Images in Clinical Rheumatology
Anterior Knee Tumor as the Form of Presentation of a Giant Synovial Cyst
Tumor anterior de rodilla como forma de presentación de un quiste sinovial gigante
C.A. Guillén Astete
, M. Ahijón Lana, A. Zea Mendoza
Corresponding author
Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Guillén Astete, M. Ahijón Lana, A. Zea Mendoza" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C.A." "apellidos" => "Guillén Astete" "email" => array:1 [ 0 => "cguillen.hrc@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ahijón Lana" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Zea Mendoza" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor anterior de rodilla como forma de presentación de un quiste sinovial gigante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 950 "Tamanyo" => 91176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Side view of the right knee of the patient.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 91 year old woman without known chronic diseases. As significant history she had been diagnosed with a lipoma in the right knee extensor region over 60 years ago, but did not provide evidence or reports related to the diagnosis. The patient consulted because the lesion had changed color becoming more violet in recent months, had increased in size and prevented her from kneelling comfortably. Throughout the whole process, the lesion was never painful.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a soft consistency tumor of conical shape with a base circumference of 8<span class="elsevierStyleHsp" style=""></span>cm and a height of 6<span class="elsevierStyleHsp" style=""></span>cm located in front of the patellar tendon. The tumor was painless, apparently not dependent of deep tissue and had no local heat. At its distal region thin, purple and scaly skin could be seen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The mobility of the knee joint was not compromised and the tumor did not move during the performance of knee flexor movement. The remaining physical examination was not relevant.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During radiological examination of the knee we observed that the tumor was of soft tissue in origin, showed no radiopaque images inside and respected the integrity of the patellar tendon. Other findings highlighted a degree of osteoarthritis and the presence of radiological signs of atheromatosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound examination of the lesion showed heteroechoic content that moved under pressure exerted by the probe or by the examiner. Studying the patellar tendon from the lateral approach demonstrated their integrity and no relation to the tumor.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, we performed magnetic resonance imaging (MRI) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) which confirmed the diagnosis of a cystic tumor but was unable to identify any communication with the prepatellar bursa, although it recognized a small non-communicating fold in the rear wall thereof. The anatomy of the rest of the knee was unremarkable except for characteristics associated with the age of the patient.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient underwent complete surgical excision of the tumor after needle aspiration of its contents (11 cc of serosanguineous fluid). The volume of fluid obtained and the surgical specimen were sent to pathology. The surgeons reported an extra-articular thin-walled and complete cystic structure of 7<span class="elsevierStyleHsp" style=""></span>cm×7<span class="elsevierStyleHsp" style=""></span>cm×6<span class="elsevierStyleHsp" style=""></span>cm with little adherence to surrounding tissues, located anteriorly to the patellar tendon without making contact with this or with the prepatellar bursa and removed in its entirety. Pathological report indicated that the cystic structure was lined by synovial tissue and the fluid content consisted of synoviocytes, macrophages, red cells and synovial fluid.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After surgery, the patient resumed her usual activities normally.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comments</span><p id="par0045" class="elsevierStylePara elsevierViewall">The differential diagnosis of tumors of the knee include lipoma, hemangioma, giant cell tumor of the tendon sheath, synovial cysts, ganglions and nodular localized synovitis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> In general, their progression is benign and may rarely be related to an intra or paraarticular tumor.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Synovial cysts are usually benign entities located outside the joint capsule but anatomically related to it by means of small channels that can be permeable or obliterated.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> In our case, we identified a fold of the posterior wall of the cyst which could be the remnant of a canal structure, now obliterated, that connected the cyst with the joint (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Synovial cysts are caused by mucinous degeneration, trauma or tumors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For any of these reasons, a shift of synovial fluid from regions of high to low pressure causing a progressive mobilization of the synovial tissue and its eventual outgrowth outside the capsule.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Once this phenomenon occurs, the liquid may organize or move freely from the joint to the cyst through a channel with a permeability can be permanent, episodic or short lasting.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The displacement of fluid in one direction or another conditions an increase or decrease in the size of the cavity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Ganglia are cystic formations similar to synovial cysts.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> They differ in that the walls of synovial cysts are coated by synoviocytes, while ganglia are covered by the adjacent tissue itself.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> This makes histological testing critical for the final diagnosis. Both structures are considered extra-articular, but may rarely occur inside the knee joint, or paraligamentary1 or intramenisca.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">l,8,9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the technique of choice for the diagnosis of synovial cysts is MRI, histological demonstration is the definitive test and should not be overlooked before definitively ruling out all other possibilities.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">As for treatment, synovial cysts may be treated by aspiration of its content without requiring more than local anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9</span></a> The drawback of this technique is that the mechanism that gives rise to the lesion may still be patent and as a result, the cyst can replenish synovial fluid in time.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Surgical excision is the definitive treatment<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but procedures have been tested including needle aspiration of intracystic content and administration of fibrin-based substances that affect the final sealing of the walls.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Comments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Guillén Astete CA, et al. Tumor anterior de rodilla como forma de presentación de un quiste sinovial gigante. Reumatol Clin. 2013;<span class="elsevierStyleBold">9</span>:69–71.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 950 "Tamanyo" => 91176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Side view of the right knee of the patient.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1172 "Ancho" => 950 "Tamanyo" => 103264 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lateral radiograph of the knee under load.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 949 "Ancho" => 772 "Tamanyo" => 105753 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MRI of the knee. Within the circle the crease of the rear wall of the cyst is identified.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intra-articular synovial cyst of the knee joint: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Mine" 1 => "K. Ihara" 2 => "H. Kawamura" 3 => "Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 15 | 27 |
| 2024 October | 61 | 34 | 95 |
| 2024 September | 69 | 20 | 89 |
| 2024 August | 83 | 41 | 124 |
| 2024 July | 81 | 35 | 116 |
| 2024 June | 111 | 38 | 149 |
| 2024 May | 78 | 42 | 120 |
| 2024 April | 67 | 23 | 90 |
| 2024 March | 70 | 30 | 100 |
| 2024 February | 70 | 25 | 95 |
| 2024 January | 52 | 24 | 76 |
| 2023 December | 62 | 25 | 87 |
| 2023 November | 59 | 37 | 96 |
| 2023 October | 75 | 27 | 102 |
| 2023 September | 67 | 38 | 105 |
| 2023 August | 57 | 22 | 79 |
| 2023 July | 58 | 32 | 90 |
| 2023 June | 50 | 28 | 78 |
| 2023 May | 41 | 13 | 54 |
| 2023 April | 57 | 6 | 63 |
| 2023 March | 73 | 20 | 93 |
| 2023 February | 77 | 37 | 114 |
| 2023 January | 63 | 22 | 85 |
| 2022 December | 59 | 31 | 90 |
| 2022 November | 70 | 29 | 99 |
| 2022 October | 69 | 28 | 97 |
| 2022 September | 70 | 26 | 96 |
| 2022 August | 79 | 39 | 118 |
| 2022 July | 95 | 43 | 138 |
| 2022 June | 75 | 32 | 107 |
| 2022 May | 69 | 40 | 109 |
| 2022 April | 76 | 51 | 127 |
| 2022 March | 87 | 53 | 140 |
| 2022 February | 61 | 31 | 92 |
| 2022 January | 67 | 40 | 107 |
| 2021 December | 65 | 37 | 102 |
| 2021 November | 72 | 42 | 114 |
| 2021 October | 152 | 46 | 198 |
| 2021 September | 63 | 35 | 98 |
| 2021 August | 65 | 31 | 96 |
| 2021 July | 63 | 33 | 96 |
| 2021 June | 91 | 37 | 128 |
| 2021 May | 83 | 44 | 127 |
| 2021 April | 169 | 86 | 255 |
| 2021 March | 115 | 22 | 137 |
| 2021 February | 59 | 14 | 73 |
| 2021 January | 47 | 19 | 66 |
| 2020 December | 43 | 16 | 59 |
| 2020 November | 40 | 22 | 62 |
| 2020 October | 38 | 16 | 54 |
| 2020 September | 60 | 16 | 76 |
| 2020 August | 40 | 19 | 59 |
| 2020 July | 46 | 19 | 65 |
| 2020 June | 30 | 18 | 48 |
| 2020 May | 32 | 13 | 45 |
| 2020 April | 34 | 17 | 51 |
| 2020 March | 13 | 4 | 17 |
| 2020 February | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 5 | 0 | 5 |
| 2018 April | 37 | 8 | 45 |
| 2018 March | 47 | 6 | 53 |
| 2018 February | 39 | 4 | 43 |
| 2018 January | 34 | 3 | 37 |
| 2017 December | 38 | 3 | 41 |
| 2017 November | 33 | 4 | 37 |
| 2017 October | 30 | 2 | 32 |
| 2017 September | 45 | 8 | 53 |
| 2017 August | 68 | 13 | 81 |
| 2017 July | 53 | 7 | 60 |
| 2017 June | 92 | 10 | 102 |
| 2017 May | 90 | 7 | 97 |
| 2017 April | 67 | 6 | 73 |
| 2017 March | 63 | 22 | 85 |
| 2017 February | 46 | 5 | 51 |
| 2017 January | 44 | 5 | 49 |
| 2016 December | 94 | 12 | 106 |
| 2016 November | 83 | 5 | 88 |
| 2016 October | 107 | 17 | 124 |
| 2016 September | 194 | 8 | 202 |
| 2016 August | 188 | 5 | 193 |
| 2016 July | 83 | 12 | 95 |
| 2016 June | 0 | 14 | 14 |
| 2016 May | 1 | 16 | 17 |
| 2016 April | 0 | 34 | 34 |
| 2016 March | 1 | 30 | 31 |
| 2016 February | 0 | 11 | 11 |
| 2016 January | 0 | 10 | 10 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 2 | 12 | 14 |
| 2015 July | 76 | 7 | 83 |
| 2015 June | 103 | 5 | 108 |
| 2015 May | 157 | 6 | 163 |
| 2015 April | 101 | 8 | 109 |
| 2015 March | 167 | 8 | 175 |
| 2015 February | 180 | 9 | 189 |
| 2015 January | 116 | 14 | 130 |
| 2014 December | 98 | 10 | 108 |
| 2014 November | 87 | 8 | 95 |
| 2014 October | 122 | 8 | 130 |
| 2014 September | 100 | 10 | 110 |
| 2014 August | 107 | 19 | 126 |
| 2014 July | 137 | 12 | 149 |
| 2014 June | 160 | 9 | 169 |
| 2014 May | 155 | 14 | 169 |
| 2014 April | 142 | 8 | 150 |
| 2014 March | 162 | 12 | 174 |
| 2014 February | 143 | 9 | 152 |
| 2014 January | 141 | 7 | 148 |
| 2013 December | 108 | 5 | 113 |
| 2013 November | 111 | 9 | 120 |
| 2013 October | 130 | 9 | 139 |
| 2013 September | 111 | 12 | 123 |
| 2013 August | 93 | 12 | 105 |
| 2013 July | 106 | 7 | 113 |
| 2013 June | 82 | 10 | 92 |
| 2013 May | 94 | 15 | 109 |
| 2013 April | 94 | 23 | 117 |
| 2013 March | 99 | 32 | 131 |
| 2013 February | 38 | 10 | 48 |
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