Abstract
A 22-year-old woman presented with an abnormal chest shadow during a medical examination two months ago. A tumor of 6 cm in diameter was detected on her right diaphragm by computed tomography (CT), and she was referred to our hospital for surgical treatment. A few days before admission, fever and right chest pain developed. A chest radiograph and CT indicated pleural effusion and rapid tumor growth. Therefore, tumor rupture and hemorrhage were suspected. In order to select an appropriate treatment strategy, CT-guided biopsy was performed, and a histopathological examination demonstrated a spindle cell tumor. Thus, we judged that there was no necessity for preoperative treatment, and performed emergency surgery for diagnostic and treatment purposes. The tumor originated from the diaphragm and had infiltrated the pericardium and middle and lower lobes of the right lung. Part of the tumor exhibited hemorrhaging and necrosis. Tumor resection, lower lobe lobectomy, partial resection of the middle lobe, and reconstruction of the diaphragm and pericardium were performed. Histopathological and immunostaining examinations revealed invasive growth by spindle cells that exhibited nuclear atypia and positive reactions to epithelial markers (cytokeratin AE1/AE3 and epithelial membrane antigen). Furthermore, the SYT-SSX chimera gene was also detected in the tumor cells. We finally diagnosed the patient with synovial sarcoma of the diaphragm, monophasic type. As additional treatment, four-cycle adjuvant chemotherapy (Adriamycin+Ifosfamide) was performed. She is now alive with no evidence of recurrence 10 months postoperatively. In the case of sarcoma, selection of the initial treatment method is generally important. However, in these patients, who must be treated immediately and cannot be diagnosed definitively, determination of the treatment strategy based on the cell form of the tumor is useful.
