Case ReportCASE REPORTS AND CLINICAL OBSERVATIONS
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Pelvic Synovial Sarcoma Clinically Masquerading as an Ovarian Malignancy

Deepika Gupta, Aasma Nalwa, Deepak Vedant, Abhishek Malik and Amit K. Gupta
Ochsner Journal March 2023, 23 (1) 82-87; DOI: https://doi.org/10.31486/toj.22.0046

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    (A, B) Loosely cohesive clusters and numerous scattered bland-looking spindle cells (hematoxylin and eosin stain [H&E], magnification ×100). (C) Spindle cells have fine chromatin, inconspicuous nucleoli, and elongated delicate cytoplasm (H&E, magnification ×400). (D) Epithelioid-like cells form acinar-like structures (H&E, magnification ×400).

  • Figure 2.
    Figure 2.

    (A) Total hysterectomy specimen with bilateral adnexa. The ovaries are normal size. (B) The pelvic mass measured approximately 11 × 8.5 × 8 cm. (C) On the cut section, the pelvic mass was solid-cystic with variable-sized cysts filled with gelatinous fluid.

  • Figure 3.
    Figure 3.

    (A) Biphasic tumor composed of epithelial and mesenchymal components (hematoxylin and eosin stain [H&E], magnification ×100). (B) Epithelial component forming glands with interspersed spindle-shaped mesenchymal cells (H&E, magnification ×400). (C) Omentum showing tumor deposits (H&E, magnification ×20). Tumor cells showing strong immunoreactivity for (D) BCL2 (immunohistochemistry [IHC], magnification ×100), (E) cytokeratin (IHC, magnification ×100), and (F) TLE1 (IHC, magnification ×400).

Tables

  • Table.

    Differential Diagnosis of Synovial Sarcoma in the Pelvis

    TumorCytomorphologic FeaturesImmunohistochemistry Profile and Cytogenetics
    Malignant peripheral nerve sheath tumorHypocellular and hypercellular areas with cells showing wavy nuclei, nuclear buckling/kinking/twisting, and nuclear pseudoinclusions26S100 protein27, SOX10
    LeiomyosarcomaSpindle-shaped cells arranged in intersecting fascicles having blunt cigar-shaped nuclei with paranuclear vacuolations and abundant eosinophilic cytoplasm26Smooth muscle actin, desmin, and h-Caldesmon; can show focal expression of epithelial membrane antigen and keratin in a dot-like pattern27
    Solitary fibrous tumorSpindle-shaped cells with ovoid vesicular nuclei arranged in a patternless way, rare mitotic figures, varying amounts of collagenous stroma, prominent thin-walled hemangiopericytic vessels26Diffuse expression of CD34,26 diffuse nuclear expression of STAT626; one-third express AE1/AE3; nuclear expression of FLI1
    Ewing sarcoma/primitive neuroectodermal tumorIsolated or sparsely clustered round to oval uniform small cells with central nuclei, rosette formation28Positive periodic acid-Schiff stain, strong membranous immunoreactivity for CD99,18 caveolin-126 Cytogenetic analysis for t(11;22) for confirmation of Ewing sarcoma14
    FibrosarcomaDiagnosis of exclusion, spindle cells arranged in a herringbone pattern, can be pleomorphic, produces intercellular collagen2Negative for cytokeratin and epithelial membrane antigen2
    Sarcomatoid carcinoma and Müllerian adenosarcomaMore pleomorphic than synovial sarcoma2Diffuse cytokeratin positivity2
    Sarcomatoid mesotheliomaLarger and less uniform nuclei,2 single cells and loose aggregates, short spindle-shaped cells without microvilli30Calretinin, podoplanin (D2-40), WT1, CK5/6, mesothelin31
    Synovial sarcomaMixed population of cohesive tissue fragments and scattered cells, tissue fragments contain thin branching capillaries, mitosis and mast cells present, sometimes admixed with epithelial-like structures20,21Epithelial membrane antigen, CK7,24 CK19,24 BCL2 (nearly 100% of synovial sarcoma cases), CD56 (nearly 100% of synovial sarcoma cases),25 CD99 (60% of synovial sarcoma cases),20 S100P (30% of synovial sarcoma cases),20 TLE1(most sensitive and specific)29 Cytogenetic analysis for detection of t(X;18)(p11.2;q11.2) translocation for confirmation of synovial sarcoma24,28,32
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