HSS What’s the Diagnosis Case 165

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Findings Large, slightly heterogenous mass of the hand extending into and within the thenar musculature. The mass is near many joints but not within any joint.

Within the mass are areas of fluid signal (very high T2 and very low T1 signal).

The lesion has a somewhat multilobulated architecture and with punctate, low signal foci at the periphery in keeping with signal voids/prominent vascularity.

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Diagnosis: Synovial Sarcoma Synovial sarcoma is an uncommon malignancy but should be thought of particularly for a mass found of the extremities in adolescents and young adults. The name of the malignancy is confusing and leads to confusion. The cells of the tumor were originally thought to resemble synovial cells and hence the name. The cells are however not derived from synovial cells and the mass extremely infrequently begins in a joint. The mass often occur snear joints and can pedunculate into joints but again rarely begins in a joint. No radiograph was available but these masses will frequently calcify. They also undergo necrosis and hemorrhage accounting for the areas of heterogeneity of the mass and fluid signal. The malignant nature of the mass is associated with neovascularity and hence prominent signal voids/vessels as identified in this case. Classic descriptions include a “bowl of grapes” where areas of septation create multiple rounded portions of the mass and a triple sign. The triple sign is areas of low, intermediate, and high signal on T2 imaging corresponding to areas of hemorrhagic debris, mass, and necrosis (fluid). Although classic, these imaging findings do not have to be present.

The mainstay of treatment is surgical resection with frequent employment of radiation treatment. Radiation treatment can be employed prior to surgical resection and frequently follows the surgical resection. The role of chemotherapy in a neo-adjuvant and/or adjuvant role is still debated. In this case, the patient underwent treatment including surgical resection and as of last follow up has thankfully had no recurrence. The following images are from the most recent postoperative study showing no recurrence.

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References Synovial Sarcoma: Imaging Features of Common and Uncommon Primary Sites, Metastatic Patterns, and Treatment Response. Amit Bakri, Atul B. Shinagare, Katherine M. Krajewski, Stephanie A. Howard, Jyothi P. Jagannathan, Jason L. Hornick, Nikhil H. Ramaiya. American Journal of Roentgenology. 2012; 199:W208–W215. DOI:10.2214/AJR.11.8039.

Imaging of Synovial Sarcoma with Radiologic-Pathologic Correlation. Mark D. Murphey, Michael S. Gibson, Bryan T. Jennings, Ana M. Crespo-Rodríguez, Julie Fanburg-Smith, Donald A. Gajewski. Radiographics. Sep 1 2006 https://doi.org/10.1148/rg.265065084.

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