Orbital Synovial Sarcoma: Novel Case Report and Review of the Literature.

Purpose: To describe the clinical, histologic, and molecular features of a rare case of orbital synovial sarcoma and to provide a comprehensive literature review.

Methods: We present a case report and up-to-date literature review of orbital synovial sarcoma. Variables analyzed included patient demographics, clinical presentations, imaging findings, histopathologic features, molecular diagnostics, treatment, and outcomes.

Results: A 25-year-old female presented with a left orbital mass causing swelling, tearing, and mild vision impairment. Imaging identified a mass in the inferior orbit, which was subsequently confirmed by pathology as a monophasic spindle cell synovial sarcoma. Notably, initial fluorescence in situ hybridization testing for the SS18 rearrangement was negative; however, next-generation sequencing later identified an SS18-synovial sarcoma X breakpoint protein 2 fusion. The patient underwent complete surgical resection, followed by proton beam radiotherapy and chemotherapy. A PubMed and Medline search revealed 10 prior cases of orbital synovial sarcoma. Most patients were female (90.9%) and presented with painless swelling, lacrimation, and headaches. All tumors were localized at diagnosis. Surgical resection was the primary treatment in 81% of cases, with adjuvant radiation or chemotherapy each administered in 36% of cases. No recurrence or metastasis was observed on follow-up (average 11.6 months).

Conclusions: Orbital synovial sarcoma is rare and typically localized at diagnosis. This is the first reported orbital synovial sarcoma with an SS18-synovial sarcoma X breakpoint protein 2 fusion identified by next-generation sequencing after negative fluorescence in situ hybridization. The case underscores the diagnostic value of molecular profiling when standard testing is inconclusive.