Textbook of Radiology and Imaging David Sutton

7th Edition, Vol.2, Section 5 . Chapter 40. Page 1311

Chapter 40: Tumours and Tumour-Like

Conditions of Bone (2)

SYNOVIOMA
Presented By: Rizki Amallia
Consultant : dr. Amri Wicaksono Pribadi, Sp.Rad
Presentation Date : November 26 th, 2018
 SECTION 5. SKELETAL SYSTEM : SOFT TISSUE
CHAPTER 40 : Tumours and tumour-like condition of bone (2)

Tumours Related to Joints

 Synovial Chondromatosis
(osteochondromatosis)
 Pigmented Villonodular Synovitis
 Lipoma Arborescens
 Dyalisis-related Amyloidosis
 Synovioma
 Intraosseous Ganglion
 Subarticular Arthritic Cyst and Geode
 INTRODUCTION OF SYNOVIOMA
1st reported in 1893. Known as Synovial
Sarcoma, Malignant Synovioma, Tendosynovial
Sarcoma, Synovial Cell Sarcoma, Synovial
Endothelioma, Synovioblastic Sarcoma, synovial
sarkomesotelioma
Do not always originate from the synovial tissue
(<5%). Many cases occur outside of the
synovium/without any relation to synovial structure
(as paranasal, parapharyngeal, retroperitoneal, &
mediastinal region)

They are so named because of their

histologic similarity to synovium

is an intermediate- to high-grade
neoplasm with extensive metastatic
potential but growing slowly

is the 4th most common type of soft-tissue

sarcoma, after Malignant Fibrous Histiocytoma
(MFH), Liposarcoma, Rhabdomyosarcoma

Sutton, D. Textbook of Radiology and Imaging. 7th edition, Vol.2, London: Elsevier, 2003. p. 1311
Knipe H, Gaillard AF. Synovial sarcoma. Retrieved from : http://radiopaedia.org/articles/synovial-sarcoma
Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia. International Journal of Surgical Oncology, 2011 : 1-5
Kwon OY, Lee SK, Cho MK, et al. A case of biphasic synovial sarcoma of frontal bone in an elderly patient. J Korean Neurosurg Soc, 2007 (42) : 67-70
 EPIDEMIOLOGY OF SYNOVIOMA
Occur at any age (newborn - elderly), usually 3rd & 4th decades

Male : female = 1 : 2

.,

No race / ethinic predilection has been reported

Occurs in about 2 per 100.000 people a year

Prevalences : US (10%), Japan (8,3 %), Sweden (7%), France (10,5 %)

2,5 % - 10 % of all primary soft tissue sarcoma worldwide. Rarely

presents as a primary bone tumor, 20% show invasion of local bone
Sumber : http://sarcomahelp.org/synovial-sarcoma.html
http://radiopaedia.org/articles/synovial-sarcoma
Murphey MD, Gibson MS, Jennings BT. Imaging of Synovial Sarcoma with Radiologic-Pathologic Correlation1. RadioGraphics, 2006 : A26 (5) : 1543-1565
 LOCATION OF SYNOVIOMA

Head & Neck 5 %

Upper limb 15-25 %

Lower limb 60 - 70 %

Foot & ankle 18 %

Soft tissue Extremities

80-95 %

Rare : skin, lung, heart, pleura,

kidney, prostate

http://radiopaedia.org/articles/synovial-sarcoma
 Lower limb 60 - 70 %

It can arise from tendon

sheaths, bursae or joint
capsules (<5%), Popliteal
fossa being the most
common location

http://en.m.wikipedia.org/wiki/Synovial_joint
https://slideplayer.com/slide/6351525/
www.interactive-biology.com/3922/functional-anatomy-of-the-knee-movement-and-stability/amp/
http://www.atlantaequine.com/pages/client_lib_PDsynovitis.html
 ETIOLOGY & PATHOGENESIS
This translocation
Associated with the occurs in more than
chromosomal 90% of all synovioma
translocation t(X;18)
(p11;q11)  parts of
chromosome 18 & X
Contain
have switched places
a mutant gene

Possibly trauma
reveals a pre existing
occult tumor in some
ocurrences

http://radiopaedia.org/articles/synovial-sarcoma
 PRIMARY SYNOVIOMA OF BONE

Some cases located : mandible, C3 vertebra, sternum,

sacrum, proximal femur, proximal tibia, & distal tibia

1st report located tibia in 1997, only 9 reported arising from

the bone

Aggressive bone invasion & destruction of the trabeculae in

the marrow canal is less common, approximately 5% of cases

While 20% of synovioma show invasion of local bone, it is

extremely rare for it to present as a primary bone tumour.

M Zulkarnaen, et al. Intraosseous synovial sarcoma of the proximal femur: Case report. Malaysian Orthopaedic Journal 2012 Vol 6 No 1. 49-52
Cardoso P, Coelho A, Esteve J, et al. Intraosseous synovial sarcoma of the body of the scapula. Imaging Med, 2016 : 8(2) : 49-51
  Local swelling
CLINICAL
 May be painful, if nerves are involved
FINDINGS
 Symptoms may be presented from days to as
long as 20 years before initial diagnosis
(average 2-4 ys)

 The long duration of symptoms, initial slow

growth of synovioma, and small size (< 5 cm)
may simulate those of or give a false
impression of a benign process

 This unusual manifestation is important to

recognize, because diagnosis may be
significantly delayed otherwise.

Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia : Case Report. International Journal of Surgical Oncology,2011 : 1-5
http://handtoelbow.com/solid-lumps-in-the-hand-images/
http://it.nextews.com/9dc719ed/
 GROSS PICTURE of SYNOVIOMA

Fig. 2a: Gross specimen of the
proximal femur with a normal looking
muscle cuff surrounding the tumour
and fracture site (red arrow)
Fig. 2b: Cut section of the proximal femur
showing the fleshy grey, haemorrhagic tumour
(red arrow) involving the metaphysis and
diaphysis. Note that there is minimal
involvement of the surrounding soft tissue.

M Zulkarnaen, et al. Intraosseous synovial sarcoma of the proximal femur: Case report. Malaysian Orthopaedic Journal 2012 Vol 6 No 1. 49-52
 HISTOPATHOLOGY OF SYNOVIOMA

Murphey MD, Gibson MS,

Jennings BT. Imaging of
Synovial Sarcoma with
Radiologic-Pathologic
Correlation1. RadioGraphics,
2006 : A26 (5) : 1543-1565

Figure 6. Photomicrographs of various histologic types of synovioma

(a) Biphasic (magnification, 250; H-E) has a blue spindle cell mesenchymal component (arrow) & pinker glandular elements
(arrowheads).
(b) Monophasic (magnification, 200; inset magnification, 400; H-E) typically appears with fascicles & uniform oval cells BUT
WITHOUT a glandular component. Inset shows scattered mast cells (arrowheads).
(c) Monophasic with positive keratin stain (original magnification, 300; Kermix stain) shows the brown staining (arrowheads) in
individual tumor cells.
(d) Poorly differentiated (magnification, 250; H-E) has an epithelioid growth pattern & uniform round cells
 TYPES OF SYNOVIOMA
MONO BI
POORLY
PHASIC PHASIC
DIFFERENTIATED

50% – 20% – 15% –

60% 30% 25%

Spindle cells with a Similar to the generally epithelioid in

fascicular monophasic, but with morphology and have high
arrangement, epithelial cluster or mitotic activity with
no glandular pattern glandular-like spaces geographic necrosis.

Murphey MD, Gibson MS, Jennings BT. Imaging of Synovial Sarcoma with Radiologic-Pathologic Correlation1. RadioGraphics, 2006 : A26 (5) : 1543-1565
https://www.orthodnb.com/2018/04/synovioma-synovial-sarcoma.html
 IMAGING
MODALITIES

Plays a key role in establishing

the initial diagnosis of bone
tumors
Plain
Radiograph

May be used to evaluated

CT potential internal matrix and
Scan or/ cortical erosion

MRI

Necessary to better
characterize lesion of soft tissue

MEYERS SP. MRI OF BONE AND SOFT TISSUE TUMORS AND TUMORLIKE LESIONS, DIFFERENTIAL DIAGNOSIS AND ATLAS. THIEME PUBLISHING GROUP. (2008)
ISBN:3131354216. READ IT AT GOOGLE BOOKS - FIND IT AT AMAZON -MANASTER BJ, DISLER DG, MAY DA ET-AL. MUSCULOSKELETAL IMAGING, THE REQUISITES. MOSBY INC.
(2002) ISBN:0323011896. READ IT AT GOOGLE BOOKS - FIND IT AT AMAZON
 PLAIN RADIOGRAPH

Figure 1: (a) A/p radiograph of the Figure 1: (b) Lateral radiograph shows
left knee shows a large 5 cm round a stippled mineralization (arrow) project
lucency at the lateral tibial with well- ing into the soft tissues posteriorly, mea
defined proximal margins and a less suring approximately 2.5 cm in maximal
well-defined distal margin diameter
Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia : Case Report. International Journal of Surgical Oncology,2011 : 1-5
 CT SCAN

Figure 6: A CT scan reveals multiple soft tissue nodules (arrow) above and below the
knee including areas medial, lateral, anterior, posterior and in the suprapatellar
recess.
Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia : Case Report. International Journal of Surgical Oncology,2011 : 1-5
 MRI

heterogeneous
heterogeneous heterogeneous
intermediate
high signal contrast
signal
intensity on fat- enhancement
intensity
suppressed

T1 T2 T1 C+

Wu Xi, Popovic M, Chow E, et al. Primary synovial sarcoma of the distal femur: A rare case report. J Pain Manage 2014;(7)1:95-98
 Fig. 1: MRI showing an
intraosseous lesion (arrow) at the proximal femur with
an intertrochanteric fracture.

Zulkarnaen M, Intraosseous synovial sarcoma of the proximal femur: Case report. Malaysian Orthopaedic Journal 2012 Vol 6 No 1. 49-52
 Treatment & Prognosis
Combination : surgery (wide excision surgical resection to achieve
clear margins) + adjuvant radiotherapy and or chemotherapy

GOOD POOR  Large size (>5 cm)

 Small size (<5 cm)  Older age
 Younger age (<20)  Cystic/haemorraghic
 Solid homogenous components
mass  poorly differentiated
 absence of poorly areas
differentiated areas  Metastatic lesions are
 presence of extensive most commonly seen
calcification in the lungs.
 Neurovascular
involvement

GOOD POOR

5 yrs survival (26 – 76 %)

10 yrs survival(20 – 63 %)

Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia : Case Report. International Journal of Surgical Oncology,2011 : 1-5
Zulkarnaen M, et al. Intraosseous Synovial Sarcoma Of The Proximal Femur: Case Report. Malaysian Orthopaedic Journal 2012 Vol 6 No 1. 49-52
 CASE 1
A 20 y.o girl, with a 6-month history of the lower left thigh, had difficulty weight bearing & complained of a
slight swelling of left knee joints. There is no obvious skin change, but slight limited motion secondary to pain
in his left leg. Alkaline phosphatase (ALP) is undetectable.

Figure 1a. A/p radiograph of the left knee shows a round Figure 1b. Lateral radiograph shows a mixed
lucency at the lateral femur with poor-defined distal density lump surrounding soft tissues posteriorly,
margins, measuring approximately 6.1cm in maximal measuring approximately 6.1cm in maximal
diameter. diameter.
Wu Xi, Popovic M, Chow E, et al. Primary synovial sarcoma of the distal femur: A rare case report. J Pain Manage 2014;(7)1:95-98
 Figure 2a,b. MRI showing
an intraosseous lesion a 6.1 X 4.2 X 5.6 cm3 at the distal femur with the surrounding soft tissue
lump extension postero-laterally (low T1 & high T2) & cortical bone discontinuity

Wu Xi, Popovic M, Chow E, et al. Primary synovial sarcoma of the distal femur: A rare case report. J Pain Manage 2014;(7)1:95-98
 CASE 2
a 10-year-old girl who developed progressive pain, swelling in the knee joint & flexion
contracture over 2 years after mild trauma.

Figure 4.
(a) Sagittal short inversion time inversion recovery (STIR) (5000/26/160) MR image shows a large high-
signal-intensity soft-tissue mass that appears to originate in the Hoffa fat pad (*) with invasion throughout
the joint and the distal femoral (F) & proximal tibial (T) epiphyses.
(b) Photograph of the sagittally sectioned gross specimen reveals the intraarticular mass (straight arrows)
with hemorrhage (H) & invasion of the distal femoral (arrowhead) & proximal tibial (curved arrow)
epiphyses.
Murphey Md, Gibson Ms, Jennings Bt. Imaging Of Synovial Sarcoma With Radiologic-pathologic Correlation1. Radiographics, 2006 : A26 (5) : 1543-1565
 CASE 3
The patient, a 47-year-old man,
with a 2-year history of progressive limitation of joint movement

Figure 5. Synovioma with secondary joint

invasion.
Sagittal proton-density-weighted (2450/38.5)
MR image of the knee shows a large
popliteal soft-tissue mass (*) with invasion of
the knee joint, as evidenced by tumor
(arrows) surrounding the posterior cruciate
ligament (P). also had invasion of the femur
(arrowheads).

Murphey Md, Gibson Ms, Jennings Bt. Imaging Of Synovial Sarcoma With Radiologic-pathologic Correlation1. Radiographics, 2006 : A26 (5) : 1543-1565
DIFFERENTIATION SYNOVIOMA OF BONE CHONDROBLASTOMA GCT OF BONE

Age 30-40 y.o < 30 y.o 20-40 y.o

Sex (F : M) F>M F<M F>M
Clinical finding Join pain, local swelling, Joint pain, local swelling, Bone pain, local swelling,
pathologic fracture pathologic fracture pathologic fracture
Site Predilection Epiphysis of Mandible, Epiphysis of Humerus, Metaphysis extend to
sternum, elbow, femur, tibia epyphysis of humerus,
sacrum, femur, radius, sacrum, femur, tibia,
tibia
Imaging Finding • Round/oval lucency,  Round shape, • Round/oval lucency,
(Plain Radiograph) • Eccentric,  Eccentric, • Eccentric,
• Well-ill defined margins,  Well defined, margins, • Well-ill defined,
1. Narhan P,et al. Spontaneous • Sclerotic rim (+),  Non/thin sclerotic rim, • Sclerotic rim (-),
conventional osteosarcoma
transformation of • Mineralization (+),  Mineralization (+), • Mineralization (-),
chondroblastoma: A case
report and literature review. • Cortical erosion (+),  Cortical thin / erosion, • Cortical erosion (+grd.3)
Indian J Orthop, 2018: 52
(1):87-90
• Periosteal reaction (-),  Periosteal reaction(+-) • Periosteal reaction (-)
2. Neto FA, et al. Knee bone • Joint effusion (-)  Joint effusion (+) • Joint effusion (-)
tumors:finding on
conventional radiology. Radiol • Soft tissue expansion  Soft tissue expansion • Soft tissue expansion (+)
Bras,2016:49(3):182-9
(+) (rare)
 RESUME MIND MAPPING
 Also known as Synovial Sarcoma, Malignant
Synovioma, Tendosynovial Sarcoma, Synovial Cell
Sarcoma, Synovial Endothelioma, and
1. Introduction Synovioblastic Sarcoma
 Do not always originate from the synovial tissue.
Rarely presents as a primary bone tumor, 20% show
invasion of local bone

 Occur at any age (range newborn & elderly), usually

3rd and 4th decades
2. Epidemiology  Male : female = 1 : 2
 Site predilection : mandible, C3 vertebrae, sternum,
femur, tibia

3. Clinical  Pain >>

 Local swelling
SYNOVIOMA Findings  Symptoms vary from weeks to decades
OF BONE  Mono phasic,
4. Histopathology  Bi phasic,
 Poorly differentiated

 Plain : round lucency, with well-ill defined margins,

mineralization, soft tissue expansion, joint effusion-
5. Radiological  CT Scan : multiple soft tissue nodules
Finding  MRI : T1 heterogeneous intermediate signal
intensity, T2 heterogeneous high signal intensity on
fat-suppressed, T1+C heterogeneous contrast
enhancement
6. Differential  Chondroblastoma
diagnosis  GCT of bone
 QUIZ

WHAT CAN BE POSSIBLE DIAGNOSIS

BASED ON THIS PICTURE ?

A. SYNOVIAL CHONDROMATOSIS
B. SYNOVIOMA OF BONE
C. OSTEOSARCOMA
D. MULTIPLE MYELOMA
E. METASTASIS OF BONE

Beck SE, Nielsen GP, Raskin KA, et al. Intraosseous Synovial Sarcoma of the Proximal Tibia : Case Report. International Journal of Surgical Oncology,2011 : 1-5
 REFERENCES
1. Sutton, D. Textbook Of Radiology And Imaging. 7th Edition, Vol.2, London: Elsevier, 2003. P. 1311
2. Knipe H, Gaillard Af. Synovial Sarcoma. Retrieved From : Http://Radiopaedia.Org/Articles/Synovial-sarcoma
3. Beck Se, Nielsen Gp, Raskin Ka, Et Al. Intraosseous Synovial Sarcoma Of The Proximal Tibia. International
Journal Of Surgical Oncology, 2011 : 1-5
4. Kwon Oy, Lee Sk, Cho Mk, Et Al. A Case Of Biphasic Synovial Sarcoma Of Frontal Bone In An Elderly
Patient. J Korean Neurosurg Soc, 2007 (42) : 67-70
5. Http://Sarcomahelp.Org/Synovial-sarcoma.Html
6. Http://Radiopaedia.Org/Articles/Synovial-sarcoma
7. Murphey Md, Gibson Ms, Jennings Bt. Imaging Of Synovial Sarcoma With Radiologic-pathologic
Correlation1. Radiographics, 2006 : A26 (5) : 1543-1565
8. Http://En.M.Wikipedia.Org/Wiki/Synovial_joint
9. Http://www.Interactive-biology.Com/3922/Functional-anatomy-of-the-knee-movement-and-stability/Amp/
10. Zulkarnaen M, et al. Intraosseous Synovial Sarcoma Of The Proximal Femur: Case Report. Malaysian
Orthopaedic Journal 2012 Vol 6 No 1. 49-52
11. Cardoso P, Coelho A, Esteve J, Et Al. Intraosseous Synovial Sarcoma Of The Body Of The Scapula.
Imaging Med, 2016 : 8(2) : 49-51
12. Beck Se, Nielsen Gp, Raskin Ka, Et Al. Intraosseous Synovial Sarcoma Of The Proximal Tibia : Case
Report. International Journal Of Surgical Oncology,2011 : 1-5
13. Manaster Bj, Disler Dg, May Da Et-al. Musculoskeletal Imaging, The Requisites. Mosby Inc. (2002)
Isbn:0323011896. Read It At Google Books - Find It At Amazon
14. Wu Xi, Popovic M, Chow E, Et Al. Primary Synovial Sarcoma Of The Distal Femur: A Rare Case Report. J
Pain Manage 2014;(7)1:95-98
15. Narhan P,et al. Spontaneous conventional osteosarcoma transformation of chondroblastoma: A case report
and literature review. Indian J Orthop, 2018: 52 (1):87-90
16. Neto FA, et al. Knee bone tumors:finding on conventional radiology. Radiol Bras,2016:49(3):182-9
TERIMA KASIH
&
MOHON ASUPAN