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RadioGraphics AFIP ARCHIVES 1543

From the Archives of the AFIP

Imaging of Synovial Sarcoma with
Radiologic-Pathologic Correlation1
CME FEATURE Mark D. Murphey, MD ● Michael S. Gibson, MD ● Bryan T. Jennings,
See accompanying MD ● Ana M. Crespo-Rodrı́guez, MD ● Julie Fanburg-Smith, MD
test at http:// Donald A. Gajewski, MD
www.rsna.org
/education
/rg_cme.html Synovial sarcoma is the fourth most common type of soft-tissue sar-
coma, accounting for 2.5%–10.5% of all primary soft-tissue malignan-
LEARNING
OBJECTIVES cies worldwide. Synovial sarcoma most often affects the extremities
FOR TEST 6 (80%–95% of cases), particularly the knee in the popliteal fossa, of
After reading this adolescents and young adults (15– 40 years of age). Despite its name,
article and taking the lesion does not commonly arise in an intraarticular location but
the test, the reader
will be able to: usually occurs near joints. Histologic subtypes include monophasic,
䡲 Describe the radio- biphasic, and poorly differentiated; the cytogenetic aberration of the
logic manifestations
of synovial sarcoma. t(X;18) translocation is highly specific for synovial sarcoma. Although
䡲 Recognize the radiographic features of these tumors are not pathognomonic, findings
pathologic basis of
the radiologic fea-
of a soft-tissue mass, particularly if calcified (30%), near but not in a
tures of synovial sar- joint of a young patient, are very suggestive of the diagnosis. Cross-
coma. sectional imaging features are vital for staging tumor extent and plan-
䡲 Discuss the patho-
logic spectrum of
ning surgical resection; they also frequently reveal suggestive appear-
synovial sarcoma as ances of multilobulation and marked heterogeneity (creating the “triple
well as the treatment
options and progno-
sign”) with hemorrhage, fluid levels, and septa (creating the “bowl of
sis. grapes” sign). Two features associated with synovial sarcoma that may
lead to an initial mistaken diagnosis of a benign indolent process are
TEACHING
slow growth (average time to diagnosis, 2– 4 years) and small size (⬍5
POINTS cm at initial presentation); in addition, these lesions may demonstrate
See last page well-defined margins and homogeneous appearance on cross-sectional
images. Synovial sarcoma is an intermediate- to high-grade lesion, and,
despite initial aggressive wide surgical resection, local recurrence and
metastatic disease are common and prognosis is guarded. Understand-
ing and recognizing the spectrum of appearances of synovial sarcoma,
which reflect the underlying pathologic characteristics, improve radio-
logic assessment and are important for optimal patient management.

Abbreviations: H-E ⫽ hematoxylin-eosin, STIR ⫽ short inversion time inversion recovery

RadioGraphics 2006; 26:1543–1565 ● Published online 10.1148/rg.265065084 ● Content Codes:

1From the Departments of Radiologic Pathology (M.D.M., M.S.G., B.T.J.) and Soft Tissue Pathology (J.F.S.), Armed Forces Institute of Pathology,
6825 16th St NW, Building 54, Room M-133A, Washington, DC 20306; Department of Radiology and Nuclear Medicine, Uniformed Services Uni-
versity of the Health Sciences, Bethesda, Md (M.D.M.); Department of Radiology, National Naval Medical Center, Bethesda, Md (M.S.G.); Depart-
ment of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain (A.M.C.R.); and Departments of Radiology (M.D.M.) and Orthopedic
Surgery (D.A.G.), Walter Reed Army Medical Center, Washington, DC. Received May 2, 2006; revision requested May 19 and; received June 9;
accepted June 9. All authors have no financial relationships to disclose. Address correspondence to M.D.M. (e-mail: murphey@afip.osd.mil ).

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official nor as reflecting the views of the
Departments of the Army, Navy or Defense.
 1544 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 1. Synovial sarcoma with an intermuscular origin adjacent to the hip of

an 18-year-old man who noticed an enlarging soft-tissue mass. (a, b) Axial T1-
weighted (a, repetition time msec/echo time msec ⫽ 690/25) and T2-weighted (b,
2301/95) magnetic resonance (MR) images show a large juxtaarticular heteroge-
neous soft-tissue mass (M) with signal intensity slightly higher than that of muscle
with T1 weighting and intermediate signal intensity with T2 weighting. The lesion
is centered between the rectus (arrow), tensor fascia lata (T), and sartorius (S)
muscles, which are displaced. A small amount of intermuscular fat is seen posteri-
orly (arrowhead). (c) Photograph of the axially sectioned gross specimen reveals
similar features with a septated, multilobulated soft-tissue mass (*) arising between
the rectus (arrow), tenor fascia lata (T), and sartorius (S) muscles.

Introduction
Synovial sarcoma was first reported in 1893 and
represents a relatively common type of primary neity (creating the “triple sign”) with hemor-
soft-tissue malignancy (1–5). Synovial sarcoma rhage, fluid levels, and septa (creating the “bowl
accounts for 2.5%–10.5% of all primary malig- of grapes” sign). In this article, the clinical fea-
nant soft-tissue neoplasms (6 –13). Previous ter- tures, pathologic characteristics, spectrum of ra-
minology for this lesion includes tendosynovial diologic appearances, and treatment and progno-
sarcoma, synovial cell sarcoma, synovioma, syno- sis of synovial sarcoma are discussed and illus-
vial endothelioma, malignant synovioma, and trated.
synovioblastic sarcoma (2,4). Despite this no-
menclature, these lesions do not arise in an intra- Clinical Characteristics
articular location but usually occur near joints. Synovial sarcoma is the fourth most common
Synovial sarcomas typically affect adolescents and soft-tissue sarcoma in the material from the
young adults. The extremities, particularly the Armed Forces Institute of Pathology (AFIP), fol-
knee in the popliteal fossa, are most frequently lowing malignant fibrous histiocytoma (currently
affected. Synovial sarcoma is an intermediate- to known as undifferentiated high-grade pleomor-
high-grade neoplasm with extensive metastatic phic sarcoma), liposarcoma, and rhabdomyosar-
potential. coma (1–10). In the United States, the prevalence
Because of the aggressive potential behavior of of synovial sarcoma ranges from 2.5% to 10% of
synovial sarcoma, pathologic and radiologic as- all soft-tissue sarcomas as reported by several in-
sessment is important for staging and evaluating stitutions (6 –10). Similar rates have been re-
lesion extent to direct appropriate therapy. Imag- ported in population-based studies from Japan
ing findings, although not pathognomonic, fre- (8.3%) (11), Sweden (7%) (12), and France
quently suggest the diagnosis. Radiographic find- (10.5%) (13).
ings of a soft-tissue mass near but not in a joint in Synovial sarcoma occurs most frequently in
Teaching
a young patient (15– 40 years old), particularly if adolescents and young adults, with the majority
Point
calcification is present, are very suggestive of sy- of patients presenting at 15– 40 years of age (2,9).
novial sarcoma. Cross-sectional imaging appear- In the study by Cadman et al (8), 84% of patients
ances often seen with synovial sarcoma include with synovial sarcoma were 10 –50 years old. The
multilobulated morphology and marked heteroge- median age at presentation in several recent large
series ranged from 30 to 38 years (13–18). How-
ever, as with most neoplastic processes, there is a
broad age range and cases have been reported in
newborns and the elderly (6,19). In the pediatric
 RG f Volume 26 ● Number 5 Murphey et al 1545

RadioGraphics

Figure 2. Synovial sarcoma near the elbow in a 15-year-old boy who had a small mass there for 9 years
that recently rapidly increased in size. (a) Anteroposterior radiograph of the forearm shows a soft-tissue
mass (arrowhead) below the elbow with a small focus of amorphous calcification superiorly (large arrow)
and extrinsic erosion of the adjacent radius (small arrow). (b, c) Coronal T1-weighted (630/20) (b) and
axial T2-weighted (2339/90) (c) MR images reveal the soft-tissue mass (*) with intermediate signal in-
tensity on the short TR image and intermediate to high signal intensity on the long TR image. Low-sig-
nal-intensity focus (arrowheads in b) represents the calcification, which is better seen on the radiograph.
Extrinsic erosion of the radius is seen on the axial MR image (arrow in c). (d) Photograph of the coro-
nally sectioned gross specimen shows the synovial sarcoma with hemorrhage (H) and focus of calcifica-
tion (between arrowheads).

population, synovial sarcoma is the most com- ness at the site of the mass are frequent, and some
mon nonrhabdomyosarcomatous soft-tissue sar- patients present with pain but no palpable mass
coma (20). A mild male predominance (1.2:1 (8). This symptom is unusual compared with
ratio) has been described by some authors (15). other soft-tissue sarcomas that typically manifest
In contradistinction, other reports have indicated as painless masses. Symptoms of sensory and mo-
a slight female predominance (13,17). In the larg- tor dysfunction distal to the lesion, caused by pri-
est single group reported, a series of 672 cases mary or secondary involvement of adjacent
seen in consultation over a 10-year period at the nerves, have been reported (8). Weight loss and
AFIP, there was no significant difference in gen- constitutional symptoms are unusual, but when
der distribution (9). No race or ethnic predilec- present usually indicate a poorly differentiated
tion has been reported. tumor (2). Although synovial sarcoma has occa-
Patients with synovial sarcoma usually present sionally been cited in association with trauma in
with a palpable soft-tissue mass or swelling (6,8). the literature (2), most cases with this history are
These lesions are often slow growing initially. likely coincidental. Local trauma may cause hem-
Duration of symptoms before diagnosis varies orrhage in a soft-tissue mass or may bring the
widely, from weeks to decades (8); however, the mass to the attention of the patient or examining
average duration of symptoms is 2– 4 years (2). physician.
There are reported cases with as long as a 20-year The majority of synovial sarcomas (80%–95%)
history of symptoms. The long duration of symp- occur in the extremities (Fig 1). The lower ex-
toms and initial slow growth of synovial sarcomas tremity is most often affected, accounting for
Teaching may simulate those of or give a false impression of 60%–71% of cases, whereas 16%–25% occur in
Point a benign process. This unusual manifestation is the upper limb (8,9,15,16,18) (Fig 2). The single
important to recognize, because diagnosis may be
significantly delayed otherwise. Pain and tender-
 1546 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics most frequent site of involvement is the popliteal

fossa of the knee (8,9,15,16,18). Synovial sar-
coma is the most common malignancy of the
deep soft tissues of the foot and ankle in patients
6 – 45 years of age and the most common malig-
nancy of the lower extremity in patients 6 –35
years of age (9). In the AFIP series, 18% of all
synovial sarcomas occurred in the foot and ankle.
Other less commonly affected sites include the
head and neck (5% of cases); trunk, thorax, and
chest wall (7%; Fig 3); retroperitoneum (0.3%);
and pelvis (8%) (8,9,15,16,21–23). However,
synovial sarcoma has also been reported in almost
all anatomic locations, with rare involvement of
the skin, viscera (kidney, lung, prostate, esopha-
gus, heart), central nervous system, pleura, pe-
ripheral nerve, and bone (2–5,21–23). Despite its
name, synovial sarcoma infrequently (estimated
5%–10% of cases) originates within a joint (8,14)
(Fig 4). The majority of tumors occur either adja-
cent to (40%–50% of cases) or within 5 cm of
(60%–75%) a joint (24). In the study by Jones
and colleagues (25), 63% of lesions were within
7 cm of a joint. When intraarticular involvement
does occur, it is more commonly because the jux-
taarticular neoplasm extended into the joint
rather than the tumor arose there (Fig 5).

Pathologic Features Figure 3. Synovial sarcoma of the posterior chest

Synovial sarcoma is a distinctive pathologic entity wall in a 31-year-old man with a nontender, progres-
that, despite its name, does not arise from syno- sively enlarging, soft-tissue mass. (a) Axial postcontrast
vium, as it shows dual epithelial and mesenchy- computed tomographic (CT) scan shows a large poste-
mal differentiation (26,27). The gross pathologic rior chest wall mass with low attenuation centrally (*)
appearance of synovial sarcoma is typically non- resulting from necrosis and a thick nodular wall pe-
specific, with a gray to yellow color and fish flesh ripherally (arrows). (b) Photograph of the axially
sectioned gross specimen reveals similar features,
consistency. These lesions may be well defined, with necrosis (N) centrally and a thick nodular wall
particularly if they are small, or poorly defined. of viable tumor (T) peripherally.
Synovial sarcomas are frequently multilobulated,
and areas of necrosis, hemorrhage, and cyst for-
mation are also common. has both a mesenchymal spindle cell component
There are three main histologic subtypes of and an obvious epithelial component as seen at
synovial sarcoma: biphasic, monophasic, and light microscopy (Fig 6a). The epithelial cells
poorly differentiated (28) (Fig 6). Biphasic syno- usually form glands, but they may also be seen as
vial sarcoma represents 20%–30% of lesions and solid sheets, nests, cords, and papillary structures,
and they may show squamous metaplasia. The
glandular component may predominate and oc-
casionally obscure the spindle cell elements, an
appearance suggestive of adenocarcinoma and
 RG f Volume 26 ● Number 5 Murphey et al 1547

RadioGraphics

Figure 4. Synovial sarcoma arising in the knee joint of a 10-year-old girl who developed progressive pain, swelling,
and flexion contracture over 2 years after mild trauma. (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) and proximal tibial (T) epiphyses. (b) Photo-
graph of the sagittally sectioned gross specimen reveals the intraarticular mass (straight arrows) with hemorrhage (H)
and invasion of the distal femoral (arrowhead) and proximal tibial (curved arrow) epiphyses.

Figure 5. Synovial sarcoma with secondary joint inva-

sion. (a) 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 liga-
ment (P). The patient, a 47-year-old man with a 2-year
history of progressive limitation of joint movement, also
had invasion of the femur (arrowheads). (b) Photograph
of a sagittally sectioned, whole-mounted specimen (hema-
toxylin-eosin [H-E] stain) from a 35-year-old man reveals
invasion of the anterior recess of the ankle by a soft-tissue
mass (*), which originates adjacent to the joint (arrow).
The intraarticular component of the lesion also causes ex-
trinsic erosion of the anterior tibial cortex (arrowhead).
The patient presented with clinical symptoms of limited
foot dorsiflexion.
 1548 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 6. Photomicrographs of various histologic types of synovial sarcoma. (a) Biphasic synovial sarcoma (origi-
nal magnification, ⫻250; H-E stain) has a blue spindle cell mesenchymal component (arrow) and pinker glandular
elements (arrowheads). (b) Monophasic synovial sarcoma (original magnification, ⫻200; inset magnification, ⫻400;
H-E stain) typically appears with fascicles and sheets of uniform oval cells but without a glandular component. Inset
shows scattered mast cells (arrowheads). (c) Monophasic synovial sarcoma with positive keratin stain (original mag-
nification, ⫻300; Kermix stain) shows the brown staining (arrowheads) in individual tumor cells. (d) Poorly differen-
tiated synovial sarcoma (original magnification, ⫻250; H-E stain) has an epithelioid growth pattern and relatively
uniform round cells, a characteristic that makes differentiation from other small round blue cell tumors (eg, Ewing
sarcoma) difficult without immunohistochemical staining.

that has been referred to as the purely glandular obvious in the monophasic subtype (Fig 6b) and
type monophasic synovial sarcoma. can aid in diagnosis of this tumor (although mast
Monophasic synovial sarcoma represents cells are also observed in nerve sheath tumors,
50%– 60% (the most common subtype) of all le- lipomatous tumors, and other neoplasms). The
sions, and in this subtype the mesenchymal monophasic subtype also generally demonstrates
spindle cell component predominates (Fig 6b). a hemangiopericytoid vascular pattern, often stro-
These relatively bland spindled cells have ovoid mal collagen, and occasionally microcalcifications
pale-staining nuclei with indistinct nucleoli, a fas- and metaplastic bone (calcifying synovial sar-
cicular interlacing growth pattern, and mild to coma) (30).
moderate mitotic activity. The stroma is often Poorly differentiated synovial sarcomas are
pinkish, a characteristic that distinguishes this generally epithelioid in morphology and have high
lighter stroma tumor from a darker bluish appear- mitotic activity (usually ⬎15–20/10 high-power
ance (at low power) of malignant peripheral nerve field) with geographic necrosis (18,31–33) (Fig
sheath tumors. Scattered mast cells (29) are more 6d). This subtype represents up to 15%–25% of
all synovial sarcomas. A very distinctive low-
power microscopic pattern for poorly differenti-
ated synovial sarcoma is perivascular tissue spar-
 RG f Volume 26 ● Number 5 Murphey et al 1549

RadioGraphics ing, in which rings of tumor form around vessels, identified to date in any other tumors, to the best
with large areas of adjacent geographic necrosis. of our knowledge. Molecular testing is usually
Poorly differentiated synovial sarcomas can be performed when there is very little tissue, when
confused with round cell tumors, such as Ewing the immunohistochemical stains are not diagnos-
sarcoma, although differentiation can be accom- tic for synovial sarcoma, or when the tumor is
plished with immunohistochemical staining and poorly differentiated and mimics Ewing sarcoma.
molecular methods. Several variations of the t(X;18) translocation
Grading of synovial sarcoma is achieved by leading to two different gene fusions have been
applying the highly reproducible, widely accepted described and associated with the vast majority of
grading scheme for all sarcomas, the FNCLCC synovial sarcomas. These are the SYT-SSX1 and
(French Federation Nationale des Centres de SYT-SSX2 types that account for 67% and 33%
Lutte Contre le Cancer) scheme, which uses a of gene fusions, respectively (2–5,42,43). Al-
combined score from three separate parameters, though much controversy exists in the literature,
including degree of differentiation, mitotic activ- there is no definite prognostic difference between
ity, and necrosis (34,35). Both biphasic and these two gene fusion types (41). However, bi-
monophasic synovial sarcomas are usually inter- phasic tumors are generally SSX1, and monopha-
mediate grade (grade 2/3); however, both types sic tumors are either SSX1 or SSX2 (42).
can be high grade (grade 3/3). Poorly differenti- The pathologic differential diagnosis for syno-
ated synovial sarcomas are high-grade tumors. vial sarcoma includes the following: carcinosar-
The presence of keratin (epithelial marker) coma; other biphasic tumors of the gynecologic
positivity (approximately 90% of cases), mea- tract; teratoma; mixed tumor; malignant me-
sured with immunohistochemical staining in cor- sothelioma; fibrosarcoma; solitary fibrous tumor
relation with the histologic appearance, is diag- or hemangiopericytoma; cellular schwannoma;
nostic for synovial sarcoma (37,38) (Fig 6c). Both leiomyosarcoma; malignant peripheral nerve
the glandular component (diffusely) and the sheath tumor (36); Ewing sarcoma or primitive
spindle cell component (focally) demonstrate neuroectodermal tumor; and other small round
single cells (monophasic and poorly differentiated cell tumors, depending on whether biphasic,
subtypes) or clusters of cells (biphasic subtype) monophasic, or poorly differentiated. These le-
that are positive for epithelial markers, most nota- sions can all be distinguished by the specific mor-
bly pankeratins, EMA, and CK7. CK7 is gener- phologic features of synovial sarcoma (such as
ally absent from malignant peripheral nerve stromal collagen, scattered mast cells, and bland
sheath tumor (as well as pankeratins in this tu- cytology of ovoid tumor cells in fascicles; soft tis-
mor) and Ewing sarcoma, and this finding can aid sue or specific organ location; patient age; and
in diagnosis of synovial sarcoma (39). CD99, immunohistochemical findings of EMA, keratins,
which is found as a cytoplasmic membrane and CK7) and particularly by molecular methods
marker in Ewing and primitive neuroectodermal in difficult cases or those with scant material.
tumors, can also be positive in synovial sarcoma
(62% of cases). CD34, which is diffusely positive Imaging Features
in hemangiopericytoma and solitary fibrous tu- Radiographs appear normal in approximately
mor, is negative in synovial sarcoma. Epithelial- 50% of cases of synovial sarcoma, particularly
type and neural-type cadherins can be found in those with small lesions (1,43). Larger legions
biphasic synovial sarcoma and to a lesser degree that are deeply seated or that occur in areas of
in monophasic and poorly differentiated synovial complex anatomy such as the pelvis may also be
sarcoma, but they may be useful, in combination occult at radiography. Synovial sarcomas detected
with other markers, to separate biphasic synovial at radiography typically appear as nonspecific,
sarcoma from mesotheliomas or other tumors round to oval juxtaarticular soft-tissue masses.
(40). Calcification is identified in up to 30% of synovial Teaching
Cytogenetic studies can be performed on for- sarcomas at radiography (1,43) (Figs 2, 7). These Point
malin-fixed paraffin embedded tissues. The hall- calcifications are often eccentric or peripheral
marks for synovial sarcoma are the t(X;18) trans- within the soft-tissue mass and nonspecific in ap-
location and SYT-SSX gene fusion products, pearance. In rare cases, extensive chondroid or
which can be identified by using FISH (fluores- osteoid mineralization has been described in sy-
cence in situ hybridization) or RT-PCR (reverse novial sarcoma (44) (Figs 8, 9). Extensively calci-
transcription polymerase chain reaction) studies, fied lesions may also be associated with an im-
respectively. This genetic aberration has been proved prognosis (30,45).
identified in greater than 90% of synovial sarco-
mas and is highly specific, since it has not been
 1550 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics Figure 7. Largely cystic synovial sarcoma in the popliteal region in a 12-year-old boy with a painless soft-tissue
mass first noted 4 years ago. (a) Lateral radiograph shows soft-tissue fullness in the popliteal fossa (*) with a small,
nonspecific calcification superiorly (arrow). (b– d) Axial T1-weighted (b, 700/16), sagittal T1-weighted fat sup-
pressed postcontrast (c, 800/20), and coronal STIR (d, 2550/30/150) MR images reveal a largely cystic, popliteal
soft-tissue mass (C) with a focal nodular area of solid tissue anteriorly (arrowheads). The lesion is intermuscular as
demonstrated by the surrounding fat (split fat sign) (arrows). The cystic component (C) demonstrates thin peripheral
enhancement and is low signal intensity with T1 weighting (b) and very high signal intensity with the STIR se-
quence (d), an appearance simulating that of a ganglion or popliteal cyst. However, the solid component (S) reveals
diffuse enhancement and is higher signal intensity with T1 weighting (b) and lower signal intensity with the STIR
sequence (d). (e) Transverse sonogram of the solid component shows a heterogeneous intermediate echogenicity,
ovoid soft-tissue mass. Note the foci of increased echogenicity (arrows), which correspond to calcifications on the
radiographs. (f) Photograph of the sectioned gross specimen reveals the solid component (S) and smooth walls of the
collapsed cyst cavity (*), corresponding to the imaging findings.
 RG f Volume 26 ● Number 5 Murphey et al 1551

RadioGraphics Figure 8. Extensively calcified synovial sarcoma in a 36-year-old woman who presented with a mass
anterior to the elbow that had progressively enlarged over 15 months, resulting in a flexion deformity.
(a) Lateral elbow radiograph shows a large calcified soft-tissue mass (arrows) anterior to the elbow with-
out evidence of an effusion. (b) Axial CT scan also reveals the extensively calcified soft-tissue mass (ar-
rows). (c, d) Coronal oblique T1-weighted (650/36) (c) and sagittal gradient-echo (1000/13/30°) (d)
MR images demonstrate the large heterogeneous soft-tissue mass (arrowheads) with low- to intermedi-
ate-signal-intensity areas (*) corresponding to the calcifications seen on radiographs and CT scans. The
extent of low to intermediate signal intensity is not as prominent as might be expected from the radio-
graphic or CT appearance, likely related to intermixture with viable tumor cells. The mass is anterior to
the anterior recess of the elbow, and lack of joint effusion is consistent with juxtaarticular but not intraar-
ticular origin. (e) Photograph of the coronally sectioned gross specimen shows extensive calcification (*)
superiorly.
 1552 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 9. Synovial sarcoma of the thigh with extensive calcification and metastatic disease to the chest in a
52-year-old woman who presented with an enlarging soft-tissue mass in her thigh. (a) Axial postcontrast CT
scan shows a large heterogeneous soft-tissue mass with both solid (arrows) and necrotic (N) regions and exten-
sive calcification (arrowheads). (b) Coronal T2-weighted (2050/90) MR image reveals marked heterogeneity
with the triple sign, including areas of high (H), intermediate (I), and low (L) signal intensity in the large soft-
tissue mass. (c) Frontal chest radiograph demonstrates multiple pulmonary nodules (arrows) and a mediastinal
mass (M). (d) Photograph of the sectioned gross specimen shows the large heterogeneous soft-tissue mass with
hemorrhage (H) and large areas of calcification (C) that histologically (not shown) revealed metaplastic bone.
 RG f Volume 26 ● Number 5 Murphey et al 1553

RadioGraphics

Figure 10. Synovial sarcoma of the foot with indolent erosion of bone in a 14-year-old girl with an en-
larging foot mass. (a) Anteroposterior radiograph of the foot shows indolent extrinsic erosion of the sec-
ond and third metatarsals (arrowheads). (b) CT scan reveals a small focus of nonspecific calcification
(arrow) (not seen on the radiograph) in the soft-tissue mass, which extends between the first to third
metatarsals (arrowheads). (c) Short axis T2-weighted (2100/90) MR image shows an intermediate-sig-
nal-intensity soft-tissue mass (*) with extension dorsally (white arrow) between the second and third
metatarsals that causes the extrinsic erosion of bone (black arrow).

Involvement of underlying bone is not uncom- Aggressive bone inva-

mon, particularly in comparison to the low fre- sion and destruction of the trabeculae in the mar-
quency of osseous extension seen with other soft- row canal is less common and may be seen in ap-
tissue sarcomas (46). Extrinsic erosion of bone or proximately 5% of cases (1,43) (Figs 5, 11).
periosteal reaction has been reported in 11%– Angiographic descriptions of synovial sarcoma
20% of synovial sarcomas (46,47) (Figs 2, 10). are limited. In our experience, lesions are usually
The bone erosion often has an indolent nonag-
Teaching gressive appearance on radiographs, which can
Point lead to misinterpretation of the lesion as repre-
senting a benign process.
 1554 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 11. Synovial sarcoma in the foot with bone invasion in a 29-year-old woman with a 10-year history of foot
pain and treatment for plantar fasciitis without relief. (a, b) Short axis (a) and sagittal (b) T1-weighted MR images
(750/19) show a multilobulated soft-tissue mass (*) with septa (arrowheads) in the plantar aspect of the midfoot.
There is deep erosion and invasion of the third and fourth metatarsal bases (arrows). (c) Photograph of the sagittally
sectioned gross specimen demonstrates identical features corresponding to the imaging findings: multilobulated soft-
tissue mass (M) with deep erosion and invasion of the fourth metatarsal base (*). (d) Photograph of a sagittally sec-
tioned whole-mounted specimen (H-E stain) from a different patient also reveals a synovial sarcoma in the plantar
soft tissues (S) invading the metatarsal marrow (M).

Figure 12. Synovial sarcoma adjacent to the ankle in a 37-year-old woman with a soft-tissue mass noted after
trauma and development of hematoma. (a) Angiogram shows dense tumor staining and neovascularity (arrowheads)
of the large soft-tissue mass adjacent to the ankle. The posterior tibial artery is displaced (arrows). (b) Axial T2-
weighted (2000/80) MR image reveals marked heterogeneity and multilobulation (bowl of grapes sign) with the triple
sign (areas of high [H], intermediate [I], and low [L] signal intensity), fluid levels (arrowheads) resulting from hemor-
rhage, and cortical erosion (arrows). (c) Photograph of the sectioned gross specimen shows the multilobulated hem-
orrhagic morphology (*) corresponding to the MR imaging appearance.
 RG f Volume 26 ● Number 5 Murphey et al 1555

RadioGraphics

Figure 13. Synovial sarcoma of the foot in a 15-year-old girl with a 7-year history
of a soft-tissue mass. The patient initially presented at age 8 years with a foot mass
that was presumed to be a fibroma and was monitored; however, the patient devel-
oped increasing pain. (a) Lateral radiograph shows subtle fullness of the soft tissue
in the plantar aspect of the foot (*). (b– d) Sagittal T1-weighted 550/20) images ob-
tained without (b) and with (c) intravenous contrast material and T2-weighted (d,
2000/80) MR image show a heterogeneous plantar soft-tissue mass (large arrows).
Fusiform shape is caused by location between osseous structures, including the cal-
caneus and bones of the midfoot. Prominent serpentine flow voids are seen with all
pulse sequences (large arrowheads). There is diffuse heterogeneous enhancement
following contrast material administration; however, the vascular channels remain
low signal intensity due to high flow. Foci of increased signal intensity on the T1-
weighted image (small arrowheads in b) and low signal intensity in the correspond-
ing T2-weighted image (d) represent hemorrhage. (e) Blood flow images from
bone scintigraphy reveal marked increased radionuclide uptake (arrows) reflecting
the high degree of vascularity. (f) Photograph of the sagittally sectioned gross speci-
men demonstrates the fusiform-shaped synovial sarcoma (*) with several visible
vessels (arrows).

The radionuclide uptake is often heterogeneous

owing to the intermixture of viable and necrotic
regions frequently seen with synovial sarcoma
hypervascular and displace the native vessels (Fig (48,49). Static bone scintigraphic images may
12). Arteriovenous shunting is seen in approxi- also reveal increased radionuclide uptake, per-
mately 24% of cases (24). haps associated with calcification, although the
Scintigraphic evaluation of synovial sarcoma activity is typically less intense than that seen in
may reveal prominent increased uptake of techne- the blood flow and blood pool phases (48,49)
tium-99m methylene diphosphonate on blood (Figs 13, 14). Positron emission tomography of
flow and blood pool images, a finding that reflects
the increased vascularity of these lesions (48,49).
 1556 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 14. Synovial sarcoma of the thigh with neurovascular encasement in a 29-year-old man who pre-
sented with persistent painless swelling. (a) Transverse sonogram reveals a heterogeneous mixed echogenicity
soft-tissue mass (arrows). (b, c) Blood pool (b) and delayed static (c) images from bone scintigraphy demon-
strate heterogeneous radionuclide uptake with central photopenia. (d, e) Axial T1-weighted (a, 600/30) and
T2-weighted (b, 2000/100) MR images show a soft-tissue mass in the medial aspect of the right thigh (arrows).
The soft-tissue mass encases the neurovascular bundle, including the superficial femoral vessels (arrowhead). A
peripheral area of hemorrhage has high signal intensity (star) with both pulse sequences. (f, g) Photographs of
the sectioned gross specimen following amputation shows the encasement of the neurovascular structures (ar-
rowheads) by the tumor (*).
 RG f Volume 26 ● Number 5 Murphey et al 1557

RadioGraphics synovial sarcoma has been reported in only lim- CT is also useful for detecting calcification and
ited studies, but it demonstrates marked in- bone involvement in synovial sarcoma, particu-
creased tracer accumulation with high standard larly in complex areas of the anatomy such as the
uptake values (50). pelvis, hip, or shoulder or when the lesions are
The US appearance of synovial sarcoma has small and subtle (57,58) (Fig 10). Calcification
not been extensively reviewed. In the study by has been seen on CT images in 27%– 41% of sy-
Marzano and colleagues (51), 66% of 35 cases novial sarcomas in the largest series by Tateishi et
revealed a focal, nodular, round or lobulated, al (52) and Murphey et al (24). Calcification may
solid but hypoechoic soft-tissue mass suggestive also be identified in metastatic deposits, particu-
of a more indolent, less aggressive process (Fig 7). larly in the lung, on CT scans. Bone involvement,
Prominent heterogeneity with irregular margins either as erosion or marrow invasion, can be seen
was reported in only 14% of the 35 cases (51). A in nearly 25% of lesions in our experience (1,24,
complex sonographic appearance was seen in 43) (Fig 10).
20% of the 35 cases, with both homogeneous hy- With its superior contrast resolution, MR im-
poechoic well-defined areas (representing regions aging is the optimal radiologic modality for as-
of hemorrhage or necrosis) and heterogeneous sessing the extent and intrinsic characteristics of
more echoic areas with irregular margins (corre- synovial sarcomas (similar to its ability to depict
sponding to cellular areas of aggressive viable tu- other soft-tissue tumors) for staging and diagno-
mor) (51) (Fig 14). Doppler US studies would be sis, respectively (25,59 – 64). On T1-weighted
expected to demonstrate vascularity in the areas MR images, synovial sarcoma typically appears as
of viable tumor. a prominently heterogeneous multilobulated soft-
The most common CT appearance of synovial tissue mass with signal intensity similar to or
sarcoma is that of a heterogeneous deep-seated slightly higher than that of muscle (60 – 65).
soft-tissue mass with attenuation similar to or Prominent heterogeneity with predominant high
slightly lower than that of muscle (1,19,51–55) signal intensity is also a feature of these lesions on
(Fig 8). Areas of lower attenuation representing T2-weighted MR images (60 – 65). This signal
necrosis or hemorrhage are also common (Figs 3, heterogeneity has been described as the triple sign
8), although smaller lesions may be more homo- by Jones and co-workers (25), represented by in-
geneous. In a minority of cases, low-attenuation termixed areas of low, intermediate, and high sig-
areas may be the predominant CT feature, an nal intensity on long repetition time images (Figs
appearance that simulates a hematoma or cystic 9, 12, 15). This marked heterogeneity and triple
mass (56). This CT appearance was described by sign on T2-weighted MR images is presumably
Nakanisha et al (56) in seven patients and in 6% the result of the mixture of solid cellular elements
of 35 cases by Marzano and colleagues (51). Sy- (intermediate signal intensity), hemorrhage or
novial sarcoma frequently demonstrates a multi- necrosis (high signal intensity), and calcified or
nodular morphology on CT scans. In a study by fibrotic collagenized regions (low signal inten-
Tateishi and colleagues (52), a well-defined mar- sity). The triple sign has been described as occur-
gin was observed in 53% of 30 lesions, compared ring in 35%–57% of cases in larger series (25,51,
with 47% that had an irregular margin. CT scans 52). Based on our own experience, we agree that
obtained after administration of intravenous con- this feature is frequent in synovial sarcoma. How-
trast material show heterogeneous enhancement ever, the triple sign is also seen in other soft-tissue
in 89%–100% of cases (52) (Fig 9). This feature neoplasms, particularly malignant fibrous his-
is quite helpful for distinguishing those synovial tiocytoma; therefore, this finding alone lacks a
sarcomas that initially appear as a cystic lesion or high degree of specificity. The multilobulated
hematoma on precontrast images, as the hetero-
geneous enhancement pattern excludes these di-
agnoses (56). Nodular areas of enhancement may
also be seen in these lesions (Fig 3).
 1558 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics

Figure 15. Synovial sarcoma about the knee in a 46-year-old man with
knee pain of several years duration and a progressively enlarging soft-tissue
mass. (a– c) Coronal T1-weighted (600/18) MR images without (a) and
with (b) intravenous contrast material and T2-weighted (c, 3000/108) MR
image show a juxtaarticular heterogeneous soft-tissue mass (arrows) medial
to the knee. The triple sign is present on the T2-weighted MR image (c),
with the hemorrhagic nonenhancing high-signal-intensity regions (H, also
high signal intensity on the T1-weighted image), a low-signal-intensity focus
(arrowhead), and diffusely enhancing intermediate-signal-intensity cellular
solid areas (*). (d) Photograph of the sectioned gross specimen also reveals
solid (S) and hemorrhagic cystic (H) regions.

appearance with intervening septa described in

67%–75% of cases by Tateishi and colleagues Lesion margins of synovial sarcomas may be
(52) and by Blacksin and co-workers (65) (Figs well defined on MR images in 53%–91% of cases
7, 11, 12, 16) is particularly well seen on T2- or poorly defined and irregular in 9%– 47% (24,
weighted images of larger lesions. Areas of hem- 25,52,64). Lesions smaller than 5 cm are much
orrhage, seen as fluid levels or foci of high signal more frequently well defined, again mimicking a
intensity on T1- and T2-weighted MR images are less aggressive process (65) (Fig 17). Areas of cal-
frequent and are seen in up to 47% of cases (Figs cification remain low to intermediate signal in-
12, 16). Fluid levels have been described in 10%– tensity on all MR images regardless of pulse se-
25% of synovial sarcomas in several series. In our quence but are much more easily and frequently
experience, this combination of features, particu- detected on radiographs or CT scans (Figs 8, 10).
larly largely cystic areas or prominent hemor- Areas of calcification may also appear less exten-
rhagic foci, often creates a bowl of grapes appear- sive on MR images compared with radiographs or
ance (Fig 12). Smaller lesions (⬍5 cm at presen- CT scans owing to intermixture with viable tu-
tation) may have a predominantly homogeneous mor cells (Fig 8). Bone involvement, manifested
appearance on all MR images, regardless of pulse either by cortical erosion or invasion of the mar-
sequence, a finding that simulates a less aggres- row space, is seen on MR images in up to 21% of
sive process as described by Blacksin and co- cases (24,25,64) (Figs 5, 10 –12). In our experi-
workers (65) (Fig 17). ence, neurovascular encasement is also not un-
usual and has been reported in 17%–24% of cases
of synovial sarcoma (24,25,64) (Fig 14). We be-
lieve the frequency of neurovascular encasement
 RG f Volume 26 ● Number 5 Murphey et al 1559

RadioGraphics

Figure 16. Synovial sarcoma of the popliteal fossa with a large cystic component in a
39-year-old woman who presented with a slow-growing soft-tissue mass. (a– c) Axial T1-
weighted (a, 500/12), sagittal T2-weighted (3575/90) fat-suppressed (b), and sagittal T1-
weighted (637/9) fat-suppressed postcontrast (c) MR images show a large multilobulated
popliteal soft-tissue mass (large arrows). Large nonenhancing hemorrhagic regions (H) with
fluid levels (small arrows) are prominent (bowl of grapes sign) with intervening septa (arrow-
heads). Solid viable regions of the tumor (*) reveal diffuse enhancement and intermediate
signal intensity on the long repetition time image (b). (d) Photograph of the sectioned gross
specimen shows hemorrhagic cystic areas (H) and solid regions (S) that correlate with the
imaging appearance.

Figure 17. Small synovial sarcoma adjacent to the elbow with well-defined margins in a
16-year-old boy with a 1-year history of pain and swelling. (a, b) Sagittal T1-weighted (a,
383/8) and axial fat-suppressed proton-density-weighted (b, 2700/32) MR images show a
small well-defined homogeneous soft-tissue mass (arrows) adjacent to the anterior recess
of the elbow joint. There is a mild lobulation at the lesion margins. (c) Photograph of the
sectioned gross specimen reveals a small well-defined relatively homogeneous soft-tissue
mass (M) with mildly lobulated margins that corresponds to the imaging findings.
 1560 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics is likely related to the origin of the majority of followed by washout (five of six patients) or pla-
these lesions in an intermuscular site near the teau (one patient), whereas 40% revealed a late
neurovascular bundle. An intermuscular origin is sustained increase in enhancement after the initial
also suggested by a rim of fat about these lesions rapid enhancement (66). The only pharmokinetic
seen on MR images (Fig 7); this split fat sign is a feature highly associated with malignancy that
common feature in our experience. Because the was seen in all 10 synovial sarcomas was early
neurovascular bundle is surrounded by fat nor- enhancement within 7 seconds following arterial
mally, masses arising in this site maintain a rim of enhancement (66). The pattern of initial en-
fat about them as they slowly enlarge. The split hancement was diffuse (40% of cases), heteroge-
fat sign is not specific for synovial sarcoma, be- neous (40%), or peripheral (20%) (66). Contrast
cause any mass arising in an intermuscular loca- material enhancement can be particularly impor- Teaching
Point
tion may have similar features. Synovial sarcomas tant for distinguishing synovial sarcomas with
also frequently invade adjacent muscle. Synovial predominantly cystic characteristics with standard
sarcomas originating in a joint, although unusual, T1- and T2-weighted sequences (57) (Fig 16). In
are well evaluated with MR imaging. An intraar- these lesions, solid nodular foci of enhancement
ticular synovial sarcoma most commonly occurs are invariably seen, findings that represent viable
in the anterior portion of the knee in the Hoffa fat nonnecrotic regions (Fig 16). Recognition of
pad in our experience (Fig 4). A synovial sarcoma these solid areas is particularly important, as im-
that invades the adjacent joint is more frequent aging guidance (with either CT or US) may be
than an intraarticular lesion because of these le- required to direct biopsy of these foci that harbor
sions’ proximity to articulations and is also well diagnostic tissue for our pathology colleagues,
evaluated with MR imaging. We believe this leading to the correct diagnosis. We have never
manifestation is most commonly seen in synovial seen (nor has any case been reported in the litera-
sarcomas arising in the popliteal fossa, and sagit- ture, to the best of our knowledge) a synovial sar-
tal MR imaging may reveal joint invasion through coma that truly simulates a cyst on contrast-en-
the posterior knee capsule with involvement of hanced MR images (thin peripheral and septal
the posterior and anterior cruciate ligaments enhancement only).
(Fig 5). The prognostic significance of imaging features
MR imaging performed after intravenous in- (CT and MR) for synovial sarcoma was recently
jection of contrast material typically shows promi- described by Tateishi and co-workers (52). Statis-
nent enhancement in synovial sarcomas. The en- tically significant imaging features that favored a
hancement is more commonly heterogeneous high-grade synovial sarcoma included absence of
(83%–100% of lesions) than homogeneous (0%– calcification, presence of cystic components, pres-
17% of lesions) (24,25,64). This heterogeneous ence of hemorrhage, and presence of the triple
enhancement reflects the intermixture of nonen- sign (52). Imaging findings that were seen only
hancing necrotic, cystic, or hemorrhagic regions with high-grade lesions were cystic components,
and enhancing solid regions. The pattern of con- hemorrhage, fluid levels, and the triple sign (52).
trast enhancement may be diffuse when the ma- In addition, Tateishi and colleagues (52) ob-
jority of the tumor is viable, or, in largely necrotic served a statistically significant improvement in
lesions, it may appear peripheral or nodular with disease-free survival for patients whose lesions
or without thick septa (⬎3 mm) (Fig 16). In ap- had calcification but no hemorrhage or triple sign.
proximately one-third of synovial sarcomas, we Metastases-free survival was statistically signifi-
have noted serpentine vascular channels, a feature cantly increased for patients whose lesions had
that is unusual in many other soft-tissue neo- internal septa but no fluid levels (52). We are not
plasms (24) (Fig 13). The identification of these aware of any studies that have shown any signifi-
vascular channels largely limits the radiologic dif- cant imaging differences between monophasic
ferential diagnosis to alveolar soft part sarcoma, and biphasic synovial sarcomas.
metastatic renal carcinoma, hemangiopericytoma, Following chemotherapy or radiation therapy,
hemangioendothelioma, rhabdomyosarcoma, increasing signal intensity may be seen within the
extraskeletal Ewing sarcoma, and synovial sar- synovial sarcoma on T2-weighted MR images, a
coma. The dynamic contrast-enhanced MR im- finding that corresponds to progressive necrosis.
aging appearance of synovial sarcoma has been Tumor size may also show a reduction in re-
described by van Rijswijk and colleagues (66) in sponse to this therapy. Edema surrounding the
10 patients. In their study, 60% of cases showed tumor, typically not a significant feature before
rapid progressive linear increase in signal intensity therapy, may also develop subsequent to adjuvant
treatment. These posttreatment changes are often
not apparent on short echo time images.
 RG f Volume 26 ● Number 5 Murphey et al 1561

RadioGraphics

Figure 18. Recurrent synovial sarcoma of the finger in a 19-year-old man who had under-
gone resection and radiation therapy 1 year before. (a, b) Axial T1-weighted (550/20) (a)
and sagittal T2-weighted (3984/94) (b) fat-suppressed MR images show a multilobulated
recurrent soft-tissue mass (*) with septa (arrowheads) surrounding the flexor tendon (T).
There is intermediate signal intensity with both pulse sequences. (c, d) Photographs of the
gross specimen both before (c) and after (d) longitudinal sectioning reveal the multilobular
growth (*) with septa surrounding the flexor tendon (T), corresponding to the imaging
findings.

Treatment and Prognosis coma without removing an adequate rim of nor-

As with many intermediate- to high-grade pri- mal surrounding tissue is associated with high
mary malignant soft-tissue neoplasms, local con- local recurrence rates (70%– 83%) (67) (Fig 18).
trol of synovial sarcoma is primarily achieved with Amputation should be reserved for those cases in
surgery. In the past, the standard treatment of which gross resection of the tumor and preserva-
synovial sarcoma was radical surgical excision tion of a functional limb is not possible.
(removal of the entire tumor and anatomic com- The role of adjuvant therapy in the treatment
partment involved) with limb-sparing surgery if of synovial sarcoma remains controversial. Che-
possible. However, because synovial sarcoma motherapy has been used to treat metastatic or
commonly occurs near large joints and neurovas- residual disease. Studies have shown a limited
cular structures, radical surgical excision that survival benefit for high-risk patients following
leaves an adequately functional limb may be diffi- adjuvant chemotherapy (16,68 –70). The agents
cult or impossible. For that reason, the current employed are combinations of adriamycin, cispla-
treatment of choice is wide local excision (re- tin, vincristine, doxorubicin, and particularly
moval of the tumor, its pseudocapsule, and a more recently ifosfamide (71). Several groups
normal cuff of surrounding tissue). The surgical including Ruka et al (72) and Eilber et al (73)
margins should be closely evaluated to determine have shown improved 5-year disease-free survival
the need for adjuvant therapy. As expected, mar- with aggressive chemotherapeutic regimens.
ginal excision (surgical dissection plane passing
through the pseudocapsule) of the synovial sar-
 1562 September-October 2006 RG f Volume 26 ● Number 5

RadioGraphics Radiation therapy plays an important role in nostic significance. Tumor size greater than 5 cm
the treatment of marginally resected tumors at presentation has the greatest impact on prog-
(74,75). Radiation therapy should be initiated nosis, with studies showing 5-year survival rates
preoperatively if the surgeon believes that the sur- of 64% and 26% for patients with tumors less
gical margins will be positive or close. If the mar- than 5 cm and those with masses greater than 5
gins are microscopically positive in a mass that cm, respectively (16,53). Patients with tumors in
was thought to be easily resectable in a wide local the extremities have a more favorable prognosis
fashion, radiation should be given postopera- than those with lesions in the head and neck area
tively. In 1965, Cadman and co-workers (8) re- or axially, a feature that likely reflects better surgi-
ported the results of treatment in 134 cases of cal control available for extremity lesions. Desh-
synovial sarcoma. They showed a reduction in mukh and colleagues (15) reported a poorer prog-
local recurrence from 92% to 50% for patients nosis for patients with synovial sarcomas located
treated with local excision versus those treated in the proximal extremities. Others have reported
with local excision followed by postoperative ra- better prognosis for patients with tumors located
diation therapy. However, 64% of those patients in the upper extremities compared with those
with synovial sarcoma of the extremity treated with lower extremity lesions (31). Patient age of
with either amputation or wide local excision and less than 15–20 years is also associated with a bet-
radiation therapy eventually died of metastatic ter long-term prognosis (79,80). Varela-Duran
disease (8). In 1994, Mullen and Zagars (76) and Enzinger (81) reported that the presence of
demonstrated 5-, 10-, and 15-year survival rates extensive calcifications suggests improved long-
of 76%, 63%, and 57%, respectively, for synovial term survival, with 5-year survival rates of 82%
sarcoma patients treated with conservative sur- and decreased rates of local recurrence (32%) and
gery and radiation therapy. More recently, Ferrari metastatic disease (29%). There is considerable
and colleagues (16) reported a 5-year local-recur- controversy about the prognostic significance of
rence-free survival rate following marginal resec- tumor cell type (monophasic or biphasic). Al-
tion with postoperative irradiation of 57% versus though some authors report more indolent behav-
7% for patients who did not undergo radiation ior with biphasic synovial sarcomas compared
therapy. There was no statistically significant dif- with monophasic synovial sarcomas (16), other
ference in survival rates for patients whose syno- authors have found no statistically significant out-
vial sarcomas were completely resected (16). come (79,82). However, the poorly differentiated
Patients with synovial sarcoma, since it is an subtype is associated with a worsened prognosis,
intermediate- to high-grade sarcoma, have a with a 5-year survival rate of only 20%–30%
5-year survival rate ranging from 36% to 76%. At (83,84). In addition, the presence of 20% or
10 years, the survival rate has been reported to greater areas of poorly differentiated components
range from 20% to 63% (16). The clinical course is associated with an adverse outcome (31). Other
of synovial sarcoma is characterized by a high rate pathologic factors associated with worsened prog-
of local recurrence and metastatic disease. Local nosis include presence of rhabdoid cells, extensive
recurrence following resection occurs in 30%– tumor necrosis, high nuclear grade, p53 muta-
50% of patients, and distant metastasis develops tions, and high mitotic rate (⬎10 mitoses/10
in 41% (16) (Fig 18). The majority of metastases high-power field) (2–5,85). More recently, the
occur within the first 2–5 years after treatment. gene fusion type SYT-SSX2 (more common in
However, there are numerous reports of late me- monophasic lesions) has been associated with an
tastases occurring up to 26 years after the initial improved prognosis, compared with that for
diagnosis, which likely reduces the 10-year versus SYT-SSX1, and an 89% metastasis-free survival
5-year survival rates. Metastases are present in (2–5,86,87).
16%–25% of patients at their initial presentation
(77,78). The most frequent metastatic site is the Summary
lung, which is affected in 94% of cases, followed Synovial sarcoma is the fourth most common ma-
by lymph nodes (4%–18%) and bone (8%–11%) lignant primary soft-tissue neoplasm. The radio-
(1–5,16,77,78) (Fig 9). logic manifestations and spectrum of synovial
Multiple clinical and pathologic factors, in- sarcoma reflect the underlying pathologic ap-
cluding tumor size, location, patient age, and pearance. We have reviewed, illustrated, and cor-
presence of poorly differentiated areas, have prog- related the clinical, pathologic, and radiologic
features of synovial sarcoma as well as the treat-
ment and prognosis. Although the radiographic
 RG f Volume 26 ● Number 5 Murphey et al 1563

RadioGraphics characteristics of synovial sarcoma are not patho- 7. Hare HF, Cerny MJ Jr. Soft tissue sarcoma: a re-
gnomonic, the findings of a soft-tissue mass, par- view of 200 cases. Cancer 1963;16:1332–1337.
8. Cadman NL, Soule EH, Kelly PJ. Synovial sar-
ticularly if calcified, near but not in a joint in a coma: an analysis of 34 tumors. Cancer 1965;18:
young patient (15– 40 years of age) are very sug- 613– 627.
gestive of this diagnosis. Cross-sectional imaging 9. Kransdorf MJ. Malignant soft-tissue tumors in a
features are vital for staging extent and for plan- large referral population: distribution of diagnoses
ning surgical resection. They also frequently re- by age, sex, and location. AJR Am J Roentgenol
1995;164:129 –134.
veal suggestive appearances of multilobulation 10. Thompson DE, Frost HM, Hendrick JW, Horn
and marked heterogeneity (creating the triple RC Jr. Soft tissue sarcomas involving the extremi-
sign) with hemorrhage, fluid levels, and septa ties and the limb girdles: a review. South Med J
(creating the bowl of grapes sign). Two features 1971;64:33– 44.
associated with synovial sarcoma that may lead to 11. Tsujimoto M, Aozasa K, Ueda T, et al. Soft tissue
sarcomas in Osaka, Japan (1962–1985): review of
an initial mistaken diagnosis of a benign indolent 290 cases. Jpn J Clin Oncol 1988;18:231–234.
process are slow growth (average time to diagno- 12. Gustafson P. Soft tissue sarcoma: epidemiology
sis, 2– 4 years) and small size (⬍5 cm at initial and prognosis in 508 patients. Acta Orthop Scand
presentation); in addition, these lesions may dem- Suppl 1994;259:1–31.
onstrate well-defined margins and homogeneous 13. Trassard M, Le Doussal V, Hacene K, et al. Prog-
nostic factors in localized primary synovial sar-
appearance on cross-sectional images. Synovial coma: a multicenter study of 128 adult patients.
sarcoma is an intermediate- to high-grade lesion, J Clin Oncol 2001;19:525–534.
and, despite initial aggressive wide surgical resec- 14. Spillane AJ, A’Hern R, Judson IR, Fisher C,
tion, local recurrence and metastatic disease are Thomas JM. Synovial sarcoma: a clinicopatho-
common and prognosis is guarded. Understand- logic, staging, and prognostic assessment. J Clin
Oncol 2000;18:3794 –3803.
ing and recognizing the spectrum of radiologic 15. Deshmukh R, Mankin HJ, Singer S. Synovial sar-
appearances and their pathologic bases allow im- coma: the importance of size and location for sur-
proved patient assessment and are important for vival. Clin Orthop Relat Res 2004;419:155–161.
optimal clinical management. 16. Ferrari A, Gronchi A, Casanova M, et al. Synovial
sarcoma: a retrospective analysis of 271 patients of
Acknowledgments: The authors gratefully acknowl- all ages treated at a single institution. Cancer
edge the residents, without whom this project would 2004;101:627– 634.
not be possible, who attend the AFIP’s radiologic pa- 17. Lewis JJ, Antonescu CR, Leung DH, et al. Syno-
thology courses (past, present, and future) for their vial sarcoma: a multivariate analysis of prognostic
contribution to our series of patients. factors in 112 patients with primary localized tu-
mors of the extremity. J Clin Oncol 2000;18:
2087–2094.
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 RG Volume 26 • Volume 5 • September-October 2006 Murphey et al
RadioGraphics

From the Archives of the AFIP: Imaging of Synovial Sarcoma

with Radiologic-Pathologic Correlation
Mark D. Murphey, MD et al
RadioGraphics 2006; 26:1543–1565 ● Published online 10.1148/rg.265065084 ● Content Codes:

Page 1544
Synovial sarcoma occurs most frequently in adolescents and young adults, with the majority of
patients presenting at 15-40 years of age (2,9).

Page 1545
The long duration of symptoms and initial slow growth of synovial sarcomas may simulate those of or
give a false impression of a benign process.

Page 1549
Calcification is identified in up to 30% of synovial sarcomas at radiography (1, 43).

Page 1553
The bone erosian often has an indolent nonaggressive appearance on radiographs, which can lead to
misinterpretation of the lesion as representing a benign process.

Page 1560
Contrast material enhancement can be particularly important for distinguishing synovial sarcomas
with predominantly cystic characteristics with standard T1- and T2-weighted sequences (57).