Synovial sarcoma of the neck

Primary pharyngeal synovial sarcoma in a pediatric patient: A case report

RATIONALE

Synovial sarcoma is a rare malignant tumor that typically originates from the soft tissue of the extremities. The occurrence of primary pharyngeal synovial sarcoma is even rarer, and few studies have reported its radiological features. Here, we report a case of pediatric primary pharyngeal synovial sarcoma and describe the conventional and advanced magnetic resonance imaging (MRI) findings with pathologic correlation.

PATIENT CONCERNS

An 11-year-old girl presented to the otolaryngologic clinic with dysphagia.

DIAGNOSIS

Laryngoscopy revealed a large mass in the oropharynx. MRI revealed a well-defined soft tissue mass with a maximal diameter of approximately 5 cm originating from the submucosal space of the oropharynx. The mass was primarily solid and showed homogeneous contrast-enhancement. The mass was hypointense on T1-weighted images and hyperintense on T2-weighted images. The mass showed a homogeneously low apparent diffusion coefficient value on diffusion-weighted imaging, which indicated high tumor cellularity. Dynamic contrast-enhanced MRI revealed a hypovascular tumor with low values of the volume transfer constant between the extracellular extravascular space and blood plasma and blood plasma volume per unit tissue volume. Amide proton transfer-weighted MRI revealed a relatively high amide proton transfer signal in the tumor, indicating a high protein/peptide component. The patient underwent partial surgical resection of the tumor, and the diagnosis of biphasic synovial sarcoma was confirmed on postoperative pathological examination.

INTERVENTION

The patient was started on chemotherapy with vincristine, ifosfamide, doxorubicin, and etoposide.

OUTCOMES

The tumor did not respond to the 3 cycles of the chemotherapy. Thus, the patient underwent second surgery and subsequent radiation therapy. The patient is now under ifosfamide/carboplatin/etoposide chemotherapy.

LESSON

Synovial sarcoma should be considered in the differential diagnosis of pediatric oropharyngeal submucosal tumors. Multimodal MRI may aid diagnosis, although the final diagnosis should be based on the postoperative pathological examination findings.

Synovial sarcoma of the head & neck: A review of reported cases in the literature

Synovial sarcoma is a high-grade malignancy that seldom manifests in the head and neck. The purpose of this paper is to provide a comprehensive review of the existing literature on primary HNSS. This review study includes case reports, case series and retrospective cohort studies on primary HNSS published in the English language. All cases identified via PubMed were analyzed individually. Articles were included according to specified eligibility criteria. The total number of cases analyzed was 243 (91 case reports, 53 cases from 16 case series, and 99 cases from 8 retrospective cohort studies). The average age at the time of HNSS diagnosis was 33.5 years. The ratio of male-to-female was 1.64:1. The most frequently occurring histologic subtype was biphasic (59.2%). The most common location was the neck. Hoarseness was the most common presenting symptom. Almost all patients (98.3%) underwent surgical excision. 55.6% of patients received adjuvant radiotherapy. A smaller number of patients (30.7%) received adjuvant chemotherapy. 60.3% of patients were alive with no evidence of disease at follow-up while 28.0% of patients died of HNSS at follow-up. The average follow-up period was 52.0 months. Synovial sarcoma is a rare head and neck malignancy. Surgical excision with adjuvant radiation is the most frequently employed treatment modality. Regardless of treatment modality, the prognosis of the tumor is guarded.

Postoperative Radiotherapy for Synovial Sarcoma of the Head and Neck during Pregnancy: Clinical and Technical Management and Fetal Dose Estimates

Aims and background

In vivo and phantom dosimetry is reported to estimate the fetal dose and evaluate the effectiveness of a special shielding device to reduce fetal exposure in a woman undergoing postoperative radiation therapy for synovial oral cavity sarcoma at the 30th week of pregnancy.

Methods

In vivo measurements were performed by placing thermoluminescent dosimeters on 3 points for fetal dose estimation: uterine fundus, umbilicus and pubis. A Rando anthropomorphic phantom was used to simulate radiotherapy. We also performed off-axis dose measurements for wedged beams to estimate the dose contribution of this accessory used in the treatment.

Results

The special shielding device reduced the fetal dose by 70% on average, despite the presence of wedges, which increased the dose by a factor of about 2.5. Before delivery the patient received 48 Gy, and from the in vivo measurements a fetal dose of 8.5, 1.7 and 0.7 cGy was estimated to the uterine fundus, umbilicus and pubis, respectively.

Conclusions

Pre-treatment simulation in the same irradiation conditions is the only reliable approach to predict the fetal dose. By using a special shielding device, radiotherapy can be optimized while keeping the fetal exposure below the risk of deterministic damage.

Treatment outcomes for patients with synovial sarcoma of the head and neck

Evaluation of: Harb WJ, Luna MA, Patel SR, Ballo MT, Roberts DB, Sturgis EM. Survival in patients with synovial sarcoma of the head and neck: association with tumor location, size, and extension. Head Neck 29, 731-740 (2007). Synovial sarcoma of the head and neck occurs most commonly in males in their third decade of life. Synovial sarcoma of the head is rare, accounting for less than 10% of all head and neck sarcomas. Due to its rarity, there are very few publications on the treatment approach for these tumors. However, it is uniformly accepted that all head and neck synovial sarcomas should undergo complete surgical resection followed by postoperative radiation therapy in those at high risk for locoregional recurrence. In terms of chemotherapy, there are also emerging data on its effectiveness in the treatment of synovial sarcoma of the head and neck. The paper under evaluation reports a single institution's 36-year experience on the treatment of synovial sarcoma of the head and neck. This paper highlights the importance of a multidisciplinary approach in the treatment of this disease.

Primary synovial sarcoma arising in the parotid region diagnosed by fluorescence in situ hybridization

Synovial sarcomas account for 5% of pediatric soft tissue sarcomas, and primarily arise in the extremities. We report a case of synovial sarcoma in the parotid region. A 29-year-old woman presented with a 3-year history of a slow-growing, slight painful swelling in the preauricular region. The patient underwent right deep parotidectomy preserved with facial nerve. In immunohistochemistry, the epithelial cells were positive for cytokeratin AE1/3 and epithelial membrane antigen. The stromal cells were immunoreactive for vimentin and BCL2. The both types of cells were positive for CD99. The SYT-SSX fusion gene from chromosomal translocation was detected by fluorescence in situ hybridization in this case.

Synovial sarcoma of the infratemporal fossa

OBJECTIVES

A case is reported in which synovial sarcoma (SS) is arising within the infratemporal fossa.

DESIGN AND SETTING

Case report and literature review from an academic tertiary referral practice.

RESULTS

A 46-year-old white woman presented with a 1-month history of having paresthesias on the left side of her head. There was a sensory deficit at the level of the third division dermatome (V3) of the fifth left cranial nerve. Computed tomography (CT) and magnetic resonance imaging revealed a mass centered in the left infratemporal fossa. Fine needle aspiration (FNA) revealed a spindle cell neoplasm. An endoscopic, transantral biopsy of the mass revealed SS. The SS in the infratemporal fossa was surgically removed en bloc. The patient had postoperative chemoradiotherapy and is free of disease at 1 year from completion of treatment.

CONCLUSIONS

This is the first reported case from the United States of America of SS located in the infratemporal fossa and the third case to be reported in the English language literature.

Cervical nerve root synovial sarcoma in a child with chromosomal (X;18) translocation. Case report and review of the literature

We report on an 11-year-old female with a history of cervicobrachialgia and progressive weakness of the right arm. Cervical spine MRI showed an enhancing heterogeneous intradural mass occupying the right C6-C7 foramen. She underwent a right C6-C7 foraminotomy with a complete macroscopic removal of the lesion. Pathological examination revealed a synovial sarcoma. Treatment was completed by chemotherapy and proton radiotherapy, and the girl remained free of symptoms for 3 years. After appearance of new symptoms, a local recurrence was confirmed, and despite aggressive treatment with salvage chemotherapy and radiotherapy, the disease progressed beyond medical control, and the child died, 6 years after diagnosis. Early recognition of this rare entity compared to its more benign differential diagnosis is crucial, as an aggressive management is needed.

Survival in patients with synovial sarcoma of the head and neck: Association with tumor location, size, and extension

BACKGROUND

The medical literature on synovial sarcoma (SS) of the head and neck region is limited. Thus, we determined whether clinical characteristics and treatment were associated with recurrence and survival rates in patients with SS of the head and neck.

METHODS

We retrospectively identified patients with a pathologic diagnosis of SS of the head and neck at our institution (a large tertiary comprehensive cancer center) and compared recurrence and survival rates by clinical characteristics and treatment.

RESULTS

Forty patients with SS of the head and neck were identified from 1945 to 2004 (first case in 1968), representing <5% of all head and neck sarcomas seen at our institution during this time period. Twenty-three patients (58%) had the monophasic histologic subtype, 15 (38%) biphasic, and 2 unspecified. Most patients were male (73%), with a median age of 29 years. SS tumors were most commonly located in the neck (60%); thus, the most common symptoms were a neck mass and neck pain. No patients reported a history of radiation exposure. Higher disease-specific and overall survival rates were associated with upper aerodigestive tract location, tumors of < or =5 cm, and tumors did not extend into bone. Patients treated with surgery and adjuvant radiotherapy had higher survival and lower recurrence rates than did those treated with surgery alone or a combination of surgery, radiotherapy, and chemotherapy. This difference was not significant, and the subgroups were small, with substantial confounding by adverse prognostic factors.

CONCLUSIONS

SS of the head and neck is extremely rare, and our results should be viewed with caution given the relatively small group size and treatment over a 36-year period. Survival rates were associated with tumor location, size, and extension. Treatment of SS of the head and neck should be directed toward complete surgical resection. Given the known sensitivity of SS to contemporary chemotherapy, a multimodality approach should be considered in the perioperative setting, especially in high risk patients.

Sarcomas of the head and neck region

PURPOSE OF REVIEW

This review discusses the classification, etiology, diagnosis, evaluation, treatment, and prognosis of sarcoma of the head and neck region.

RECENT FINDINGS

Sarcomas account for less than 1% of all malignancies in the United States with only 5 to 15% of these sarcomas occurring in the head and neck region. However, about 1 in 3 pediatric sarcomas will occur in the head and neck region. Occasionally, these tumors are associated with genetic syndromes or previous radiation exposures, but, most commonly, no clear etiology exists. Pathologic classification is critical to the ultimate treatment and prognosis of sarcoma of the head and neck. Osteosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, and angiosarcoma are the most common types of sarcoma to occur in the head and neck region; however, up to 20% of head and neck sarcomas will remain unclassified. Surgery has been central to the management of these malignancies with some exceptions in the pediatric population. Adjuvant chemotherapy is being utilized and/or studied for most high-grade sarcomas and adjuvant radiotherapy is important for disease control in high-grade soft-tissue sarcomas. Prognosis is clearly related to tumor grade and margin status.

SUMMARY

Sarcomas of the head and neck region are rare malignancies often without a clear etiology. Expert pathologic review and classification is critical, as are quality imaging and multidisciplinary management.

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.

Synovial cell sarcoma: diagnosis, treatment, and outcomes

OBJECTIVES/HYPOTHESIS

Synovial cell sarcoma is a mesenchymal tumor predominantly of the lower extremities. Three percent of cases arise in the head and neck region. It is thought that head and neck synovial sarcoma has a better prognosis than tumors of the extremities. Our experience has demonstrated aggressive behavior of this neoplasm in the head and neck. This compelled us to compare our experience with other studies.

STUDY DESIGN

Retrospective chart review.

METHODS

We obtained the records of patients diagnosed with head and neck synovial sarcoma from the Tumor Registry of the University of Louisville School of Medicine (Louisville, KY) and affiliated hospitals for data compiled between January 1990 and December 2000. Data on patient demographics, clinical findings and symptoms, histological findings, treatment, extent of disease, recurrence, and survival were recorded. The literature was reviewed identifying reports of synovial cell sarcoma.

RESULTS

Five consecutive patients with synovial cell sarcoma were assessed at our facility. The median patient age was 28.2 years. All of the patients underwent an aggressive primary surgical excision followed by irradiation. All patients received chemotherapy after recurrence. Four of the five patients had local recurrence, and all five of the patients developed distant metastases. Three of the patients have died, and two are alive with evidence of disease. Novel sites are reported including the ethmoid sinus and the parotid gland. This group demonstrated a 40% 5-year overall survival, which was lower than the 60% 5-year survival reported in the literature for all sites.

CONCLUSIONS

Synovial cell sarcoma of the head and neck is a disease of young people and carries a poor prognosis. The aggressive nature of the disease may require modification of accepted treatment modalities and sequence.

Monophasic synovial sarcoma of the neck in an 8-year-old girl resembling a thyroglossal duct cyst

Synovial sarcomas of the head and neck are rare. Typically, they are localized laterally in the parapharyngeal space. We report the case of an 8-year-old girl with a monophasic round cell synovial sarcoma of the anterior neck, clinically resembling a thyroglossal duct cyst. Histologic, immunohistochemic and cytogenetic findings are presented with a brief review of the literature. This case reaffirms the importance of considering malignant neoplasms in the differential diagnosis of pediatric neck masses.

Synovial Sarcoma of the Pharynx: A Case Report

Synovial sarcoma is a malignancy not usually encountered in the head and neck region. We describe a case of synovial sarcoma of the posterior pharyngeal wall in a 14-year-old girl. The mass was completely excised via the transoral route. Postoperatively, the patient received irradiation to 60 Gy. At 40 months of follow-up, the patient remains disease-free.

Small-cell variant of synovial sarcoma: fine-needle aspiration with ancillary features and potential diagnostic pitfalls

We report a small-cell variant of synovial sarcoma examined by fine-needle aspiration (FNA) biopsy. The patient is a 23-yr-old female who had a synovial sarcoma involving the left infratemporal region, diagnosed at 7 yr of age, followed by a metastatic lesion involving the lung and chest wall 16 yr later. The chest wall metastases was sampled by FNA biopsy. The aspirate consisted of numerous, small, round cells with very high nuclear-to-cytoplasmic ratios. The cytomorphologic features could potentially be confused with other pediatric small round cell tumors. Ancillary studies demonstrated positive staining of the neoplastic cells for cytokeratin, epithelial membrane antigen (EMA), and CD99. The differential diagnosis of other small round cell tumors that may be mistaken for the small-cell variant of synovial sarcoma are presented. We believe that this is the first FNA report detailing the cytologic and ancillary features of the small-cell variant of synovial sarcoma.

Synovial sarcoma of the larynx and hypopharynx

Synovial sarcoma represents a mesenchymal malignancy of unknown histogenesis that most often occurs in the lower limbs of young adults. The head and neck region is a relatively rare location, in which the hypopharynx and larynx are, respectively, the most and least often affected anatomic sites. Histologically, synovial sarcomas are classified into monophasic and biphasic variants. Immunohistochemistry plays a major part in the differential diagnosis, enabling the demonstration of epithelial differentiation. Both monophasic and biphasic synovial sarcomas are characterized cytogenetically by the reciprocal translocation t(X;18)(p11.2;q11.2) between chromosomes X and 18. Two cases of synovial sarcoma arising in the larynx and in the hypopharynx and in which cytogenetic analysis detected a diagnostic t(X;18) chromosome aberration are reported here.

Regional and distant metastases in laryngeal and hypopharyngeal sarcomas

Cervical node and distant metastases are the most important prognostic factors in malignant laryngeal neoplasms. Owing to the unusual occurrence of laryngeal sarcomas, the prevalence of their metastases has never been analyzed in detail. We reviewed the laryngeal sarcomas reported in the literature and noticed that both regional and distant metastases are rare events and variable for different histotypes. These observations have obvious therapeutic and prognostic implications.