibial adamantinoma: a case report

Background

Primary pulmonary synovial sarcoma (PPSS) is rare. We describe a case of PPSS complicated by tibial adamantinoma that required differentiation from lung metastasis.

Case presentation

A 39-year-old Japanese woman presented with hemoptysis, dyspnea, and a well-defined tumor measuring 3.0 cm in greatest diameter in the right lower lobe on chest computed tomography (CT). Positron emission tomography/CT with fluorodeoxyglucose (FDG-PET/CT) showed mild uptake of FDG (maximum standardized uptake value of 2.0). Her past history included surgery for adamantinoma of the right tibia at age 25 years. We considered the possibility of pulmonary metastasis from the adamantinoma and performed fluoroscopy-assisted thoracoscopic resection of the tumor after CT-guided Lipiodol marking. Histologically, the tumor was composed mainly of a dense proliferation of spindle cells. Immunohistochemical studies were positive for epithelial membrane antigen, B cell lymphoma 2, and transducing-like enhancer of split 1. They were negative for CD34. The synovial sarcoma, X breakpoint 1 gene-fusion transcript was detected by reverse transcription-polymerase chain reaction. It is diagnostic of PPSS. Resection margins were negative. The patient was well without evidence of recurrence or metastasis of the PPSS or adamantinoma at the 30-month and 15-year follow-ups.

Conclusion

Clinical and radiological manifestations of PPSS overlap with those of other lung tumors. The solitary pulmonary nodule in this case was indistinguishable from pulmonary metastases of the adamantinoma based on clinical symptoms, epidemiology, chest radiography, CT, and FDG-PET/CT. PPSS was diagnosed only after evaluating gross pathology, histology, immunohistochemistry, and cytogenetics. PPSS should be included in the differential diagnosis of a well-defined homogeneous round or oval lung mass. To our knowledge, this is the first report of PPSS complicated by adamantinoma.

Primary pulmonary synovial sarcoma in pregnancy

Background. Primary pulmonary synovial sarcoma is a rare malignancy with a poor prognosis. Surgical resection and postoperative management of these tumors has not been previously described in pregnancy. Case. A 38-year-old pregnant woman was admitted for evaluation of a right thoracic mass found on chest radiography at 26 weeks of gestation. A computed tomography-guided biopsy was subsequently completed and demonstrated a high-grade neoplasm. A right pneumonectomy was performed at 28 weeks of gestation due to pulmonary decompensation, and pathological examination revealed a pulmonary synovial sarcoma. The patient developed a postpartum pulmonary embolism and expired 6 weeks after delivery. Conclusion. Aggressive intervention for pulmonary malignancies during pregnancy may be necessary. Complete tumor resection is the most important prognostic factor in primary pulmonary synovial sarcoma.

Blastomatoid pulmonary carcinosarcoma: report of a case with a review of the literature

BACKGROUND

Pulmonary carcinosarcoma is a biphasic tumour with an unfavourable prognosis. The differential diagnosis includes pulmonary blastoma and is often challenging.

CASE PRESENTATION

We here describe a case of blastomatoid pulmonary carcinosarcoma in a 58-year-old patient, who underwent surgical resection. Histopathological examination revealed immature glandular epithelium resembling high-grade fetal adenocarcinoma expressing epithelial markers and membranous beta-catenin, and blastomatoid spindle cells with partial rhabdomyosarcoma-like differentiation. Both elements expressed p53, MDM2, and cyclin-dependent kinase 4 (CDK4), but not thyroid-transcription factor 1 (TTF-1). Mutation analysis of KRAS, EGFR, and beta-catenin revealed no mutations. Comparative genomic hybridization detected +1q, +6p, +6q24qter, +8q, +11q12q14, +11q23qter, +12q12q21, +12q24qter, +17q, +20q, -5q14q23, -9p13pter, -13q21q21, and amplifications at 12q14q21, 15q24qter, 20q11q12.

CONCLUSION

The observed molecular and cytogenetic findings may provide additional tools for the differential diagnosis of biphasic pulmonary neoplasms. Furthermore, TP53, MDM2, CDK4, and PTPN1 may be involved in tumourigenesis.

Synovial sarcoma: CT imaging of a rare primary malignant tumour of the thorax

PURPOSE

This paper presents computed tomography (CT) features of three patients with primary synovial sarcoma of the lung (PSSL) who came to our attention and underwent surgery; reviews of the literature on this rare thoracic tumour are also presented.

MATERIALS AND METHODS

The patients, all men, with a mean age of 58 years, underwent clinical and radiological re-evaluation after receiving a histological diagnosis. None of the patients had multifocal disease or other concomitant neoplasms. All patients had undergone both chest X-rays and computed tomography, and two had also been studied with positron emission tomography (PET)-CT. Two patients underwent surgical removal of the tumour, whereas the third initially underwent surgery (following an incorrect diagnosis) and then thoracoscopic biopsy of the pleural lesions that subsequently arose.

RESULTS

In each case, chest X-rays showed changes, with the presence of pulmonary masses noted in all patients. In one patient, pleural effusion was also visible. CT scans showed parenchymal masses that were largely of a colliquative nature (in two out of three patients). Ipsilateral pleural effusion was present in two patients, associated in one with solid nodules within the pleura. Mediastinal lymphadenopathy, which was not radiologically significant, was present in only one patient. The two patients who also underwent PET-CT examination showed pathological tracer uptake confined to the lesion site without other thoracoabdominal or musculoskeletal localisations. CT-guided biopsy, performed in one patient only, was positive for mesenchymal tumour. In the two patients who underwent surgery, a definitive diagnosis of monophasic synovial sarcoma of the lung was made. The diagnosis of monophasic synovial sarcoma in the third patient was confirmed using thoracoscopic biopsy

DISCUSSION

Both in the cases described and in those identified in the literature review, standard chest X-rays mainly showed a parenchymal mass of pleural origin with either irregular or well-defined margins. CT characteristics are more definite, with evidence of a mass with regular and sharply defined margins, occasionally polycyclic, with inhomogeneous density due to the presence of colliquative areas within the tumour.

CONCLUSIONS

Although PSSL is a rare tumour, a pulmonary mass of inhomogeneous density, associated with pleural effusion but without lymphadenopathy, detected in an asymptomatic or poorly symptomatic patient, should lead to PSSL being considered in the differential diagnosis, provided that metastases from the more common synovial sarcomas of the musculoskeletal system have been excluded.

Thymic adenocarcinoma with sarcomatoid features characterized by intracaval tumor growth: report of a case

Primary thymic adenocarcinoma is an extremely rare tumor. This report describes a case of thymic adenocarcinoma with a peculiar pathological feature and clinical course. A 54-year-old man complained of cough, dyspnea, and chest pain. Computed tomography scans revealed an anterior mediastinal mass with intracaval growth into the superior vena cava. No definitive diagnosis could be made after several examinations and palliative radiotherapy was performed. He passed away 56 days after the appearance of the initial symptoms. An autopsy revealed that the mediastinal tumor obstructed not only the superior vena cava but also the pulmonary arteries. The histological findings revealed the tumor to be an adenocarcinoma with sarcomatous features. The tumor was immunohistochemically positive for CD5 and negative for thyroid transcription factor-1. These results suggested the tumor to be a thymic adenocarcinoma with sarcomatoid features; furthermore, the tumor invaded the great vessels, thus resulting in a poor prognosis.

Synovial sarcoma of the lung presenting late with compression of mediastinal structures and its successful resection: A case report

Synovial sarcoma accounts for 5-14% of all soft tissue tumours. We present a case of 35 year-old male who presented with five months history of progressively increasing shortness of breath and cough. On evaluation, there was no air entry on the left side. CAT scan chest showed a large necrotic mass involving the entire left hemi-thorax. The tru-cut biopsy of this mass was done and it showed synovial sarcoma. The entire tumour along with the lung and the pericardium was removed completely. The patient had an uneventful recovery and was discharged home in 10 days with follow-up for adjuvant chemotherapy. Due to the rarity of this disease, no guidelines for the treatment are available. Main existing treatment includes surgery followed by either radiation, chemotherapy or both. Synovial sarcoma should be considered in the differentials of an adolescent or adult male patient presenting with a mass in the thorax.