Journal of the Louisiana State Medical Society
case at hand, atypical cytology of joint aspirate has been diagnostic in some cases. 2,3 The aspirate will often appear sanguineous, as it didwith this case. 7 If the aspirate cytology is unremarkable and there is reasonable suspicion of syno- vial metastasis, arthroscopic biopsy should be considered. At time of writing, we report the third case of metastasis to the elbow synovium. The previous cases had broncho- genic squamous cell carcinoma and colon adenocarcinoma as the primary cancers. Similar to this case, both previously reported cases featured normal cytology of the joint aspirate and required synovial biopsy for diagnosis. 8,9 Colon adenocarcinoma recurrence after polypectomy or partial colectomy usually occurs within five years post- resection. The liver is the most common metastatic site, and a spread to other organs is rare without prior liver metasta- sis. 10 There are few reported cases of colon adenocarcinoma metastasizing to the intra-articular synovium. 3,7,11 This patient’s metastasis to the synovium featured the most common histopathology (adenocarcinoma) and the second most common primary tumor location (colon). Similar to the other reported cases, unilateral joint pain was the first manifestation of a disseminated cancer. 3,7 Unusual and perhaps unique to our patient was the fact that the synoviumwas the sole initial metastatic site. The lung, bone, and muscles were later involved, but extensive oncologic workup only showed synovial involvement initially. Most reported cases have either a concurrent metastatic or primary visceral site. Bone often precedes the synovium as a metastasis site, and some postulate that synovial me- tastasis occurs by infiltration from adjacent bone. 1 This does not appear likely in this case, however, as the reverse occurred with synovial metastasis preceding and leading to subsequent bone involvement. Our case is atypical with a long latency period after resection of the primary tumor. The patient’s symptoms began 15 months following the primary tumor resection, and the diagnosis of synovial metastasis was made at 19 months post-procedure. Due to the aggressive nature of synovial metastases, localized radiation and systemic chemotherapy can be palliative in some patients, 8 but this approach did not prevent further growth and spread in this patient. CONCLUSION This case of intra-articular synovial metastasis provides an example of disease progression and can serve as a tem- plate for diagnosis andmanagement of similar cases. The dif- ferential for subacute unilateral joint pain is extensive, and synovial metastasis should not be a primary consideration. However, with the right clinical picture, and after ruling out more common etiologies, the physician should consider including synovial metastasis in their differential. When sy- novial metastasis is suspected, the first step in management should be to obtain joint aspirate for cytologic workup. This can yield a diagnosis if atypical cytology is present. If the aspirate cytology is negative, arthroscopic biopsy of synovial tissue should be considered. While arthroscopy allows for
biopsy and palliative synovectomy of hypertrophic syno- vitis, 9,12-14 it is important for the surgeon to exercise caution in the event of encountering either primary or metastatic malignancy during the procedure. Inadvertent spread of the disease may result from even minimally invasive diag- nostic procedures, including arthroscopy. 7 If malignancy is confirmed, it is reasonable, and in the patient’s best interest, to discontinue the surgery and develop an alternative plan. REFERENCES 1. Abu-Hilal M, Matteson E. Rheumatic manifestations in malignancy. Current Rheumatology Reviews . 2008;4:50-58. 2. Capovilla M, Durlach A, Fourati E, et al. Chronic monoarthritis and previous history of cancer: think about synovial metastasis. Clin. Rheumatol . 2007;26(1):60–63. 3. Ryu K, Masui F, Saito S, Marumo K. Chronic arthritis of the knee due to synovial metastasis. Jikeikai Med J . 2010;57:141-7. 4. Pieters RS, Galvin J. The rare presentation of sinus tarsi syndrome secondary to metastasis in a patient with endometrial carcinoma. Radiology Case Reports . (Online) 2011;6:414. 5. Sheldon PJ, Forrester DM, Learch TJ. Imaging of intraarticular masses. Radiographics . 2005;25(1):105–119. 6. Levine HR, Tingle E, Carter B, Dockery D. Synovial metastasis from lung cancer. Proc (Bayl Univ Med Cent) . 2013;26(1):25–27. 7. Currall VA, Dixon JH. Synovial metastasis: an unusual cause of pain after total knee arthroplasty. J Arthroplasty . 2008;23(4):631– 636. 8. Philipson JD, Birkhead R, Phillips PE. Arthritis of the elbow caused bymetastatic bronchogenic carcinoma. Clin Exp Rheumatol . 1983;1(2):165–9. 9. Ter Borg E, Slee P, Seldenrijk C. Monoarthritis of the elbow due to metastatic colon carcinoma: diagnosis based on the presence of adenocarcinoma cells in synovial fluid. Rheumatology International . 2008;28:1177-1178. 10. Scheer A, Auer RA. Surveillance after curative resection of colorectal cancer. Clin Colon Rectal Surg . 2009;22:242-50. 11. Uysal M, Goksu SS, Coskun HS, Savas B, Ozdogan M, Bozcuk H. Intraarticular hemorrhage due to bevacizumab in a patient with metastatic colorectal cancer: a case report. J Med Case Rep . 2012;6(1):188. 12. Morbidi M, Magnani M, Della Rocca C. Synovial metastasis of the shoulder detected by arthroscopy as the presenting manifestation of lung adenocarcinoma. Arthroscopy . 1998;14(5):508–511. 13. Tandogan RN, Aydogan U, Demirhan B, Arican A, Yücetürk A. Intra-articular metastatic melanoma of the right knee. Arthroscopy . 1999;15(1):98–102. 14. Tokis AV, Andrikoula SI, Chouliaras VT, VasiliadisHS, Georgoulis AD. Diagnosis and arthroscopic treatment of primary synovial chondromatosis of the shoulder. Arthroscopy . 2007;23(9):1023.e1–5.
Mr. Ballard is a third-year Medical Student at Louisiana State University Health Sciences Center in Shreveport. Dr. Cascio is the Director of Sports Medicine at Lake Charles Memorial Hospital in Lake Charles. He is also a Clinical Assistant Professor at LSUHSC in New Orleans.
52 J La State Med Soc VOL 166 March/April 2014
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