An unusual occurrence of synovial sarcoma in forearm: a case report
Karthikeyan Selvaraj1, Bharathiraja Kuppusami1, Manimaran Ramachandran1, Rajiv Kannan1,&, Ravishankar Kalambur Sundaram1
1Department of General Surgery, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
Rajiv Kannan, Department of General Surgery, Sree Balaji Medical College and Hospital, Chennai Tamil Nadu, India
Soft tissue sarcomas are group of malignant tumours arising from extra
skeletal mesenchymal tissue. Presenting a patient with swelling over
the posterior aspect of left arm for 6 months, gradually increasing
in size for four months
and rapidly increasing in size for last 2 months and not associated
with pain. Peripheral pulses felt. Ultrasound showed large solid cystic
intramuscular lesion arising from triceps muscle and Trucut biopsy
malignancy. Magnetic resonance imaging (MRI) left arm impression was
large lobulated solid cystic space occupying lesion in triceps muscle,
possibility of neoplastic
the patient underwent wide local excision and reconstruction procedure
followed by Radiotherapy, chemotherapy and regular follow up.
Soft tissue sarcomas are group of malignant tumours arising from extra skeletal mesenchymal tissues. Most of soft tissue sarcomas are located in lower extremities and next to it 25% . Located in upper extremities and torso followed by hand and neck region. Compared to the lower extremity, where liposarcoma and myxoid sarcoma are commonly encountered; synovial sarcoma, epithelioid sarcoma, and fibro-sarcoma are relatively more common in the upper extremity [2,3]. There is slight male predominance. Gold standard treatment of soft tissue sarcoma is surgical resection with adequate margin clearance.
Patient and observation
A 28-year-old male patient came with complaints of swelling over
the posterior aspect of left arm for 6 months. The swelling was
in size insidious in onset, gradual increasing in size for four
months and rapidly increasing in size for last 2 months and not
associated with pain.
No history of trauma, loss of weight and any other specific complaints.
Nil significant family history, No similar complaints in family
members, No history of any other swellings in the body. No co morbidities
patient, No similar complaints in past.
physical examination revealed (Figure 1) a single swelling of size 15×10 cm present over the posterior aspect of Left arm, 20cm inferior to the Left acromion process and 15cm inferior to the Left olecranon process smooth in surface, hard in consistency and swelling- mobility restricted on triceps muscle contraction. No pulsation felt over the swelling. Left axillary, left brachial and left radial pulses felt. No regional lymph nodes.
all routine investigations were done and it was within normal limits. Ultrasound showed large solid cystic intramuscular lesion in the posterior aspect of left arm, possibly arising from triceps muscle and Trucut biopsy showed poorly differentiated malignancy. MRI left arm impression was large lobulated solid cystic space occupying lesion of size 9.5cm×5.6cm ×5.4cm intramuscularly in the triceps muscle-possibility of neoplastic lesion (Figure 2).
synovial sarcoma - high grade - stage 3 with unfavorable prognosis.
after obtaining cardiology and anaethetic fitness patient was preceded for wide
local excision of triceps muscle with left lattismus dorsi flap reconstruction
with split skin grafting of the raw area of the back (Figure
3). Intra-operative specimen was too sent for histopathological examination
and immune-histochemistry. Postoperative period was uneventful. Patient was given
adequate analgesics, antibiotics and all supportive measures. Graft was healthy
Follow up and outcome of interventions:
physiotherapy was given simultaneously. Patient was able to move his limb in
all directions. Histopathology report showed high grade sarcoma, histomorphology
favoring embryonal rhabdomyosarcoma and immunhistochemistry showed vimentin and
Tle -1 positive which concluded with synovial cell sarcoma (Figure
5). Patient was further started with radiotherapy and chemotherapy.
I have been throughout examined by my doctor and have been updated about my condition and the surgery to be done and the outcomes briefly in my native language and reassured.
yes, patient was informed about his condition and the surgical procedure performed on him and the outcome of the procedure in his native language. It has been also discussed with his family members and they also consented to the procedure.
The most well-known site of soft tissue sarcoma is at the lower furthest
point (60%), followed by the furthest point (23%) (with inclination
for the shoulder), and the head and neck (9%). Further, it will in general
near the huge joints of the limits, particularly the knee and lower
the gold standard treatments of sarcomas are complete surgical resection. The
primary goal of the procedure is enbloc resection of tumour through normal tissue
planes and should include the previous incision biopsy scar. As the synovial
sarcoma usually encases the neurovascular bundles, injury to these structures
can be prevented by adequate exposure and meticulous dissection. For recurrent
tumours, surgery is the gold standard option. As majority of patients undergo
limb sparing surgery and amputation is still considered as a final resort, amputation
rate is still elevated . For patients with recurrence,
new adjuvant systemic therapy is the treatment of choice .
Careful patient selection is necessary for the treatment of metastatic synovial
sarcoma, based on their response . Synovial sarcomas are
a high grade tumour, which responds to adjuvant radiation therapy in the form
of external beam radiation, brachytherapy and intensity modulated radiotherapy.
For metastatic disease, chemotherapeutic agent Ifosfamide is the treatment of
choice. Various modalities of treatment have been implemented to improve the
survival of patients with high risk tumours . Another
modality of treatment that seems to provide promising results is epidermal growth
Synovial sarcomas are the most common malignant tumours usually less
than 5cm in size. They usually present early and distant metastasis
is rare. Diagnosis made depending on the lesion which is calcified not
near the joint in a young individual. Cross-sectional imaging studies
helps in careful dissection. The small size of tumour and its slow
growing nature attributes to misdiagnosis. Since synovial sarcomas are
tumours, adequate margin clearance is essential to prevent recurrences.
The authors declare no competing interest.
All authors read and approved the final version of the manuscript.
Figure 1: pre-operative image
Figure 2: MRI left arm showing large lobulated solid cystic space
Figure 3: intra-operative
picture showing median nerve
Figure 4: post-operative image
Figure 5: histological section showing embryonal rhabdomyosarcoma
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