Online Images in the Medical Sciences| Volume 364, ISSUE 4, e12-e14, October 2022

Pneumothorax in metastatic primary renal synovial sarcoma

      A 30-year-old female with a medical history of cholecystectomy and caesarean had sudden cough, expectoration, mild dyspnea and received anti-inflammatory treatment in her local hospital with a suspicion of cold. The symptoms did not relieve after 2 months of treatment. She was then admitted to our hospital and an admission thoraco-abdominal computed tomography (CT) showed a large well-circumscribed heterogeneous mass arising from the upper pole of left kidney which contained cyst necrosis and multi-septum (Figure 1A-B) and the volume of the mass was approximately 8.1 cm× 8.3 cm× 10.7 cm. The mass showed “slow wash in and slow wash out” and irregular, mild enhancement. The patient also showed retroperitoneal lymphadenopathy, vertebral body and iliac osteogenesis as well as multiple nodules, subpleural nodules and patchy opacities of different sizes in both lungs (Figure 1C). PET/CT showed that SUVmax was approximately 20.9 in the mass of the left kidney (Figure 2A-B). Immunohistochemical staining of the biopsied metastatic cervical lymph node yielded positive results for desmin and focally positive results for EMA, Ki67, PR, Vim, and SMA, indicating poorly differentiated synovial sarcoma (SS) (Figure 3A-F). The patient had no hematuria and no low back pain. The tumor markers were normal and the hemogram of the patient showed infection. Limited by systemic metastasis, the patient chose the neoadjuvant chemotherapy with Doxorubicin and Cyclophosphamide and was discharged. The patient was admitted to our hospital again for acute severe dyspnea after receiving 6 months of chemotherapy. A CT showed massive pneumothorax, patchy opacities of different sizes, multiple nodules and subpleural nodules in both lungs (Figure 1D). The patient placed the chest tube for one month and the pneumothorax did not improve significantly, and the air leak was persistent. Finally, she was discharged and died 8 months later because of disease progression.
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