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• W4281679369 abstract "A 24-year-old female presented to the emergency department (ED) with a two-day history of worsening colicky central abdominal pain and watery, non-bloody diarrhoea. Her only past medical history includes right thigh synovial sarcoma with oligometastatic pulmonary metastasis in remission for two years, managed with chemotherapy, radiotherapy, and surgical resection. Examination revealed normal vital signs, central abdominal tenderness with no guarding or peritonism. Full blood work-up including full blood count, electrolytes, creatinine, and c-reactive protein were unremarkable. She was discharged after her pain improved with paracetamol and ibuprofen. The patient re-presented 12 hours post-discharge with worsening central abdominal pain and new nausea and vomiting. Vital signs remained within normal limits. Abdominal examination elicited a tender, palpable mass in the right lower quadrant. Repeat blood tests including inflammatory markers remained normal, but an abdominal computerized tomography (CT) scan demonstrated intussusception involving the caecum and distal ileum with small amounts of free fluid in pelvis (Fig. 1). An emergency laparoscopy revealed an ileo-ileal intussusception arising 10 cm from the ileo-caecal valve, extending into the distal ascending colon (Fig. 2). The surgical team proceeded with a right hemicolectomy with end-to-end anastomosis. Initial histopathology of the resected colon revealed a 31 mm undifferentiated ovoid and round cell malignancy with clear margins and 24 negative nodes. Further immunohistochemistry testing for transducing-like enhancer of split 1 (TLE1) was positive, confirming a diagnosis of metastatic synovial sarcoma correlating with the patient's past history (Fig. 3). Postoperatively, the patient had two febrile episodes attributed to post-operative atelectasis. She was subsequently discharged five days post operation with no further complications. The patient was followed-up in the surgical clinic two weeks later. The laparoscopic wound sites healed appropriately and no further abdominal pain or concerns were reported. The patient was followed-up by her oncologist and underwent CT chest-abdo-pelvis (CAP), positron emission tomography (PET) scan and magnetic resonance imaging (MRI) of the right thigh. While CT CAP revealed no abnormalities detected, both PET and MRI reported a new subcutaneous fine nodule superficial to the rectus femoris, locating 6.5 cm below the right anterior-superior iliac spine. There was no significant change with respect to the surgical resection and flap reconstruction site of the right medial thigh when compared to her surveillance MRI six months prior. She has yet to commence adjuvant therapy and is currently awaiting ultrasound guided biopsy of the right thigh nodule. Intussusception refers to the invagination of a proximal bowel segment into a distal area, often known as ‘telescoping of the bowel’. Patients can present with serious complications, including bowel obstruction and intestinal ischaemia. Paediatric intussusception makes up most cases and is classically characterized by a triad of colicky abdominal pain, palpable abdominal mass, and haematochezia. It is most commonly benign in nature. In contrast, adult intussusception is rare, accounting for only 5% of all cases.1 The four main types of intussusception; classified according to the site of origin are enteric, ileocolic, ileocaecal and colonic. Small bowel intussusception occurs most frequently, with enteric intussusception representing half of the different types of intussusception.2 Clinical presentation of adult intussusception is often non-specific and diagnostically challenging, with abdominal pain being the most common presentation in 80% of reported cases.2 Other symptoms such as nausea, vomiting and diarrhoea may manifest from bowel obstruction and ischaemia resulting from intussusception. With clinical diagnosis proving difficult, abdominal CT remains the gold standard modality of choice to diagnose adult intussusception.1 Definitive management of adult intussusception is surgical resection and up to 90% of cases are found to have a pathological lead point, such as Meckel's diverticulum, inflammatory bowel disease or malignancy, involving the small or large intestine.3 Numerous cases of the various subtypes of sarcoma serving as a pathological lead point in intussusception have been presented in the literature previously.4, 5 Synovial sarcoma is one such subtype and presents as a slow-growing soft tissue malignancy that typically occurs in the extremities of young adults. At diagnosis, approximately 50% of patients demonstrate metastatic disease, most commonly to the lungs (80%), bone (9.9%) and liver (4.5%).6 Primary gastrointestinal synovial sarcomas and synovial sarcomas resulting in intra-abdominal or retroperitoneal metastasis are rarer manifestations of this insidious disease.7 Although cases of intestinal intussusception resulting from primary synovial sarcomas have previously been reported, we believe this is the first reported case of synovial sarcoma with metastasis to the ileum resulting in intussusception.4, 8 As with most other presentations, clinicians should keep possible differentials broad when adult patients present with abdominal pain, reserve a place for uncommon differentials, and have a low threshold for diagnostic imaging where intussusception is suspected in the adult patient. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. Zhi Shyuan Choong: original draft; writing - review and editing. Gamze Aksakal: Writing – review and editing. Jean Flanagan: Writing – review and editing. Amy Jennifer Chan: Resources. Quinton Smith: Supervision. John Stuchbery: Supervision; writing – review and editing." @default.
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• W4281679369 date "2022-06-06" @default.
• W4281679369 modified "2023-09-26" @default.
• W4281679369 title "Ileo‐ileal intussusception: a rare manifestation of metastatic synovial sarcoma" @default.
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