PMC4895772_01
19-year-old man with primary synovial sarcoma of the lung. AP chest radiograph shows a large well circumscribed mass in the left mid lung and a small left pleural effusion.
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Chest radiography revealed a large, left lung mass with well-defined margins and a small left pleural effusion (Fig. 1). Immunohistochemical stains showed focal positivity for cytokeratins (Fig. 6A) AE1/AE3, epithelial membrane antigen (EMA), cluster of differentiation (CD) 99, and strong positivity for bcl-2 (Fig. 6B) and calponin.
19-year-old man with primary synovial sarcoma of the lung. A, B, Contrast-enhanced chest CT (mediastinal window) shows a well circumscribed heterogeneous left lung mass abutting the left hilum and pericardium. The lesion exhibited soft tissue and low attenuation components, the latter with fluid-fluid levels consistent with cystic change.
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Contrast-enhanced chest CT (Fig. 2) demonstrated a well-defined, heterogeneous ovoid lung mass in the left lung that measured 8.9 by 9.5 cm. Irregular, enhancing tissue elements were appreciated within the lesion as well as low attenuation areas and fluid-fluid levels (Fig. 2A).
19-year-old man with primary synovial sarcoma of the lung. A, Axial, and B, coronal, double inversion recovery magnetic resonance images through the lesion demonstrate a heterogeneous mass in the left mid lung that abuts the ipsilateral hilum and displaces the hilar structures.
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On subsequent thoracic magnetic resonance imaging (MRI) the mass showed heterogeneous signal intensity on T1-weighted and proton density pulse sequences (Figs. 3A, B). Contrast-enhanced fast gradient echo sequences demonstrated heterogeneous enhancement of the lesion with peripheral polylobular enhancement and enhancing tissue septa surrounding low signal intensity areas that likely corresponded to necrosis (Figs. 3C, D).
19-year-old man with primary synovial sarcoma of the lung. C, Axial, and D, coronal, contrast-enhanced fast gradient echo sequences through the lesion demonstrate heterogeneous signal with medially located nodular enhancement and enhancing tissue septa and areas of low signal intensity that correlated with the cystic changes observed on CT.
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A preoperative restaging whole-body fluorine-18 fluorodeoxyglucose integrated PET-CT study was performed (Fig. 4) after completion of chemotherapy, which demonstrated reduction in the size of the lesion from 8.9 by 9.5 cm to 7.8 by 4.7 cm.
19-year-old man with primary synovial sarcoma of the lung. F-18 FDG PET/CT fused image following chemotherapy shows interval decrease in the size of the mass, decreasing mass effect on the adjacent hilum and very little metabolic activity (SUV of 1.3).
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Microscopically (Fig. 5), the tumor showed a dense, monotonous and atypical spindle cell proliferation consistent with high-grade monophasic synovial sarcoma.
19-year-old man with primary synovial sarcoma of the lung. Photomicrograph (Hematoxylin and Eosin stain; original magnification 200 power) demonstrates a tumor composed of fascicles of monotonous atypical spindle cells with scattered mitoses (arrow).
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Immunohistochemical stains showed focal positivity for cytokeratins (Fig. 6A) AE1/AE3, epithelial membrane antigen (EMA), cluster of differentiation (CD) 99, and strong positivity for bcl-2 (Fig. 6B) and calponin.