Case presentation
The case study is devoted to investigating headache and left hemiplegia in a 28-year-old man since 10 days prior to coming to the emergency room.Neurological examination revealed left sided hemiplegia,without gait instability and ataxia.Brain computed tomography(CT) scan revealed an intra axial mass lesion with central necrotic component and surrounding vasogenic edema in right frontal white matter causing midline shift to the left side.(FIGURE 1) The patient underwent magnetic resonance imaging (MRI) with gadolinium contrast for more evaluation,and the findings were as mentioned bellow:An Intra axial well-circumscribed heterogenous mass with central necrosis and irregular peripheral enhancement and significant surrounding vasogenic edema in right frontal white matter.restriction of peripheral solid component of mass was also seen.(FIGURE 2)
The patient was taken to the operation room and underwent total excision of the mass.Many hours later the left hemiplegia was gradually improved.The histopathological assessment of the mass revealed neoplastic tissue composed of biphasic pattern: large irregular sheets of monotonous cells some with central necrosis set in fibroblastic stroma.Tumoral cells are plump and have very high N/C ratio.Frequent mitotic figures are present.
IHC staining show positive reactivity for TLE1,FEI1 and INI1 negative reactivity for Synaptophysin,Olig 2,SMA,CK CD 99.GFAP staining is nonspecific.Above findings are consistent with Synovial Sarcoma.PET scan didn’t show any other metastatic disease. Abdominopelvic CT scan was also normal.
The patient was discharged 1 week after surgery without any neurological problems.
He underwent radiotherapy 1 month after his discharge.
4 months later,the patient came back to the neurology emergency room with left hemiplegia,he underwent CT scan findings revealed recurrence of the previous tumor(FIGURE3) ,so he was taken to operation room again and underwent total excision of the mass.The histopathological assessment showed Synovial sarcoma recurrence.PET scan was done again and there were no evidence of primary synovial sarcoma anywhere else or any other metastasis.The patient was discharged one week later without any neurological sign and symptoms.