Hidden in Plain Sight

Hidden in Plain Sight

A case report of synovial sarcoma. A soft tissue lesion with typical diagnostic features: misdiagnosed + mistreated.

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Kenrick Turner

March 24, 2012
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    lipoma benign arcoma lump calcified periosteal chondroma enign pain calcified

    lesion cancer periosteal chondroma lipoma benign synovial sarcoma lump calcified lesion cancer periosteal chondroma lipoma synovi lump periosteal chond lipoma benign synovial sarcoma lump pain calcified lesion cancer periosteal chondroma lipoma benign synovial sarcoma lump pain calcified lesion cancer periosteal chondroma lipoma benign synovial sarcoma lump pain calcified lesion cancer periosteal chondroma a benign pain calcified lesion cancer periosteal chondroma lipoma benign synovial sarcoma lump pain calcified lesion cancer periosteal chondroma HIDDEN IN PLAIN SIGHT A soft tissue lesion with typical diagnostic features: misdiagnosed + mistreated
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    2008 2009 2010 SD GP painful lump on the postero-medial

    Right Knee ˂ 52 ºPMH doctor, my knee hurts!
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    2008 2009 2010 SD GP XR painful lump on the

    postero-medial Right Knee ˂ 52 ºPMH XR Right Knee: There is a 2.3cm calcific density in the soft tissues over the posterior aspect of the distal femur. The appearance is most probably due to post traumatic calcification but there is the outside possibility of more sinister pathology. Suggest CT & MRI.
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR Old Haem atoma Painful Lump CT Right Knee: 20x16mm soft tissue mass p o s t e r i o r t o m e d i a l femoral condyle. This could represent a partially calcified old haematoma.
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump MRI Right Knee: This MRI confirms a soft tissue mass of 23x18x23mm. It is closely related to periosteum. No bony invasion. I cannot exclude a low grade tumour, possibly a synovial sarcoma. Suggest surgical excision.
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy Lipoma + Discharged Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump Histology Report: Macro: Fatty tissue 5.5cm Micro: Mature adipose tissue most in keeping with origin from a benign lipoma.
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy Lipoma + Discharged Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump
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    GP 2008 2009 2010 SD GP Working diagnosis painful lump

    on the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy Lipoma + Discharged Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump doctor, my knee STILL hurts!
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    GP 2008 2009 2010 SD GP Working diagnosis painful lump

    on the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy MRI Lipoma + Discharged Periosteal Chondroma Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump MRI Right Knee: There is a 27x27x22mm lesion with broad contact onto the posteromedial cortex of the distal femoral metaphysis No evidence of cortical invasion. It appears that this lesion was not excised at the time of surgery with only superficial fatty tissue excised. This lesion most likely represents a periosteal chondroma.
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy MRI Biopsy ∆ Lipoma + Discharged Periosteal Chondroma Synovial Sarcoma ?! Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump GP Histology Report: The morphological and immunophenotypic features as synovial sarcoma with clinically no local extension or metastatic lesions
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    2008 2009 2010 SD GP Working diagnosis painful lump on

    the postero-medial Right Knee ˂ 52 ºPMH CT XR MRI Excision Biopsy MRI Biopsy ∆ Lipoma + Discharged Periosteal Chondroma Synovial Sarcoma ?! Old Haem atoma Soft tissue mass ?Synovial Sarcoma Painful Lump GP
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    Discussion: Synovial Sarcoma •Rare! 5-10% of soft tissue sarcomas •Predilection

    for young people •Affects Extremities 90% in limbs, lower >> upper •‘Synovial’ is a misnomer Morphology is similar to synovium but originate elsewhere •Treatment = Surgery + RT ± Chemo •Diagnostic features for soft tissue malignancy: Rapid growth, constant pain, deep to fascia, size >5cm PPV 86% if all 4 present
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    Learning Points 1. Needle biopsy ≠ representative Even open biopsy

    can be challenging, as in this case. 2. Frequently misdiagnosed Insidious onset, variable radiographic presentation, joint pain. 3. Serendipitous subtype This was a less aggressive subtype; which is uncommon. We got lucky. 4. Doubts over diagnosis? Refer early to the National Orthopaedic Centre