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The roentgen features of synovial sarcomas
Clin. RadioL (1973) 24, 481-484
TIlE R O E N T G E N
FEATURES
OF S Y N O V I A L
SARCOMAS
A L F R E D L. HOROWITZ, D O N A L D R E S N I C K and ROBIN CAIRD WATSON
From the Department of Diagnostic Radiology, Memorial Hospital for Cancer and Allied Diseases, 424 East 68th Street, New York, N. ¥. 10021, America
The radiographic manifestations o f synovial sarcomas are described. The roentgen features can conveniently be divided into three categories: (a) soft tissue mass, (b) soft tissue calcifications, and (c) bony erosion. 67 per cent of cases had a soft tissue mass, and in 20 ~o calcification was seen. Osseous involvement was apparent in 20 ~o- The occurrence of a soft tissue mass with associated calcifications and bony erosion, with a predilection for the lower extremity, is quite characteristic and allows the radiologist to arrive at a correct pre-operative diagnosis.
SYNOVIAL sarcomas are uncommon malignant tumours of the soft tissue and have received little attention in the radiological literature. Despite this relative infrequence, the tumours possess certain characteristic radiographic features which allow their recognition. With this in mind, we reviewed all the synovial sarcomas seen at Memorial Hospital from 1966 to 1970.
Cadmon et aL, 1965; Thompson et al., t971). The average age of the patients in our series is 34 years which agrees well with the reports in the literature. In our group, 13 of the 15 cases arose in the lower
CLINICAL MATERIAL AND RESULTS Of the 45 proven cases of synovial sarcomas, 15 patients had radiographs available for review (Table 1). The roentgenographic findings can be classified under three headings: (1) Soft tissue mass, (2) Soft tissue calcification, and (3) Bony erosion. In group (1), there were 10 cases (67 ~ ) ; in group (2) there were 3 cases (20 ~ ) ; and in group (3) there were 3 cases (20 ~). One case showed bony erosion and calcification and was included in both groups. Clinically the patients presented with soft tissue masses with a variable degree of associated pain. The ages ranged from 9 to 64 years with a mean age of 34 years. The anatomical distribution of the lesions is indicated in Table 2. DISCUSSION Synovial sarcomas are uncommon malignant tumours. Thompson et al. (1971) reviewed 112 cases o f soft tissue neoplasms, and found only 4 cases of synovial origin. They need not arise within a joint capsule but may appear along a tendon sheath anywhere in an extremity. Published series show a distinct predilection for lower extremity involvement (Pack and Arial, 1950; Tillotson et al. 1951;
FIG. I A soft tissue mass is seen along the medial aspect o f the distal femur. There are small flecks o f calcification within the mass but no evidence o f bony involvement.
481
482
CLINICAL RADIOLOGY limbs a n d this incidence o f 86 % compares favoura b l y with previous reports. The m o s t c o m m o n sites o f origin include the thigh, foot a n d knee (Tillotson et al. 1951 ; C a d m o n et al. 1965). I n o u r series, 4 0 % o f the cases arose in the thigh a n d hip region a n d 27 % arose in the feet. The m o s t c o m m o n r a d i o g r a p h i c features o f the t u m o u r m a y be divided into three categories: (a) soft tissues mass, (b) soft tissue calcification a n d (c) b o n y erosion. (a) S o f t Tissue M a s s . - - I n o u r series, 67 % o f the turnouts presented solely with a soft tissue mass. Characteristically, these masses are fairly well defined a n d m a y a p p e a r lobulated. (Fig. 1). This a p p e a r a n c e o f a soft tissue mass with or w i t h o u t calcification or associated b o n y erosion is the m o s t c o m m o n m e t h o d o f presentation.
FIG. 2 Discrete calcification is' seen adjacent to the lateral aspect of the femur without an associated soft tissue mass.
(b) S o f t Tissue Caleifieation.--Calcification was seen in three turnouts (20 %). The calcified areas are generally discrete (Fig. 2) a n d m a y or m a y n o t be associated with a soft tissue mass. One o f our cases presented with soft tissue calcification a n d b o n y destruction b u t h a d n o definite mass. I n a previous series o f 134 cases o f synovial sarcomas, 32 % o f the 57 cases w i t h available x-rays showed calcification ( C a d m o n , 1965). (c) B o n y E r o s i o n . - - T h e a p p e a r a n c e o f a b n o r m a l b o n e in the vicinity o f a synovial s a r c o m a is n o t
TABLE2 Case No.
,Sex
Age
Site
X-ray findings
9 10 11 12
F M M F M F M M M F M F
54 51 33 18 9 64 5l 15 26 43 17 25
L hip L foot L elbow L hip R foot R thigh L calf L knee R thigh L hand L foot L foot
13 14 15
F M M
32 32 43
R hip L thigh L knee
Mass (soft tissue) Mass Mass Mass Mass Mass Mass Calcification Calcification Metacarpal erosions Calcaneous and cuboid erosions Metatarsal erosion and calcification Mass Mass Mass
1
2 3 4 5 6 7 8
THE R O E N T G E N F E A T U R E S OF S Y N O V I A L S A R C O M A S
483
FIG 3A.
(A & B) A large soft tissue mass on the plantar surface of the foot with minimal soft tissue calcification and extensive erosive and destructive changes in the bones. Note the tapered appearance of the metatarsals. FIG. 3B
484
CLINICAL RADIOLOGY
unusual. The incidence of such involvement is reported as 5-10 ~ (Cadmon, 1965) although in our series 2 0 ~ of the cases had definite osseous abnormality. In most cases this consisted of erosive changes (Fig. 3) due tO the pressure from the adjacent mass. Actual bony invasion does occur, however, and may take the form of cystic areas of rarefaction (Fig. 4). There is, in most instances, little reactive sclerosis unless treatment has been given (Fig. 5).
FIG. 4 Cystic changes are present at the bases of the 3rd and 4th metacarpals due to destruction from adjacent soft tissue tumour.
REFERENCES CADMON,N. L., SOULE,E. H. & KELLY,P. J. (1965) "Synovial Sarcoma", Cancer, 18, 613-627. PACK, G. T. & AreAL, I. M. (1950) "Synovial Sarcoma" Surgery, 28, 1047-1084. THOMPSON,D. E., FROST,H. M., HENDRICK,J. W. • HORN, R. C. January, 1971. "Soft tissue sarcomas involving the extremities and the limb girdles". Southern Medical Journal, 64, 33-44. TILLOTSON,J. F., McDONALD,J. R. and JONES,J. i . (1951). "Synovial Sarcomata", Journal of Bone and Joint Surgery 33A, 459-473.
FIG. 5 A lateral film of the foot demonstrates extensive destruction of the calcaneum and cuboid bones. There is surrounding sclerosis but the patient has already received cobalt therapy.
TIlE R O E N T G E N
FEATURES
OF S Y N O V I A L
SARCOMAS
A L F R E D L. HOROWITZ, D O N A L D R E S N I C K and ROBIN CAIRD WATSON
From the Department of Diagnostic Radiology, Memorial Hospital for Cancer and Allied Diseases, 424 East 68th Street, New York, N. ¥. 10021, America
The radiographic manifestations o f synovial sarcomas are described. The roentgen features can conveniently be divided into three categories: (a) soft tissue mass, (b) soft tissue calcifications, and (c) bony erosion. 67 per cent of cases had a soft tissue mass, and in 20 ~o calcification was seen. Osseous involvement was apparent in 20 ~o- The occurrence of a soft tissue mass with associated calcifications and bony erosion, with a predilection for the lower extremity, is quite characteristic and allows the radiologist to arrive at a correct pre-operative diagnosis.
SYNOVIAL sarcomas are uncommon malignant tumours of the soft tissue and have received little attention in the radiological literature. Despite this relative infrequence, the tumours possess certain characteristic radiographic features which allow their recognition. With this in mind, we reviewed all the synovial sarcomas seen at Memorial Hospital from 1966 to 1970.
Cadmon et aL, 1965; Thompson et al., t971). The average age of the patients in our series is 34 years which agrees well with the reports in the literature. In our group, 13 of the 15 cases arose in the lower
CLINICAL MATERIAL AND RESULTS Of the 45 proven cases of synovial sarcomas, 15 patients had radiographs available for review (Table 1). The roentgenographic findings can be classified under three headings: (1) Soft tissue mass, (2) Soft tissue calcification, and (3) Bony erosion. In group (1), there were 10 cases (67 ~ ) ; in group (2) there were 3 cases (20 ~ ) ; and in group (3) there were 3 cases (20 ~). One case showed bony erosion and calcification and was included in both groups. Clinically the patients presented with soft tissue masses with a variable degree of associated pain. The ages ranged from 9 to 64 years with a mean age of 34 years. The anatomical distribution of the lesions is indicated in Table 2. DISCUSSION Synovial sarcomas are uncommon malignant tumours. Thompson et al. (1971) reviewed 112 cases o f soft tissue neoplasms, and found only 4 cases of synovial origin. They need not arise within a joint capsule but may appear along a tendon sheath anywhere in an extremity. Published series show a distinct predilection for lower extremity involvement (Pack and Arial, 1950; Tillotson et al. 1951;
FIG. I A soft tissue mass is seen along the medial aspect o f the distal femur. There are small flecks o f calcification within the mass but no evidence o f bony involvement.
481
482
CLINICAL RADIOLOGY limbs a n d this incidence o f 86 % compares favoura b l y with previous reports. The m o s t c o m m o n sites o f origin include the thigh, foot a n d knee (Tillotson et al. 1951 ; C a d m o n et al. 1965). I n o u r series, 4 0 % o f the cases arose in the thigh a n d hip region a n d 27 % arose in the feet. The m o s t c o m m o n r a d i o g r a p h i c features o f the t u m o u r m a y be divided into three categories: (a) soft tissues mass, (b) soft tissue calcification a n d (c) b o n y erosion. (a) S o f t Tissue M a s s . - - I n o u r series, 67 % o f the turnouts presented solely with a soft tissue mass. Characteristically, these masses are fairly well defined a n d m a y a p p e a r lobulated. (Fig. 1). This a p p e a r a n c e o f a soft tissue mass with or w i t h o u t calcification or associated b o n y erosion is the m o s t c o m m o n m e t h o d o f presentation.
FIG. 2 Discrete calcification is' seen adjacent to the lateral aspect of the femur without an associated soft tissue mass.
(b) S o f t Tissue Caleifieation.--Calcification was seen in three turnouts (20 %). The calcified areas are generally discrete (Fig. 2) a n d m a y or m a y n o t be associated with a soft tissue mass. One o f our cases presented with soft tissue calcification a n d b o n y destruction b u t h a d n o definite mass. I n a previous series o f 134 cases o f synovial sarcomas, 32 % o f the 57 cases w i t h available x-rays showed calcification ( C a d m o n , 1965). (c) B o n y E r o s i o n . - - T h e a p p e a r a n c e o f a b n o r m a l b o n e in the vicinity o f a synovial s a r c o m a is n o t
TABLE2 Case No.
,Sex
Age
Site
X-ray findings
9 10 11 12
F M M F M F M M M F M F
54 51 33 18 9 64 5l 15 26 43 17 25
L hip L foot L elbow L hip R foot R thigh L calf L knee R thigh L hand L foot L foot
13 14 15
F M M
32 32 43
R hip L thigh L knee
Mass (soft tissue) Mass Mass Mass Mass Mass Mass Calcification Calcification Metacarpal erosions Calcaneous and cuboid erosions Metatarsal erosion and calcification Mass Mass Mass
1
2 3 4 5 6 7 8
THE R O E N T G E N F E A T U R E S OF S Y N O V I A L S A R C O M A S
483
FIG 3A.
(A & B) A large soft tissue mass on the plantar surface of the foot with minimal soft tissue calcification and extensive erosive and destructive changes in the bones. Note the tapered appearance of the metatarsals. FIG. 3B
484
CLINICAL RADIOLOGY
unusual. The incidence of such involvement is reported as 5-10 ~ (Cadmon, 1965) although in our series 2 0 ~ of the cases had definite osseous abnormality. In most cases this consisted of erosive changes (Fig. 3) due tO the pressure from the adjacent mass. Actual bony invasion does occur, however, and may take the form of cystic areas of rarefaction (Fig. 4). There is, in most instances, little reactive sclerosis unless treatment has been given (Fig. 5).
FIG. 4 Cystic changes are present at the bases of the 3rd and 4th metacarpals due to destruction from adjacent soft tissue tumour.
REFERENCES CADMON,N. L., SOULE,E. H. & KELLY,P. J. (1965) "Synovial Sarcoma", Cancer, 18, 613-627. PACK, G. T. & AreAL, I. M. (1950) "Synovial Sarcoma" Surgery, 28, 1047-1084. THOMPSON,D. E., FROST,H. M., HENDRICK,J. W. • HORN, R. C. January, 1971. "Soft tissue sarcomas involving the extremities and the limb girdles". Southern Medical Journal, 64, 33-44. TILLOTSON,J. F., McDONALD,J. R. and JONES,J. i . (1951). "Synovial Sarcomata", Journal of Bone and Joint Surgery 33A, 459-473.
FIG. 5 A lateral film of the foot demonstrates extensive destruction of the calcaneum and cuboid bones. There is surrounding sclerosis but the patient has already received cobalt therapy.