The document discusses the case of a 70-year-old male with a soft tissue tumor in his right leg. Biopsy results showed a poorly differentiated spindle cell sarcoma. Special stains and morphology were more consistent with synovial sarcoma. All surgical margins were free of tumor and lymph nodes were negative. Synovial sarcoma is an aggressive tumor most commonly found in young adults near joints. It can be diagnosed through histology showing a biphasic pattern and presence of specific gene fusions. Prognosis is poorer with larger tumor size, high grade features and metastasis.

1. Tumor Board
20/02/2018

2. PATIENT DETAILS
• Age/Sex : 70/Male
• Hospital OP/ IP No: A18005479
• Biopsy No: 78/18
• Date Of Receiving Specimen : 9/1/2018
• Clinical Diagnosis : Soft tissue tumor right leg
• Nature of Specimen : Trucut Biopsy from lesion on
right leg.
.

3. Gross Examination
Received multiple (four) linear grey white soft
tissue fragments, each measuring 0.8cm in length.
All embedded.

4. Microscopical Examination
4x 10x
40x

5. Microscopical Examination
4x
10x 40x

6. Microscopy
• Sections studied show fragments of soft
tissue including tendinous structures, one of
which appears highly cellular with small
undifferentiated cells with high N/C ratio and
suggestion of spindling in some areas;
arranged focally is alveolar pattern infiltrating
in fibrofatty soft tissue.

7. Impression
• Biopsy – right leg – soft tissue mass
suggestive of a poorly differentiated spindle
cell sarcoma with differential diagnosis of –
1. Alveolar Rhabdomyosarcoma.
2. Synovial sarcoma.
3. Fibrosarcoma

8. PATIENT DETAILS
• Age/Sex : 70/Male
• Hospital OP/ IP No: A18005479
• FNAC No: 12/18
• Date Of FNAC: 12/01/2018
• Clinical Diagnosis : Soft tissue sarcoma right leg
• Site of FNAC - Right inguinal lymph node.
.

9. Microscopical Examination
• Scanty cellular smear comprising of scattered
lymphocytes , eosinophils and occasional
polymorphs in the background of dense
hemorrhage.

10. Impression
• Inadequate smear for evaluation.
• No definite opinion possible.
• Advised USG Guided FNAC.

11. PATIENT DETAILS
• Age/Sex : 70/Male
• Hospital OP/ IP No: A18005479
• Biopsy No: Fro 1/18
• Date Of Receiving Specimen : 2/2/2018
• Clinical Diagnosis : Soft tissue sarcoma
• Nature of Specimen : Vertical group of right inguinal
lymph nodes
.

12. Gross Examination
• Received two lymph nodes, largest measuring
3 x 2 x 1 cm and the smallest measuring 1 x
0.5 x 0.5 cm.

13. Microscopical Examination
• Section studied from frozen section of lymph
nodes (A,B and C) appear free of tumor.
• The rest of the morphology of lymph node
will be commented on routine paraffin
embedded sections.

14. PATIENT DETAILS
• Age/Sex : 70/Male
• Hospital OP/ IP No: A18005479
• Biopsy No: Fro 2/18
• Date Of Biopsy : 2/2/2018
• Clinical Diagnosis : Soft Tissue Sarcoma
• Nature of Specimen - Wide local excision of tumor
from right leg.
.

15. Gross Examination
• Received skin covered
soft tissue mass
measuring 13.5 x 13 x 5
cm. The external surface
is skin covered having an
irregular growth
measuring 13 x 12 x 4.5
cm.
• The external surface also
shows an ulcer measuring
1x 1 cm and nodular in
appearance.

16. Gross Examination
• C/S : homogeneous grey
yellow to tan lobular
areas with ill-defined
margins.
• The shaved deep resected
margin taken - frozen A.
• superior margin (double
suture) a bit taken -
frozen B.
• median margin (single
suture) a bit taken -
frozen C.

17. Microscopical Examination
Sections studied from A, B and C show shaved deep resected,
superior and medial margins are respectively free of tumor.

18. PATIENT DETAILS
• Age/Sex : 70/Male
• Hospital OP/ IP No: A18005479
• Biopsy No: 272/18 and 273/18
• Date Of Receiving Specimen : 2/2/2018
• Clinical Diagnosis : Soft tissue sarcoma Right leg.
• Nature of Specimen : Wide local excision of soft
tissue Sarcoma Right leg.
.

19. Gross Examination
272/18 - Container labelled vertical group of inguinal
lymph nodes:
• Received two lymph nodes, the largest measuring
3x2x1cm and the smallest measuring 0.5x0.5cm.
• All embedded in A to H

20. Gross Examination
273/18 - Container labelled excision
specimen of soft tissue Sarcoma
 Received skin covered soft tissue mass
measurement of the specimen-
13.5x13x5cm. The external surface shows
an irregular poorly circumscribed nodulo-
ulcerative growth measuring
13x12x4.5cm.
 The external surface of the skin also
shows an ulcer measuring 1x1cm.
 On serial cut sections, grey yellow to tan
lobular areas with extending ill defined
margins. There is no hemorrhage and
necrosis.

21. Gross Examination
 Distance of tumor
• < 0.5 cm from the closest margin(fascia)
• 0.1cm away from deep resected margin,
• 2cm away from superior surgical margin,
• 3cm away from medial margin,
• <0.5 cm from lateral surgical margin
• 3cm away from inferior surgical margin.
 Tumor is also abutting the superficial ulcerated skin.
 Tumor interface with the normal tissue-infiltrative in nature.

22. Microscopical Examination
 Biopsy 272/18 –
• Sections studied show two lymph nodes with features of
reactive sinus histiocytosis and free of tumor deposits.

23. Microscopical Examination
4x 10X
40X
10X
40x

24. Microscopical Examination
 Biopsy 272/18 –
• Sections studied from deep shaved, medial, superior, inferior,
lateral, closest surgical and superficial skin margins being free
of tumor.
• Sections studied from the tumor proper show skin with
ulcerated epidermis. Dermis shows a tumor composed of
round to ovoid cells with nucleus showing moderate
pleomorphism, hyperchromatic nucleus arranged in solid
clusters and in lobules. Few cells are spindly. Occasional
atypical mitoses are seen. Tumor is infiltrating upto
subcutaneous fat. Several small cleft like spaces are seen
resembling synovial lining with tumor cells projecting into
these spaces.

25. Impression
•Excision biopsy from soft tissue of right leg are with features of
a Malignant Spindle cell Soft tissue Sarcoma. The pattern seen is
more in favour of Synovial Sarcoma than fibrosarcoma.
•Two vertical inguinal group of lymph nodes are free of tumor.
•All the surgical margins are free of tumor.

26. DISCUSSION

27. SYNOVIAL SARCOMA
• Typically found in adolescents or young adults but can occur
at any age.
• Presents as a deep-seated, often painful mass; has often been
present for years.
• Usually arises near the joint in close relation to tendons and
bursa but not in the joint space itself.
• Lower extremities are commonly affected.
• Synovial sarcoma has been described in virtually every
location, including viscera.

28. SYNOVIAL SARCOMA
Special Stains & IHC
Cytokeratin, EMA, E-cadherin: epithelial component is
positive, and mesenchymal-like component often shows
focal positivity for at least one of these markers:
• CD99: membranous staining in either or both
components.
• CD56, CD57, and bcl-2: cytoplasmic staining in either or
both components.
• TLE1 - a highly sensitive (nuclear) marker for all
morphologic types.
• SYT: nuclear staining.
• S-100 protein: focal nuclear staining in 33% of cases.
• CD34, Fli-1, and CD117 negative.
CD99 (positive)
positive for epithelial membrane
antigen (EMA)

29. SYNOVIAL SARCOMA
Other Techniques for Diagnosis
Presence of t(X;18)(p11;q11) can be demonstrated in greater
than 90% of synovial sarcomas by cytogenetic or molecular
techniques; fusion genes are SYT-SSX1/SSX2 or SSX4.

30. Fibrosarcoma Synovial Sarcoma
Usually extensive herringbone pattern Herringbone pattern usually only focal
Keratin, EMA negative Keratin, EMA often positive
No ropy collagen Ropy collagen frequent
Calcification rare Calcification may be present
No hemangiopericytomatous vessels Hemangiopericytomatous vessels
frequent
Thin elongate nuclei Plump nuclei
Chromatin not stippled Stippled chromatin
No SYT-SSX gene fusion SYT-SST gene fusion present
TLE1 0% (0/3) TLE1 97%

31. SYNOVIAL SARCOMA
Synovial sarcoma is an aggressive tumor that is frequently
complicated by distant metastasis to the lungs and lymph
nodes; which may be manifested late in the course of disease

32. Prognostic Factors
• Favorable prognostic characteristics include
• age younger than 25 years
• tumor size less than 5 cm.
• low mitotic rate.
• heavy calcification.

33. Prognostic Factors
The following factors indicate poor prognosis–
• More than 5 cm size.
• Presence of neurovascular invasion.
• Lower extremity tumour location.
• Grade 3 nuclei
• Presence of rhabdoid cells.
• More than 10 mitosis/ 10 HPF.
• Atleast 20% of tumour shows poorly differentiated areas.
• Overexpression of p53.
• High Ki-67 proliferation index.