|Year : 2018 | Volume
| Issue : 3 | Page : 248-251
Giant intra-articular synovial chondromatosis of knee joint mimicking malignancy: A rare case report
Abhijeet Ingle, Suhela Rachakonda, N Anil Kumar, Sandeep Satyanarayana
Department of Pathology, Yashoda Hospital, Hyderabad, Telangana, India
|Date of Web Publication||29-Jun-2018|
Yashoda Hospital, Malakpet, Nalgonda X Roads, Hyderabad - 500 036, Telangana
Source of Support: None, Conflict of Interest: None
Synovial chondromatosis is a rare benign condition arising from the synovial membrane of the joints, synovial sheaths, or bursae around the joints. Primary synovial chondromatosis typically affects the large joints in the third to fifth decade of life. The purpose of this case report is to document this rare giant synovial pathology, which was mimicking malignancy clinically but diagnosed as intra-articular synovial chondromatosis histopathologically. In our case, the gross size was measuring 11 cm × 8 cm × 6 cm.
Keywords: Giant, knee joint, synovial chondromatosis
|How to cite this article:|
Ingle A, Rachakonda S, Kumar N A, Satyanarayana S. Giant intra-articular synovial chondromatosis of knee joint mimicking malignancy: A rare case report. Med J DY Patil Vidyapeeth 2018;11:248-51
|How to cite this URL:|
Ingle A, Rachakonda S, Kumar N A, Satyanarayana S. Giant intra-articular synovial chondromatosis of knee joint mimicking malignancy: A rare case report. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Sep 26];11:248-51. Available from: http://www.mjdrdypv.org/text.asp?2018/11/3/248/235569
| Introduction|| |
Synovial osteochondromatosis (SOC) is a monoarticular, synovial disease. It is a rare disease which presents as multiple cartilaginous nodule formations in synovial joints, bursae, or tendon sheaths.,, Mostly although it is generally a primary condition, it can be secondary to other conditions such as osteoarthritis. This disease is more prevalent in the fourth and fifth decades. It affects males more than females,, but in our case, it is female of the sixth decade associated with Grade 4 osteoarthritis. SOC most commonly involves knee joint with a frequency of 55%–65%. Other places that are involved frequently include other joints such as hip, elbow, shoulder, and ankle. It rarely involves temporomandibular joint. Synovial chondromatosis of the temporomandibular joint is four times more common in women than in men. The symptoms are pain and swelling, sometimes joint effusions, locking, and tenderness may also occur. Synovial chondromatosis is also called as chondrometaplasia  or Reichel's syndrome.
| Case Report|| |
A female aged 60 years came to Orthopedic Department at Yashoda Hospital, Malakpet, with pain in both knee joints with a history of diabetes and hypertension. The patient had difficulty in standing and walking with relief of pain on rest and nonsteroidal anti-inflammatory drugs. On examination, there were bilateral varus deformity, large swelling over the right knee, and restricted movements. The patient was admitted for bilateral total knee replacement. Complete blood picture revealed leukocytosis with eosinophilia and high erythrocyte sedimentation rate. X-ray revealed right genu varus and left genu valgus deformity, large osteophytes on tibial, femoral condyles and patella, well-circumscribed lobulated calcific density in suprapatellar recess likely myositis ossificans, or large osteophyte complex [Figure 1].
|Figure 1: X-ray images showing radiodense opacity in lower end of femur in lateral view|
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Intraoperative findings revealed a mass measuring 11 cm × 8 cm × 6 cm and weighing 250 g retrieved from intra-articular space attached to synovium. On gross examination, there was a pearly white hard mass measuring 11 cm × 8 cm × 6 cm and attached soft tissue mass measuring 4 cm × 3 cm × 1 cm. On cut section, the mass was multinodular and showed pearly white areas; cystic areas were also seen [Figure 2]. Microscopy showed a tumor composed of cartilaginous matrix with chondrocytes, focally the chondrocytes show increased cellularity and 1–2 chondrocytes per lacunae. The chondromyxoid matrix is seen in between the metaplastic bony trabeculae. The interstitium also showed fat [Figure 3] and [Figure 4].
|Figure 2: Gross image showing tumor mass with cartilaginous element and adipose tissue|
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|Figure 3: H and E section showing cartilage and beneath it layer of adipose tissue, ×10 view|
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|Figure 4: H and E section showing cartilaginous areas, high power view, ×40 view|
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| Discussion|| |
Synovial chondromatosis is a rare, mono-articular benign neoplasm with an unknown cause. It occurs at any joint and tendon sheath that have synovial tissue. It is characterized by cartilaginous nodule formation secondary to synovial metaplasia. The nodules may show calcification. It is progressive in nature, it can be self limited and can also regress. Delay in diagnosis of synovial chondromatosis can occur due to slow progression of disease with calcification of free cartilage fragments at late stage. Patient's complaints are usually due to mechanical effects of free bodies. It is aggravated by infection and trauma., Milgram  defined this disease in three stages: Stage I which is the early stage or the active intrasynovial stage and Stage II which is the transition stage from intrasynovial disease to free bodies. In Stage III (late stage), there are multiple free bodies but the absence of intrasynovial involvement. When our case was diagnosed, the disease was at Stage I. Some authors make a distinction between both the primary form, which represents metaplasia of cartilage, and a secondary form that is characterized by low cellular atypia. Lexer postulated an overactivity of the embryonic rests at the junction of the synovial membrane and articular cartilage as the cause of chondromatosis.
Radiologic features of disease may vary according to stages of disease; first, there will only be swelling around the involved joint. The most common radiologic finding includes radiopaque free bodies with different sizes. Calcification usually occurs at the last stage and may not be seen in all patients. Intra-articular masses, noncalcified masses, and septate swellings may be differentiated with magnetic resonance imaging (MRI) or computed tomography.,
Differential diagnosis of synovial chondromatosis can be many other diseases which may be benign or malignant. Benign lesions such as synovial hemangioma, pigmented villonodular synovitis, and lipoma arborescens and malignant lesions such as synovial chondrosarcoma and synovial sarcoma. Follow-up cases show malignant transformation rarely. Anract et al. reported that malignant transformation is very rare, and this condition should be thought and suspected when there is bone involvement in MRI and a quick progression clinically. If the lesion is large and in elderly patient, more prevalent differential diagnosis should be chondrosarcoma.,
Surgery is considered the treatment of choice. The primary prognostic consideration is the possibility of a late recurrence. Some studies have shown that a partial synovectomy with the removal of all loose bodies cannot prevent a late recurrence., Moreover, a review of the literature by von Lindern et al. revealed a high rate of recurrence in cases where total synovectomy has not been performed. Aydin et al. concluded that the stage of the disease is associated with the risk of recurrence, and they proposed a treatment based on stage. The presence of orderly ossification favors a benign course. There are a few reports with sarcomatous change in a nodule requiring radical or total surgery.
Gross appearance is that of a multilobulated synovium with multiple white or bluish nodules that are composed of hyaline cartilage attached to the synovium. These nodules may detach to form loose bodies. Most nodules are small in size; cases of many nodules have been reported, with multiple nodules combining into giant nodules measuring up to 20 cm in size.
Microscopically, the metaplastic synovium shows cartilaginous nodules beneath the surface lining of the synovial membrane with formation of many cartilaginous nodules within the joints, bursae, or tendon sheaths. They may be highly cellular and of moderate pleomorphism. The nodules are variably cellular with the chondrocytes seen in clusters, a very characteristic finding.
Prognostic factors include the entity being self-limiting illness but may recur locally after excision, especially in the early stage of disease. Damage to the joint surface may result in secondary degenerative joint disease. Bone erosion has also been reported in few cases.
| Conclusion|| |
Giant SOC with monoarticular involvement is a very rare disease. Clinical diagnosis is very difficult as it commonly mimics malignancy based on large size and rapid progression. Opinion of clinical, radiological, and histological findings should be correlated in every case, and the patient is treated accordingly, thus avoiding a wrong diagnosis and in the benefit of the patient. Hence, we conclude that correlation of biopsy finding is compulsory before coming to diagnosis, and proper diagnosis by histopathology is the only confirmed way in diagnosing such giant cases.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]