A High School Volleyball Player With Thigh Swelling - Page #4

Working Diagnosis:
Synovial Sarcoma

Patient initially underwent several rounds of neoadjuvant chemotherapy along with radiation therapy.
Radical surgical resection in January with negative margins
Followed by adjuvant chemotherapy

Chemotherapy was complicated by neutropenia, nausea/vomiting, heart thrombus now on xarelto

Patient is still undergoing chemotherapy and on anticoagulation, and is not participating in sports at this time
She is a senior in high school and is on track to graduate
Plans to attend college, not planning on playing collegiate sports

Author's Comments:
Rare cancer found in children, adolescents, and young adults with a mean age of 35
6-8% of soft tissue sarcomas, and is found in limbs about 66% of the time, but can be found anywhere in the body
Poor prognostic predictors include:
size >5 cm
deep seated
mitotic activity of >10 cells per high power field
inadequate surgical resection/local recurrence
patient age >20 years

The main teaching point of this case is not to miss this diagnosis. When you are concerned for a mass and you are unsure exactly what it is, you are never wrong to order imaging.

Editor's Comments:
Careful physical exam is another teaching point in this case. Physical exam is used to narrow the differential diagnosis you made during history.

As her sports medicine physician, we can work in conjuction with her oncologist and cardiologist for an exercise prescription appropriate for an anticoagulated teen receiving chemotherapy.

“Synovial sarcoma in children and adolescents: the European Pediatric Soft Tissue Sarcoma Study Group prospective trial (EpSSG NRSTS 2005).” Ferarri, et al. Annals of Oncology 26: 567–572, 2015

Synovial Sarcoma: Prognostic Significance of Tumor Size, Margin of Resection, and Mitotic Activity for Survival. Samuel, S; et al. Journal of Clinical Oncology, 1996.
“Synovial sarcoma: the importance of size and location for survival.” Deshmukh, R, et al. Clinical orthopedics and related research. 2004, Feb; (419): 155-61.

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