A rare case of synovial sarcoma presenting as abdominal pain
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Sarcomas are a rare but aggressive type of malignancy that are often diagnosed late. This case describes an atypical presentation of sarcoma manifesting as abdominal pain, which previously has not been found in literature and highlights the importance of pursuing additional workup when clinical suspicion for malignancy arises.

A 47-year-old male triathlon athlete presents to primary care clinic with 2 months of abdominal discomfort that evolved from an epigastric to a generalized abdominal pain. It is associated with nausea, decreased oral intake, early satiety, odynophagia, and unintended weight loss of 20 pounds over 2 months. The pain is worse with meals and did not improve with the use of H2 blockers. He did not have unexplained fever, respiratory symptoms, or chest pain.

He also had no changes in bowel movement, melena, or hematochezia. Review of systems was unremarkable other than feeling like he pulled a muscle in this right thigh a few months ago as he was training for a triathlon, for which he takes ibuprofen. His right hip and thigh area gradually grew more sore, contributing to performance decline. On examination, he had abdominal tenderness to palpation in all quadrants without organomegaly, guarding, rebound, or referred pain.

Initial labs with CBC, CMP, and lipase were within normal limits. Patient underwent an upper endoscopy after initial presentation of abdominal pain associated with food intake and weight loss due to concern for upper GI malignancy. The EGD was negative.

In the setting of progressive symptoms, imaging with CT abdomen and pelvis was ordered. It showed a large soft tissue mass measuring 7.3 × 8.3 cm in the right anterior quadriceps femoris muscle, with mass effect upon the vastus lateralis, vastus medialis, and rectus femoris muscles.

Pathology from the mass biopsy revealed high-grade monomorphic synovial sarcoma, spindle cell type. The synovial sarcoma had a SS18 gene locus rearrangement present.

He was treated with four cycles of neoadjuvant chemotherapy with ifosfamide and mesna, as well as neoadjuvant radiation therapy. He underwent surgery of the thigh mass 3 weeks after completion of neoadjuvant treatment. He continued on adjuvant chemotherapy with adriamycin and ifosfamide and has completed six cycles.

Source: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.3432?af=R
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