Synovial Sarcoma 101…Explained by a Soft Tissue Pathologist

[@JMGardnerMD]

A complete organized library of all my videos, digital slides, pics, & sample pathology reports is available here: kikoxp.com/posts/5084 (dermpath) & kikoxp.com/posts/5083 (bone/soft tissue sarcoma pathology).

[@lopamudrakakoti]

Can Poorly differentiated synovial sarcoma have fibrosarcomatous pattern other than round cell morphology?

[@francocarbajal3629]

Hi Jerad, Some experience from GLI1 tumors? Apperently I have this type… they thought it was BCOR first….

[@lightenupamputee7076]

Thank you! I was diagnosed almost 4 years ago. I appreciate the info.

[@JMGardnerMD]

I am glad you found it helpful/interesting! I hope you are recovering well now and are in good health. Best wishes to you.

[@kazumithumargondalia9171]

There is a book and then there is you... Hearing you has become a priority and overseas people like us can have oppertunity to learn ..... Thanks for this hard work and we shall always be obliged...

[@JMGardnerMD]

It is my pleasure to help. Best wishes to you, my friend.

[@SandhyaRamachandran]

@kazumithumar gondalia aptly put!

[@preethipaul7180]

Thanks for sharing this amazing video with pearls of wisdom on diagnosis of Synovial Sarcoma. It's one thing to read a book, it's another to hear an expert talking and showing slides of the same. So much better! Thanks again! #SarcomaSucks

[@dohlebody]

Awesome video, thank you for taking the time to share these cases with us. Can you please do a video for myxoid lesions?

[@lehu8529]

Also reminds me a bit of angiomatoid fibrous histiocytoma in the way it forms cystic spaces and also (at least in some of the examples you’ve showed) appears to sometimes have a bit of a circumscribed border with a discrete pseudocapsule

[@JMGardnerMD]

I've seen a case of AFH that had herringbone pattern and looked very much like synovial sarcoma! They can mimic one another sometimes.

[@grigoriospanselinas1783]

Great video. Really enjoy to watch your lectures. Greetings from Greece

[@JMGardnerMD]

Thank you!!

[@jaijuvekar4211]

Wonderful as always , from basics to the diagnosis !!

[@dangthinh90]

Ok,it does not originate from synovial lining cell. Biphasic or monophasic. - Solid, might have cystic change or multinodular appearrance. - Monotonous cells. Mesenchymal cells have spindle morphology or roundish looking with necrosis in poorly differentiated case. Stag-horn vessels. Great lesson, thank you sir!

[@FiaT_LuX..1990]

Multinodular as in visual or pathologically

[@alfonzomma]

Thanks for all the content. Really appreciated. Alfonzo Halfin. Path resident in pittsburgh

[@medhachem5943]

I am from algeria I'm very grateful thank you very much I can't find the words to thank you

[@JMGardnerMD]

‏عفوا

[@yanpingwang2405]

Thanks for this wonderful video about synovial sarcoma. It covers everything about it!

[@janiranavarro]

Great video!! Thanks Dr. Gardner!

[@foxtride7890]

Had gotten this when I was 9. Wasn’t so bad, worst part of everything was probably the dozens of blood tests and when they stuck a gigantic needle in my leg to get a sample of it. Didn’t hurt though but scary. 21 now and doing good as far as I know.

[@JMGardnerMD]

Wonderful to hear you are a long term survivor! Thanks for sharing your story.

[@Kenny-gj2xl]

Omg I’m 16 and am going through treatment rn. This just gave me mad hope u have no idea.

[@luisdelascasas5799]

Excellent video. You are making a difference. Outstanding video.

[@paolatacuribravo8141]

Excellent explanation ! Thank you so much !

[@dryusra1702]

You are absolutely amazing. Thank youuu soo soo much 👍👍

[@johnfazio2892]

Nice presentation, great cases.

[@htg4666]

Hello Dr. Gardner , and thank you so much. We always pray for you for sharing your knowledge and improving pathology education all around the world. I have a question please, If a tumor's morphological, cytological and IHC features are completely identical and compatible with synovial sarcoma, but only lacks t(x ; 18), can we diagnose it as synovial sarcoma? Is the presence of t(x ; 18) mandatory and "sine qua non" for diagnosis of synovial sarcoma? Millions times thanks,

[@foxtride7890]

And this is exactly why I will never be a doctor or surgeon...

[@antoinettelatham5455]

My son was diagnosed with synovial sarcoma two years ago. No one ever mentioned monophasic etc.

[@赵柯明-t2e]

My father was diagnosed with synovial sarcoma in this year earlier . He had surgery and chemotherapy, and there seems to be no cure for this disease. How is your son? Is it cured?

[@antoinettelatham5455]

@@赵柯明-t2e Good. No Evidence of Disease. Sorry to hear about your father. Make sure he's going to a sarcoma specialist...

[@赵柯明-t2e]

@@antoinettelatham5455 I took him to see almost the best doctors in China, and also performed the most advanced treatments in China, but the lack of specific medicines still worries me. Good luck to your son and my father. I heard that the most advanced therapy is Trct therapy. I don't know how far this therapy has progressed in the United States. You can inquire

[@niftynuggets1805]

thank u so much sir.. i learn a lot from your videos

[@savikanuri7004]

Thank you sir 🙏

[@firoozehsamim4858]

Great teaching. Would it possible to include IHC slides in your videos as well?

[@JMGardnerMD]

I try to include them when it’s important to actually show what the stain looks like. But it’s hard for me to do all the time because many of these cases are from my teaching slide study set Which is almost exclusively made of H&E slides. But I will try to be more mindful in the future of saving good examples of IHC slides to use in videos.

[@svncegulsunm622]

I wish to know more about sarcoma ..since i myself one of the patients who suffered so much from it ..i dream about finding a cure for this disease.. my graduation project is going to be about it but am kind of lost and i dont know where to start from ..please do you have any suggestions ? What to work on ? What makes the synovial cells different from the normal ones ..any website suggestion to search on..do you suggest testing phyto (natural plants ) or genetics or biochemistry ? What is the best route to take to try to find a cure

[@umarfarooqkhan8208]

Very good presentation

[@amaliyadipita6906]

Thank you so much❤

[@savikanuri7004]

Sir can you please add subtitles , when you are telling about ihc

[@JMGardnerMD]

Video has subtitles. Just turn on closed caption setting.

[@lisamun1969]

excellent , I really enjoy it

[@sahilsaraf6199]

Hi thanks for the video, it was very helpful. The synovial sarcoma with geographic necrosis reminded me of epitheliod sarcoma, which would also express EMA and CK. So other than TLE1 would there be any markers that would help differentiate such cases?

[@JMGardnerMD]

INI-1. It shows loss of nuclear expression in epithelioid sarcoma. Also epithelioid sarcoma is often cd34 positive but synovial sarcoma is almost always CD34 negative. I am not a huge fan of TLE-1 since it has been relatively non specific in my experience. If I have a difficult case I just send it for SS18 FISH. It’s cheaper than doing a large panel of immunostains and much more specific.

[@sahilsaraf6199]

@@JMGardnerMD thanks that's very helpful!

[@ben16510]

Always pleasant and clear straightforward videos. Got addicted since I was initiated. What is your take on NY -ESO- on SS? Any experience on such? Thanks a million

[@JMGardnerMD]

Thank you! Re: NY-ESO, I’ve never used it so no personal experience with it. But my thoughts on it are similar to my thoughts on TLE: if it looks good for SS on H&E and it’s got CK or EMA+, then I usually just sign out as SS. If it’s difficult case on H&E, then I go straight to molecular as I won’t feel confident in stains if the histologic features are unusual. Stains are often reported as very specific at first but over time we find more and more exceptions to the rule. Same is true with molecular to some extent, but at least for SS18, it’s pretty much as close to a gold standard test as we can get in soft tissue pathology! Obviously as a sarcoma pathologist who has seen many SS, my comfort level for making a diagnosis of SS with only limited stains is probably higher than most pathologists’ would be.

[@shinyambervarshney]

Thank you for this classic presentation. Can we have a video on paediatric soft tissue tumours?

[@JMGardnerMD]

Thanks! I have several pediatric entities covered already. Plan to add more in future.

[@LOLsaudi]

So changes that may happen within a synovial sarcoma: Hypocellular myxois areas Hyalanized or keloid like collagen areas Hemangiopericytoma like vasculture Cystic changes Calcifications

[@JMGardnerMD]

Yes exactly!

[@anandraj5832]

My 30 days old baby girl has been diagnosed with this type of cancer. what are the chances of her surviving this?

[@JMGardnerMD]

I am so sorry to hear that. Synovial sarcoma is a serious type of cancer but there are many people who survive it. You might find this synovial sarcoma patient support group a helpful source of general information and empathy for you and your family: facebook.com/groups/synovialsarcomasupport/?ref=share Best wishes for healing and health for your baby girl!

[@kiransunuwar2585]

My 34 year husband also suffring from ss sarcom in lung tumor can u plzz help me

[@henatabassum7757]

Amazing explaination

[@zegganeabdennour6949]

thank you

[@raychand4776]

At 16.03 you mention that there are distinct nuclear differences between MPNST and monomorphic spindle celled synovial sarcoma; could you elaborate exactly what those are? Thank you.

[@JMGardnerMD]

Synovial sarcoma has uniform monotonous nuclei. MPNST has pleomorphism. That’s the simple explanation. Here’s the synovial sarcoma video to contrast: kzbin.info/www/bejne/e4O4hXl-f5atkK8

[@docislam8974]

thank you so so so mutch , Amazing explaination

[@yuritolkach1315]

Nice material! Thank you.

[@mdmusial]

Hi, I had a slow growing tumor 16,5 x7,3x 6,5 cm for about 15 years Surgically removed , turned out to be Low-grade fibromyxoid sarcoma Would you recommend radiation? Or just regular check up? MRI,ultrasound? Thank you very much

[@JMGardnerMD]

As a pathologist, I diagnose sarcoma but I don’t treat it. So I am not an expert in therapy. Also, since I am not your doctor and you are not my patient I cannot give you official advice of course. But for your general education, most of the sarcoma surgeons and oncologists I’ve worked with did not usually use radiation for low-grade fibromyxoid Sarcoma. But it is a rare subtype of sarcoma and I’m not sure how much proven research data exists about the role of radiation for it. It’s a good question to discuss with your doctors. In general, I think it’s a good idea for patients with Sarcoma (especially very rare types) to see doctors who have experience in treating Sarcoma. Best wishes for health and healing for you.

[@mdmusial]

@@JMGardnerMD Thank You very much for your answer all the best for you

[@123kankana]

Nice cases...Thank you

[@borahmunmi]

Very useful.

[@misterB2231]

i've seen a Synovial sarcoma in the Larynx in a 24 yo man.

[@JMGardnerMD]

Wow that’s a rare presentation.

[@misterB2231]

@@JMGardnerMD yeah unfortunately the patient died, and at presentation we tought it was a lymphoma, we were so surprised that we asked for a second pathologist opinion which confirmed the diagnosis.

[@juanchoca1961]

That poorly diferenciated SS with geographical necrosis looks like a MPNST to my inexpert eyes. Any comment about this Jerad? Thank you very much for another excellent lecture

[@JMGardnerMD]

Most helpful to me on H&E is that MPNST usually has pleomorphism (at least some) while synovial sarcoma almost never has pleomorphism. When I was a fellow, I felt the same way that these two tumors look very much alike. My mentor Mark Edgar told me no they don’t when you compare them side-by-side and he gave me a few examples of synovial sarcoma and a few examples of MPNST. When looking at them Side-by-side in direct comparison, they really do have different cytologic features even though the low power pattern is similar. Then, of course we can use immunohistochemistry and molecular testing to confirm the diagnosis of synovial sarcoma. It’s harder to prove the diagnosis of MPNST definitely since no totally specific marker or molecular, but these things help support MPNST: history of NF-1, presence of background neurofibroma, arising in nerve, PATCHY and/or weak (but not strong diffuse) s100 or sox-10 staining in about 50% of cases - the remainder are negative for these markers, and loss of H3K27me3 staining (in majority of cases but not specific finding, also this stain can be technically difficult and isn’t available in many labs). un abrazo, amigo!

[@divyasethi1509]

Thanks😀Great videos😀😀

[@goforkranthi79]

Those epitheliod cells on the last slide look a lot like PTC orphan Annie nuclei!

[@ericaayomo]

Thanks a lot!

[@sukanyabanerjeenair2803]

Thanks for that! Great compilation. What were the IHC profiles of these cases? And do you routinely confirm with FISH?

[@JMGardnerMD]

Thank you! On obvious biphasic synovial sarcoma, I usually make the diagnosis on H&E only without IHC. In monophasic synovial sarcoma, I use pancytokeratin and EMA, both of which are typically positive, and CD34, which is almost always negative. I sometimes use TLE1 (positive in most synovial sarcoma) although it isn't my favorite marker (see video for why). I don't find bcl2 or CD99 to be helpful personally. If it is an unusual case and/or IHC isn't showing expected results, then I send for SS18 breakapart FISH to confirm diagnosis. I discuss all of this and other tips about the IHC findings in detail in the video.

[@kiransunuwar2585]

SS sarcoma return in Lung tumor can u plzz help me what we do my 34 year husband suffring plzz answer

[@JMGardnerMD]

I’m so sorry. I only diagnose these tumors but I don’t treat them. Please have him seen by an oncologist at a center specializing in sarcoma treatment if possible. Also there is a synovial sarcoma patient support group on Facebook that might be helpful for you and him: facebook.com/groups/synovialsarcomasupport/?ref=share

[@TheFarfaraway92]

great!

[@bryanlatham2195]

This cancer is horrible😖

[@JMGardnerMD]

I totally agree.

[@cinderthedragon2076]

I had synovial sarcoma It’s very scary 😫

[@JMGardnerMD]

I'm so sorry to hear that. I know that any sarcoma diagnosis must be very scary for patients. Just so you know many synovial sarcoma patients do very well after treatment and are cured of their disease. I very much hope you fall into that group. Best wishes to you for good health! Jerad

[@JMGardnerMD]

Also did you know that there is a synovial sarcoma Facebook patient support group? It might be a useful place to find empathy and support from others who have experienced your disease: facebook.com/groups/synovialsarcomasupport/