eMedicine Specialties > Orthopedic Surgery > Neoplasms

Synovial Cell Sarcoma: Workup

Author: Bernardo Vargas, MD, Consulting Staff, Department of Orthopedic Surgery, Hôpital Universitaire de Geneva, Switzerland
Coauthor(s): Mark Clayer, MD, MBBS, FRACS, FAOrthA, Head of Musculoskeletal Tumor Service, Department of Orthopaedics and Trauma, Queen Elizabeth Hospital; Senior Visiting Medical Specialist, Royal Adelaide Hospital and Women's and Children's Hospital, Australia
Contributor Information and Disclosures

Updated: Aug 7, 2008

Workup

Laboratory Studies

  • Other than molecular diagnostic tests (see below), no laboratory studies are specific for this diagnosis.

Imaging Studies

  • Plain radiographs may aid in the diagnosis, as synovial sarcoma typically produces a spotty calcification (snowstorm) within the matrix of the soft tissue tumor that may be visualized on plain radiographs (see Image 1).
  • CT scanning is used to confirm the presence of a mass, its size, and its location, but it is nondiagnostic. CT scan also may detect secondary bony involvement, which is not uncommon with larger synovial sarcomas. Synovial sarcoma is a malignant disease; therefore, CT scanning of the chest is mandatory to exclude metastatic disease.
  • MRI is the investigation of choice for soft tissue sarcomas. Low signal intensity is observed on T1-weighted images (see Image 2), and high signal intensity is observed on T2-weighted images (see Image 3). The signal from the matrix is fairly homogeneous unless calcification is present.

Other Tests

  • Cytogenetic analysis aids the physician in detecting the specific chromosomal translocation t(X;18)(p11;q11).13
  • The chromosomal translocation produces either the SYT/SSX1 or SYT/SSX2 fusion gene, which can be identified by reverse transcriptase-polymerase chain reaction (RT-PCR) in tumor tissue and possibly in blood.9,10,14

Diagnostic Procedures

The histologic picture can be confused with many other round blue cell tumors. Cytogenetic analysis aids the physician in detecting the specific chromosomal translocation between chromosome 18 and chromosome X.13 This translocation produces either the SYT/SSX1 SYT/SSX2, or SYT/SSX4 fusion gene. Identification of this anomaly is obtained by reverse transcriptase-polymerase chain reaction (RT-PCR) in tumor tissue, with a sensitivity of 96% and specificity of 100%. Detection of fusion transcripts is possible by molecular diagnostic techniques in biopsy samples. Fluorescence in situ hybridization (FISH test) is less expensive than RT-PCR.  It has been suggested as a good method of first choice.14 This method has a lower sensitivity than RT-PCR, but they are concordant in 76% of cases.

Histologic Findings

Macroscopically, the tumor is a grayish-white and often has a greasy feel. Histologic features of synovial sarcoma are identical in children and adults.

Three types have been described:

  • In monophasic type there is a predominance of spindle cells, mixed with round cells. Cells are arranged in fascicles with a poorly defined cytoplasm. The monophasic variant does not have glandular areas.
  • The biphasic type has a layer of columnar epithelium in addition to spindle cells. It consists of plump, round cells and spindle-shaped fibroblasts alternating with glandular-like areas that are lined by synovial-like cells and contain mucin.
  • A third type, called poorly differentiated, has numerous mitosis, high cellularity, and tumor necrosis.
The histologic grade is determined by a score of the mitotic activity and tumor necrosis, ranging from grade 1 (differentiated) to grade 3 (poorly differentiated). Synovial sarcoma is very often associated with a grade 2 or grade 3.6,8,9,15 Punctuate areas of calcification may be observed.

Staging

Staging requires local imaging with MRI. The most likely site of distant spread (the lungs) can be observed with CT scanning. Synovial sarcoma is a high-grade lesion.

More on Synovial Cell Sarcoma

Overview: Synovial Cell Sarcoma
Workup: Synovial Cell Sarcoma
Treatment: Synovial Cell Sarcoma
Follow-up: Synovial Cell Sarcoma
Multimedia: Synovial Cell Sarcoma
References
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References

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  2. Spira AI, Ettinger DS. The use of chemotherapy in soft-tissue sarcomas. Oncologist. 2002;7:348 –359. [Medline].

  3. Siehl J., Thiel E. Schmittel A. et al. Ifosfamide/Liposomal Daunorubicin Is a Well Tolerated and Active First-Line Chemotherapy Regimen in Advanced Soft Tissue Sarcoma Cancer. 2005;104 .3:611-617. [Medline].

  4. Zagard G. Ballo M., Pisters P.et al. Prognostic factors for patients with localized soft tissue sarcoma treated with conservation surgery and radiation therapy. Cancer. 2003;97. 10:2530-2543. [Medline].

  5. Ladanyi M, Antonescu CR, Leung DH, and als. Impact of SYT-SSX fusion type on the clinical behavior of synovial sarcoma: a multi-institutional retrospective study of 243 patients. Cancer Res. 2002;62(1):135-40. [Medline].

  6. Deshmukh R., Mankin, H. J. Singer S. Synovial Sarcoma: The Importance of Size and Location for Survival Clin Orthop 2004 : 419, 155-161. [Medline].

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  8. Antonescu CR, Kawai A, Leung DH, Lonardo F, Woodruff JM, Healey JH, et al. Strong association of SYT-SSX fusion type and morphologic epithelial differentiation in synovial sarcoma. Diagn Mol Pathol. 2000;9(1):1-8. [Medline].

  9. Guillou L, Coindre JM, Gallagher G, et al:. Detection of the synovial sarcoma translocation t(X;18) (SYT-SSX) in paraffin-embedded tissues using reverse transcriptase-polymerase chain reaction: A reliable and powerful diagnostic tool for pathologists—A molecular analysis of 221 mesenchymal tumors fixed in different fixatives. Hum Pathol. 2001;32:105-112. [Medline].

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  11. Kawaguchi S, Wada T, Ida K, et al.:. Phase I vaccination trial of SYT-SSX junction peptide in patients with disseminated synovialsarcoma. J Transl Med. 2005;3:1. [Medline].

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  13. Bridge JA. Cytogenetic and molecular cytogenetic techniques in orthopaedic surgery. J Bone Joint Surg Am. Apr 1993;75(4):606-14. [Medline].

  14. Ten Heuvel SE, Hoekstra HJ, Suurmeijer AJ. Diagnostic Accuracy of FISH and RT-PCR in 50 Routinely Processed Synovial Sarcomas. Appl Immunohistochem Mol Morphol. Feb 8; [Epub ahead of print] 2008;[Medline].

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  16. Fukukawa C., Hanaoka H., Nagayama S. and als. Radioimmunotherapy of human synovial sarcoma using a monoclonal antibody against FZD10. Cancer Sci. 2008;99, 2 :432–440. [Medline].

  17. Sakabe T, Murata H, Konishi E, Takeshita H, Ueda H, Matsui T, et al. Evaluation of clinical outcomes and prognostic factors for synovial sarcoma arising from the extremities. Med Sci Monit. Jun 2008;14(6):CR305-310. [Medline].

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  21. Moreno Martín-Retortillo L, Andrés Moreno MM, Cañete Nieto A, Castel Sánchez V. Synovial sarcoma in children. A single centre experience. Clin Transl Oncol. Jul 2007;9(7):468-70. [Medline].

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Further Reading

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Keywords

synovial cell sarcoma, synovial sarcoma, synovial cell, connective tissue tumor, connective tissue neoplasm, synovioma, malignant neoplasm, malignant tumor, joint tumors

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Contributor Information and Disclosures

Author

Bernardo Vargas, MD, Consulting Staff, Department of Orthopedic Surgery, Hôpital Universitaire de Geneva, Switzerland
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Clayer, MD, MBBS, FRACS, FAOrthA, Head of Musculoskeletal Tumor Service, Department of Orthopaedics and Trauma, Queen Elizabeth Hospital; Senior Visiting Medical Specialist, Royal Adelaide Hospital and Women's and Children's Hospital, Australia
Mark Clayer, MD, MBBS, FRACS, FAOrthA is a member of the following medical societies: Australian Medical Association and Australian Orthopaedic Association
Disclosure: Orthopedics hyperguide Honoraria Independent contractor; Stryker Grant/research funds Employment

Medical Editor

Howard A Chansky, MD, Associate Professor, Department of Orthopedics and Sports Medicine, University of Washington Medical Center
Howard A Chansky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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