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Synovial Sarcoma Mimicking Haemophilic Pseudotumour

Synovial Sarcoma Mimicking Haemophilic Pseudotumour Hindawi Publishing Corporation Sarcoma Volume 2006, Article ID 27212, Pages 1–3 DOI 10.1155/SRCM/2006/27212 Case Report 1 1 1 2 Haroon A. Mann, Andrew Hilton, Nicholas J. Goddard, Michael A. Smith, 3 4 Brian Holloway, and Christine A. Lee Department of Trauma & Orthopaedics, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Department of Trauma & Orthopaedics, St Thomas’ Hospital, London SE1 7EH, UK Department of Radiology, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Haemophilia and Haemostasis Unit, Katherine Dormandy Centre, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Received 21 April 2005; Accepted 13 June 2006 This is a case of a 36-year-old gentleman with haemophilia A who was presented with an acute atraumatic soft tissue swelling in the right thigh. Open biopsy was performed with the resultant diagnosis of a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudotumour. The findings reported on MRI scan initially were highly consistent with those present in patients with mild haemophilia. An important part of orthopaedic manage- ment in haemophilia is concerned with intraarticular and intramuscular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clinician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophilic patient. Copyright © 2006 Haroon A. Mann et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION subsequent angiogram showed no evidence of vessels sup- plying the lesion or the presence of arteriovenous malfor- Soft tissue sarcomas account for approximately 5–10% of all mations. MRI scanning confirmed an 18 × 10 × 11 cm loc- mesenchymal malignancies. Synovial cell sarcomas are the ulated cystic lesion in the anterior compartment of the thigh commonest of the soft tissue sarcoma especially in people involving the vastus intermedius and vastus medialis mus- aged between fifteen and forty years. Overall there are two cles. T1 weighting (T1W) demonstrated a lesion with periph- eral high signal (Figure 1). Gradient-echo T2-weighted im- hundred new cases in the UK and eight hundred in the USA presenting to clinicians annually. ages revealed marked signal drop out centrally due to mag- netic susceptibility artefact from altered blood products, usu- We presentanunusual case of asynovialcellsarcoma in ally haemosiderin (Figure 2). The mass was shown to extend a patient with mild haemophilia A. posteriorly as far as the medial cortex of the femur and medi- ally to the femoral canal (Figure 3). No extension into bone CASE REPORT was seen. It was concluded that appearances were consistent with those of an organising haematoma. Given the past med- A 36-year-old Sudanese gentleman with mild haemophilia A ical history, a provisional diagnosis of haemophilic pseudo- (F VIII :Clevel38iu/dl/normalrange > 50 iu/dl) presented tumour was made. with a five-week history of an atraumatic cystic swelling in Standard conservative treatment was commenced with a the anterior aspect of the right thigh. Clinically this cystic continuous infusion of factor VIII, analgesia, and bed rest. lesion was typical of a haemophilic pseudotumour. Despite this, the pain and swelling increased over the next On examination there was an 8 × 10 cm mass in the an- five days and it was decided to evacuate the haematoma. terior compartment of the right thigh which was tender to The haematoma was excised and approximately one litre of palpation. freshly clotted and organised blood was drained. Haemosta- Ultrasound scan examination revealed a large heteroge- sis was achieved and the entire cavity packed. However, over neous mass of mixed echotexture with a central area of liq- the following seven days the swelling in the right thigh re- uefaction consistent with an intramuscular haematoma. A curred. A further MRI scan was performed and the findings 2 Sarcoma were once more consistent with further haematoma forma- tion. Approximately 1 litre of clotted blood was drained un- der ultrasound guidance. Six weeks after the initial presentation the swelling re- curred with an overall increase in size. It was decided to per- form an open exploration, and a biopsy was taken of the cyst wall. Subsequent histology revealed poorly differenti- ated synovial sarcoma. Staging of the tumour was performed with a CT of the thorax which demonstrated pulmonary metastatic disease. The tumour was found to be unresectable and a complete disarticulation of the hip was subsequently performed. The patient went on to a course of combination chemotherapy. Figure 1: T1-weighted axial spin-echo pulse sequence. Huge mass seen in the right anterior thigh. Peripheral high signal is in keeping with methaemoglobin. DISCUSSION Synovial cell sarcoma is a relatively frequent soft tissue sar- coma. It is the fifth most common soft tissue malignancy and is one of the most common soft tissue sarcomas in adolescents and young adults, presenting in some 13% of soft tissue malignancy. Synovial cell sarcomas are a misnomer in that they do not arise from synovium. They are so named due to their resemblance to synovium on light microscopy. The presentation is most commonly between 15 and 35 years but has been reported in children and even in neonates [1, 2]. Patients may present with symptoms of pain or a pal- pable mass slowly increasing in size. The extremities have a preponderance to synovial sarcomas with up to 90% occur- ring at these sites. The lower limb is a frequent site, with 60– 70% of tumours occurring in the thigh or calf. The popliteal fossa is also frequently involved [3, 4]. Less common sites in- clude the head and neck, thorax, pelvis, and the paravertabral regions. Radiographs may be normal but up to 50% of cases show Figure 2: T1-weighted coronal spin-echo pulse sequence. Periph- the presence of a nonspecific mass [5], 25% of tumours have eral high signal is seen within the entire lesion. areas of calcification, typically in the periphery of the lesion. Up to 20% of tumours may involve adjacent bone, evidenced as periosteal reaction, extrinsic erosion or aggressive osseous invasion. On MRI and CT scan, synovial sarcoma is usually seen as a heterogeneous mass. CT frequently shows necrosis and haemorrhagic areas of lower attenuation with other areas of soft tissue attenuation similar to that of muscle. Haemophilic pseudotumours are a rare but serious con- dition in patients with haemophilia. They present as progres- sive cystic swellings encapsulating a haematoma and com- monly involving muscles adjacent to bones to muscles in the proximal skeleton [6]. They are classified according to their location as subcutaneous, intramuscular, interfascial, subpe- riosteal, and intraosseous. Their pathology is described in ac- cordance to haematomas in various stages of resolution and occasionally by new haemorrhage within areas of fibrous or- ganisation. Features characteristic to both haemophilic pseudotu- mors and soft tissue sarcomas may be nonspecific and there- fore pose a potential diagnostic dilemma. The MRI signal characteristics of soft tissue haemorrhage depend on the age Figure 3: T2-weighted gradient-echo pulse sequence. Marked low of the haemorrhage. In the acute stage (1–6 days) an interme- signal is seen centrally secondary to magnetic susceptibility artefact from haemosiderin. diate signal intensity on T1W images and low signal intensity Haroon A. Mann et al 3 on T2Wimagesisseen. Afterthe first week,haemoglobin [5] Bogumill GP, Bruno PD, Barrick EF. Malignant lesions mas- querading as popliteal cysts. A report of three cases. Journal of is oxidised to methaemoglobin leading to high intensity sig- Bone and Joint Surgery. American. 1981;63(3):474–477. nal on T1W. T2W images may be of either low (due to [6] Fernandez de Valderrama JA, Matthews JM. The haemophilic intracellular methaemoglobin) or high (due to extracellu- pseudotumour or haemophilic subperiosteal haematoma. lar methaemoglobin) signal intensity. Gradient-echo pulse Journal of Bone and Joint Surgery. British. 1965;47:256–265. sequences, often employed in magnetic imaging are prone [7] Naito N, Ozaki T, Kunisada T, et al. Synovial sarcoma with a to magnetic susceptibility artefact. This occurs with materi- large hematoma in the inguinal region. Archives of Orthopaedic als which have paramagnetic properties, the commonest of and Trauma Surgery. 2000;120(9):533–534. which is chronic blood products. [8] Ogose A, Hotta T, Yamamura S, Shioya Y, Yazawa T. Ex- Soft tissue sarcomas mimicking haematomas have been traskeletal Ewing’s sarcoma mimicking traumatic hematoma. described previously [7–9]. To the best of our knowledge soft Archives of Orthopaedic and Trauma Surgery. 1998;118(3):172– tissue sarcomas mimicking as pseudotumours have only been [9] Imaizumi S, Morita T, Ogose A, et al. Soft tissue sarcoma mim- reported in the literature on two previous occasions [10, 11]. icking chronic hematoma: value of magnetic resonance imag- Diagnosis without open biopsy is extremely difficult since ing in differential diagnosis. Journal of Orthopaedic Science. techniques such as percutaneous aspiration have a low yield 2002;7(1):33–37. of tumour cells from the haematoma [9]. [10] Koepke JA, Browner TW. Chondrosarcoma mimicking pseu- The treatment of synovial sarcoma is often amputation of dotumour of haemophilia. Archives of Pathology. 1965;80:655– the limb, although wide enblock resection and limb salvage may also be performed. Up to 25% of patients present with [11] Rodriguez Merchan EC. The haemophilic pseudotumour. In- metatstatic disease at diagnosis and despite aggressive ther- ternational Orthopaedics. 1995;19(4):255–260. apy metatstatic lesions occur in up to 80% of patients [12]. [12] Ryan JR, Baker LH, Benjamin RS. The natural history of 60–90% of metastases occur in the lungs, 5–10% in lymph metastatic synovial sarcoma. Experience of the southwest on- cology group. Clinical Orthopaedics and Related Research. nodes, and 8–10% in bones. Local recurrence is common 1982;(164):257–260. within two years of initial presentation. Five-year survival [13] Vezeridis MP, Moore R, Karakousis CP. Metastatic patterns in can be anything from 27–55%. [4, 13]. The most important soft-tissue sarcomas. Archives of Surgery. 1983;118(8):915–918. factors determining prognosis are early diagnosis and small (< 5 cm in diameter) tumour size [4]. Other favourable prog- nostic features include extensive calcification, younger age, and lesions located in the extremities. CONCLUSION This is a case of a 36-year-old gentleman with haemophilia A who presented with an acute atraumatic soft tissue swelling in the right thigh (Figures 1, 2, 3). Open biopsy was per- formed with the resultant diagnosis a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudo- tumour. An important part of orthopaedic management in haemophilia is concerned with intraarticular and intramus- cular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clin- ician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophiliac. REFERENCES [1] Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St. Louis, Mo: Mosby; 1995. [2] Kransdorf MJ. Malignant soft-tissue tumors in a large referral population: distribution of diagnoses by age, sex, and location. American Journal of Roentgenology. 1995;164(1):129–134. [3] Cadman NL, Soule EH, Kelly PJ. Synovial sarcoma. An analysis of 134 tumors. Cancer. 1965;18(5):613–627. [4] Wright PH, Sim FH, Soule EH, Taylor WF. Synovial sarcoma. Journal of Bone and Joint Surgery. American. 1982;64(1):112– 122. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sarcoma Hindawi Publishing Corporation

Synovial Sarcoma Mimicking Haemophilic Pseudotumour

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Hindawi Publishing Corporation
Copyright
Copyright © 2006 Haroon A. Mann et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1357-714X
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1369-1643
DOI
10.1155/srcm/2006/27212
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Abstract

Hindawi Publishing Corporation Sarcoma Volume 2006, Article ID 27212, Pages 1–3 DOI 10.1155/SRCM/2006/27212 Case Report 1 1 1 2 Haroon A. Mann, Andrew Hilton, Nicholas J. Goddard, Michael A. Smith, 3 4 Brian Holloway, and Christine A. Lee Department of Trauma & Orthopaedics, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Department of Trauma & Orthopaedics, St Thomas’ Hospital, London SE1 7EH, UK Department of Radiology, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Haemophilia and Haemostasis Unit, Katherine Dormandy Centre, Royal Free Hampstead NHS Trust, London NW2 5QX, UK Received 21 April 2005; Accepted 13 June 2006 This is a case of a 36-year-old gentleman with haemophilia A who was presented with an acute atraumatic soft tissue swelling in the right thigh. Open biopsy was performed with the resultant diagnosis of a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudotumour. The findings reported on MRI scan initially were highly consistent with those present in patients with mild haemophilia. An important part of orthopaedic manage- ment in haemophilia is concerned with intraarticular and intramuscular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clinician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophilic patient. Copyright © 2006 Haroon A. Mann et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION subsequent angiogram showed no evidence of vessels sup- plying the lesion or the presence of arteriovenous malfor- Soft tissue sarcomas account for approximately 5–10% of all mations. MRI scanning confirmed an 18 × 10 × 11 cm loc- mesenchymal malignancies. Synovial cell sarcomas are the ulated cystic lesion in the anterior compartment of the thigh commonest of the soft tissue sarcoma especially in people involving the vastus intermedius and vastus medialis mus- aged between fifteen and forty years. Overall there are two cles. T1 weighting (T1W) demonstrated a lesion with periph- eral high signal (Figure 1). Gradient-echo T2-weighted im- hundred new cases in the UK and eight hundred in the USA presenting to clinicians annually. ages revealed marked signal drop out centrally due to mag- netic susceptibility artefact from altered blood products, usu- We presentanunusual case of asynovialcellsarcoma in ally haemosiderin (Figure 2). The mass was shown to extend a patient with mild haemophilia A. posteriorly as far as the medial cortex of the femur and medi- ally to the femoral canal (Figure 3). No extension into bone CASE REPORT was seen. It was concluded that appearances were consistent with those of an organising haematoma. Given the past med- A 36-year-old Sudanese gentleman with mild haemophilia A ical history, a provisional diagnosis of haemophilic pseudo- (F VIII :Clevel38iu/dl/normalrange > 50 iu/dl) presented tumour was made. with a five-week history of an atraumatic cystic swelling in Standard conservative treatment was commenced with a the anterior aspect of the right thigh. Clinically this cystic continuous infusion of factor VIII, analgesia, and bed rest. lesion was typical of a haemophilic pseudotumour. Despite this, the pain and swelling increased over the next On examination there was an 8 × 10 cm mass in the an- five days and it was decided to evacuate the haematoma. terior compartment of the right thigh which was tender to The haematoma was excised and approximately one litre of palpation. freshly clotted and organised blood was drained. Haemosta- Ultrasound scan examination revealed a large heteroge- sis was achieved and the entire cavity packed. However, over neous mass of mixed echotexture with a central area of liq- the following seven days the swelling in the right thigh re- uefaction consistent with an intramuscular haematoma. A curred. A further MRI scan was performed and the findings 2 Sarcoma were once more consistent with further haematoma forma- tion. Approximately 1 litre of clotted blood was drained un- der ultrasound guidance. Six weeks after the initial presentation the swelling re- curred with an overall increase in size. It was decided to per- form an open exploration, and a biopsy was taken of the cyst wall. Subsequent histology revealed poorly differenti- ated synovial sarcoma. Staging of the tumour was performed with a CT of the thorax which demonstrated pulmonary metastatic disease. The tumour was found to be unresectable and a complete disarticulation of the hip was subsequently performed. The patient went on to a course of combination chemotherapy. Figure 1: T1-weighted axial spin-echo pulse sequence. Huge mass seen in the right anterior thigh. Peripheral high signal is in keeping with methaemoglobin. DISCUSSION Synovial cell sarcoma is a relatively frequent soft tissue sar- coma. It is the fifth most common soft tissue malignancy and is one of the most common soft tissue sarcomas in adolescents and young adults, presenting in some 13% of soft tissue malignancy. Synovial cell sarcomas are a misnomer in that they do not arise from synovium. They are so named due to their resemblance to synovium on light microscopy. The presentation is most commonly between 15 and 35 years but has been reported in children and even in neonates [1, 2]. Patients may present with symptoms of pain or a pal- pable mass slowly increasing in size. The extremities have a preponderance to synovial sarcomas with up to 90% occur- ring at these sites. The lower limb is a frequent site, with 60– 70% of tumours occurring in the thigh or calf. The popliteal fossa is also frequently involved [3, 4]. Less common sites in- clude the head and neck, thorax, pelvis, and the paravertabral regions. Radiographs may be normal but up to 50% of cases show Figure 2: T1-weighted coronal spin-echo pulse sequence. Periph- the presence of a nonspecific mass [5], 25% of tumours have eral high signal is seen within the entire lesion. areas of calcification, typically in the periphery of the lesion. Up to 20% of tumours may involve adjacent bone, evidenced as periosteal reaction, extrinsic erosion or aggressive osseous invasion. On MRI and CT scan, synovial sarcoma is usually seen as a heterogeneous mass. CT frequently shows necrosis and haemorrhagic areas of lower attenuation with other areas of soft tissue attenuation similar to that of muscle. Haemophilic pseudotumours are a rare but serious con- dition in patients with haemophilia. They present as progres- sive cystic swellings encapsulating a haematoma and com- monly involving muscles adjacent to bones to muscles in the proximal skeleton [6]. They are classified according to their location as subcutaneous, intramuscular, interfascial, subpe- riosteal, and intraosseous. Their pathology is described in ac- cordance to haematomas in various stages of resolution and occasionally by new haemorrhage within areas of fibrous or- ganisation. Features characteristic to both haemophilic pseudotu- mors and soft tissue sarcomas may be nonspecific and there- fore pose a potential diagnostic dilemma. The MRI signal characteristics of soft tissue haemorrhage depend on the age Figure 3: T2-weighted gradient-echo pulse sequence. Marked low of the haemorrhage. In the acute stage (1–6 days) an interme- signal is seen centrally secondary to magnetic susceptibility artefact from haemosiderin. diate signal intensity on T1W images and low signal intensity Haroon A. Mann et al 3 on T2Wimagesisseen. Afterthe first week,haemoglobin [5] Bogumill GP, Bruno PD, Barrick EF. Malignant lesions mas- querading as popliteal cysts. A report of three cases. Journal of is oxidised to methaemoglobin leading to high intensity sig- Bone and Joint Surgery. American. 1981;63(3):474–477. nal on T1W. T2W images may be of either low (due to [6] Fernandez de Valderrama JA, Matthews JM. The haemophilic intracellular methaemoglobin) or high (due to extracellu- pseudotumour or haemophilic subperiosteal haematoma. lar methaemoglobin) signal intensity. Gradient-echo pulse Journal of Bone and Joint Surgery. British. 1965;47:256–265. sequences, often employed in magnetic imaging are prone [7] Naito N, Ozaki T, Kunisada T, et al. Synovial sarcoma with a to magnetic susceptibility artefact. This occurs with materi- large hematoma in the inguinal region. Archives of Orthopaedic als which have paramagnetic properties, the commonest of and Trauma Surgery. 2000;120(9):533–534. which is chronic blood products. [8] Ogose A, Hotta T, Yamamura S, Shioya Y, Yazawa T. Ex- Soft tissue sarcomas mimicking haematomas have been traskeletal Ewing’s sarcoma mimicking traumatic hematoma. described previously [7–9]. To the best of our knowledge soft Archives of Orthopaedic and Trauma Surgery. 1998;118(3):172– tissue sarcomas mimicking as pseudotumours have only been [9] Imaizumi S, Morita T, Ogose A, et al. Soft tissue sarcoma mim- reported in the literature on two previous occasions [10, 11]. icking chronic hematoma: value of magnetic resonance imag- Diagnosis without open biopsy is extremely difficult since ing in differential diagnosis. Journal of Orthopaedic Science. techniques such as percutaneous aspiration have a low yield 2002;7(1):33–37. of tumour cells from the haematoma [9]. [10] Koepke JA, Browner TW. Chondrosarcoma mimicking pseu- The treatment of synovial sarcoma is often amputation of dotumour of haemophilia. Archives of Pathology. 1965;80:655– the limb, although wide enblock resection and limb salvage may also be performed. Up to 25% of patients present with [11] Rodriguez Merchan EC. The haemophilic pseudotumour. In- metatstatic disease at diagnosis and despite aggressive ther- ternational Orthopaedics. 1995;19(4):255–260. apy metatstatic lesions occur in up to 80% of patients [12]. [12] Ryan JR, Baker LH, Benjamin RS. The natural history of 60–90% of metastases occur in the lungs, 5–10% in lymph metastatic synovial sarcoma. Experience of the southwest on- cology group. Clinical Orthopaedics and Related Research. nodes, and 8–10% in bones. Local recurrence is common 1982;(164):257–260. within two years of initial presentation. Five-year survival [13] Vezeridis MP, Moore R, Karakousis CP. Metastatic patterns in can be anything from 27–55%. [4, 13]. The most important soft-tissue sarcomas. Archives of Surgery. 1983;118(8):915–918. factors determining prognosis are early diagnosis and small (< 5 cm in diameter) tumour size [4]. Other favourable prog- nostic features include extensive calcification, younger age, and lesions located in the extremities. CONCLUSION This is a case of a 36-year-old gentleman with haemophilia A who presented with an acute atraumatic soft tissue swelling in the right thigh (Figures 1, 2, 3). Open biopsy was per- formed with the resultant diagnosis a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudo- tumour. An important part of orthopaedic management in haemophilia is concerned with intraarticular and intramus- cular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clin- ician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophiliac. REFERENCES [1] Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St. Louis, Mo: Mosby; 1995. [2] Kransdorf MJ. Malignant soft-tissue tumors in a large referral population: distribution of diagnoses by age, sex, and location. American Journal of Roentgenology. 1995;164(1):129–134. [3] Cadman NL, Soule EH, Kelly PJ. Synovial sarcoma. An analysis of 134 tumors. Cancer. 1965;18(5):613–627. [4] Wright PH, Sim FH, Soule EH, Taylor WF. Synovial sarcoma. Journal of Bone and Joint Surgery. American. 1982;64(1):112– 122. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

SarcomaHindawi Publishing Corporation

Published: Aug 6, 2006

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