Synovial Metastasis from Lung Cancer

Abstract

Intraarticular masses are infrequently encountered in clinical practice; however, the differential diagnosis can be broad. Neoplasia, both benign and malignant, and proliferative processes are the most common etiologies. We present a case of metastatic disease in the synovium in a patient with a history of lung cancer. Lung carcinoma is the most common primary malignancy to metastasize to synovial tissue, and the knee joint is the most common joint to be affected. I n this report, we discuss the diff erential considerations for intraarticular masses and the clinical presentation of metastatic synovial disease. We discuss some fi ndings that are classic for specifi c entities; however, many radiologic fi ndings concerning synovial pathology are nonspecifi c. As the diff erential considerations for intraarticular masses are vast, clinical history is often as necessary as radiologic fi ndings to elucidate the correct diagnosis. CASE PRESENTATIONA 61-year-old man who underwent a left pneumonectomy for cancer 4 months before presentation complained of knee pain with swelling since the operation. Th e knee joint was aspirated, and the fl uid demonstrated infl ammatory white blood cells but was negative for microorganisms. A diagnosis of rheumatoid arthritis had been made in the past, but the knee pain had never been of this character or intensity. Th e patient was unable to bear weight or straighten his leg in the emergency room. On examination, he was afebrile, normotensive, and tachycardic, with underlying atrial fi brillation and a ventricular rate of 90 to 127 beats per minute. Th e knee was edematous, erythematous, and warm with a range of motion of <90°. His leukocyte count was 23,600 cells/mL.Conventional gadolinium-enhanced magnetic resonance (MR) imaging of the left knee revealed diff use enlargement of the knee joint space secondary to multilobulated and heterogenous mass-like structures (Figures 1-4). Th ese structures demonstrated heterogeneously increased T2 hyperintense and intermediate T1 intensity characteristics. Most of the joint space was replaced by hyperenhancing synovium. Enlarged lymph nodes were seen in the popliteal fossa. At that time, diff erential considerations included severe infl ammatory arthritis and rather than unusual metastasis. Surgical pathology showed a diagnosis of synovial metastasis from primary large-cell lung carcinoma. DISCUSSIONApproximately 48 cases of synovial metastasis have been reported. Adenocarcinoma has been the most common type of synovial metastasis encountered. Despite the highly vascular nature of synovial tissue, neoplastic masses in articular spaces are much less frequently encountered than mass lesions secondary to infectious and infl ammatory arthritides. If intraarticular masses are discovered when they are still small, the tissue of origin such as synovium or cartilage may be delineated. However, commonly both cell types are involved, and the type can be impossible to decipher when the mass is as large, as in the case presented. Primary lung cancer is the ...

Synovial Metastasis From Urothelial Carcinoma of the Renal Pelvis Causing Recurrent Hemarthrosis: A Rare Presentation

“…Synovial metastases are uncommon, with approximately only 50 case reports in the literature, and those originating from urothelial cancer are even more rarely seen. The majority of the cases reported in the literature originate from primary lung [5][6][7][8] and colorectal malignancies [6,[9][10][11]. The clinical presentation is often that of chronic inflammatory arthritis.…”

“…A synovial biopsy may be considered if the synovial fluid cytology is unyielding, and the index of suspicion remains high [14]. Further imaging with a CT, MRI, or bone scan has been described in previous cases to delineate any bony or soft tissue pathology [4][5][6][7][8]10,12,13].…”

“…The clinical presentation is often that of chronic inflammatory arthritis. While the pathophysiology of synovial metastases remains unproven, it has been suggested to be either through direct extension from adjacent bone metastasis or through hematogenous spread into the subintimal synovial blood vessels [ 7 , 9 , 10 , 12 ], although the latter is less common [ 5 , 11 , 12 ]. Given the lack of adjacent osseous metastases in our case, a hematogenous spread may be postulated.…”

“…The prognosis for patients with synovial metastasis is generally poor, with an average survival of approximately five months [ 4 , 5 , 8 , 12 ]. Treatment is often palliative and aims to improve the patient's quality of life by controlling pain and other symptoms.…”

Intercondylar Notch Pathology

“…Synovial metastasis is an extremely rare condition. Lung cancer is the most common malignancy to metastasize to synovial tissue, with the knee most commonly affected 80 . Although 9…”