Diffuse, Aggressive Metastatic Progression after Minimally Invasive Local Resection of Primary Gastric Synovial Sarcoma: a Case Report and Systematic Review of the Literature

Rationale: When a gastric spindle cell tumor is observed, the possibility of synovial carcinoma, besides common mesenchymal tumor, should also be considered.Presenting concerns of the patient: The patient is a 51-year-old American woman who underwent medical check-up at a general hospital. Upper endoscopy showed a 2-cm sized mass covered with intact mucosa, and a central depression located on the posterior wall of the mid body. Biopsy of the mass showed focal atypical cells proliferation in mucosa on hematoxylin & eosin (H&E) staining. Endoscopic ultrasound showed a 17-mm homogenously hypoechoic mass within the submucosal layer.Interventions: After diagnostic endoscopic submucosal dissection was performed, H&E and immunohistochemical staining showed synovial sarcoma (SS). To confirm the diagnosis, reverse transcriptase-polymerase chain reaction was performed, revealing a chimeric transcript of the SYT-SSX1 fusion gene. The diagnosis of primary gastric SS was confirmed because no evidence of possible primary lesions or metastatic lesions was observed. Therefore, the patient underwent distal gastrectomy.Outcomes: After surgery, the surgical specimen demonstrated no residual tumor cells. The patient received no adjuvant therapy, and there has been no evidence of local recurrence or distant metastasis for 2 months after the operation.Lessons: When gastric subepithelial tumor is suspicious, we should also consider gastric SS.