Synovial Sarcoma Mets to Lung Presenting as PE

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

antihypertensive agent, apixaban, doxorubicin, ifosfamide, lactic acid, adult, altered state of consciousness, case report, clinical article, complication, computer assisted tomography, conference abstract, diagnosis, drug therapy, echocardiography, febrile neutropenia, female, follow up, human, human tissue, hypotension, intensive care unit, lumbar spine, lung embolism, mechanical thrombectomy, medical record review, necrotic tissue, neutropenia, radiotherapy, soft tissue sarcoma, surgery, synovial sarcoma, tachycardia, therapy, thrombectomy, tumor burden, urinalysis, urosepsis, young adult

Abstract

Introduction: Synovial sarcoma accounts for a small percentage of soft tissue sarcomas but has a high propensity for metastasis, especially to the lungs in the form of PE. While PE is usually due to thromboembolic events, tumor emboli can rarely cause PE in patients with malignancy (as rare as 3% of all malignancies) . This report details the retrospective diagnosis of PE due to metastatic synovial sarcoma in a young female who presented after the fact for febrile neutropenia. Case Presentation: A 30-year-old female with lumbar spine synovial sarcoma (L3, L4) presented to the ED for altered mental status. She was admitted a month earlier after diagnosis of bilateral PEs for which she underwent mechanical thrombectomy and Eliquis initiation.On presentation, she was tachycardic, febrile, and hypotensive. Initial labs showed neutropenia, AKI, elevated lactate and infected urinalysis. Patient was admitted to the ICU for urosepsis. While undergoing treatment, chart review revealed a previous CTA showing bilateral PEs with a large emboli burden and groundglass opacities suggesting pulmonary infarcts. Of note, the patient had received a duplex ultrasound of her lower extremities during that admission as part of her workup that was negative for DVT. A biopsy was taken during her thrombectomy which revealed necrotic tissue with a viable tumor, consistent with metastatic synovial sarcoma . However, these results were never conveyed to the patient, who was under the impression that the synovial sarcoma was localized. After stabilization of her urosepsis, the biopsy findings were discussed with the patient. Discussion: Tumor emboli, although rare, are significant complications in metastatic synovial sarcoma. Synovial Sarcoma causing PE requires aggressive management. Diagnostic modalities include CT scans and echocardiography. Treatment involves anticoagulation, though surgical intervention and chemotherapy may be required, such as in our patient. Surgical resection to achieve negative margins can improve survival, emphasizing the importance of a multidisciplinary approach to treatment. For synovial sarcoma patients, the role of chemotherapy and radiotherapy is also crucial. Chemotherapy regimens often include doxorubicin and ifosfamide, which have shown efficacy in reducing tumor burden and managing symptoms . Conclusion: Pulmonary embolism due to tumor emboli in synovial sarcoma metastasis represents a diagnostic challenge given its rarity. Sending PE biopsies to pathology is not standard, which may delay diagnosis. Therefore, a high index of suspicion for metastatic disease is important for patients with synovial sarcoma. Also, timely followup for communication of critical results could help prevent a delay in treatment for patients.

Volume

211

Issue

Supplement 1

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