Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.

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Giant-cell tumour of the tendon sheath

Giant-cell tumour of the tendon sheath. Is radiotherapy indicated to prevent recurrence after surgery?

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.

Giant-cell tumour of the tendon sheath in the foot and ankle

Introduction The aim of this retrospective study was to study the clinical presentation, investigations, histopathological findings, and the best ways of treatment of the giant cell tumour of the tendon sheath (GCTTS). Methods The medical records of all patients diagnosed to have GCTTS during the period 1994-2001 were reviewed, and follow-up was for three to ten years. Results The total number of patients was 52, of whom 36 were females, and the mean age was 32.4 years. All the tumours except one were located in the hand and wrist area, with the thumb being the most affected finger. Painless swelling was the most common presentation. All of them were treated surgically and the recurrence rate was 24 percent. Conclusion After reviewing the literature and comparing with our results, we conclude that GCTTS is a true benign tumour with local aggressive behaviour in some cases, and the best way of treatment is wide local excision.

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Giant cell tumour of tendon sheath: experience with 52 cases.

Giant cell tumor of the tendon sheath (GCTTS) is a benign tumor, presenting as the second most common mass of the hand after ganglion cysts.1 It was first described by Chassaignac in 1852 as fibrous xanthoma2 and has since been referred to by multiple names, including localized nodular tenosynovitis, pigmented villonodular proliferative synovitis, sclerosing hemangioma, benign synovioma, proliferative synovitis, xanthoma, xanthogranuloma, xanthosarcoma, myeloid endothelioma, fibrohemosideric sarcoma, giant cell fibrohemangioma, pigmented villonodular tenosynovitis, fibroma, myeloma, myeloxanthoma, and fibrous histiocytoma.1,3-5 The large range of nomenclature indicates disagreement as to the etiology of giant cell tumors. The prevailing divergence is between a neoplastic1-3,6-9 and inflammatory origin10-12 of the tumor, with multiple studies presenting evidence for each.

Despite the undetermined etiology, the clinical presentation, diagnosis, and surgical treatment of GCTTS are described. The tumor is most commonly diagnosed in the fourth and fifth decades of life (range, 4-82 years),13,14 with women affected more commonly than men (64.3% women).2,3,15 Although GCTTS most commonly presents in a digit of the hand, it may also present in the palm,1,16 wrist,2,17 foot,7,13,18 knee,7,13,18 ankle,13 elbow,13 or hip.2 Grossly, GCTTS is a multilobular and generally well-circumscribed tumor. It may be partially or completely encapsulated and may have extensions and/or satellite lesions connected by as little as a few strands of fibrous tissue.6,15 Coloration varies from gray to yellow-orange with some brownish areas, depending on the amounts of hemosiderin, collagen, and histiocytes present in the tumor.15 Histologically, giant cell tumor is composed of 4 main cell types, namely the principal synovial cell, multinucleated giant cell, foam cell, and histiocyte-like cell.18 These cells are contained within a fibrous collagenous stroma, form synovial-lined spaces, and are often surrounded by a thin, fibrous capsule.6,13,18

Giant cell tumor of the tendon sheath is most commonly found in the distal interphalangeal (DIP) joint2,15,19 and the proximal phalanx.2,4,20-22 Some authors describe an association with rheumatoid arthritis,15 while others describe an association with osteoarthritis;2,4 however, these findings are not replicated across large numbers of studies.

Diagnosis
Giant cell tumor of the tendon sheath most commonly presents as a firm, nontender, nonfluctuant nodule in a digit of the hand. The most common occurrence is in the index finger (26%), followed by the long finger, thumb, ring finger, and small finger, respectively (Table 1). The tumor is predominantly palmar,1,4,16,19,20,23 although Jones et al2 and Ushijima et al13 reported dorsal tumors to be more prevalent. Because of the slow-growing nature of the tumor, patients present an average of 6 months to 2.5 years after the initial onset of symptoms.6,20



Table 1

Anatomic location of giant cell tumor of the tendon sheath in the literature



Diagnosis of GCTTS is largely made by clinical examination; however, giant cell tumor may be misdiagnosed or left without definitive diagnosis until intraoperative findings are available. For example, Monaghan reports a provisional diagnosis of GCTTS in only 4.2% of 71 affected patients, with the remainder of tumors diagnosed as ganglion or epidermoid cyst.18 In less extreme cases, 41.5%,7 87.5%,23 and 92%16 of tumors were diagnosed as GCTTS preoperatively.

No characteristic radiographic appearance is seen with GCTTS.8 Roentgenographic findings indicate a soft tissue mass in the majority of cases; however, Reilly et al4 reported normal findings in 32% of patients. Ultrasonography shows a solid, homogeneous, hypoechoic mass generally in relation to the flexor tendons of the fingers, with increased vascularity on Doppler studies.19 Magnetic resonance imaging reveals decreased signal intensity on T1- and T2-weighted images.8 A preoperative pathological diagnosis can be made using fine-needle aspiration biopsy.24 Although radiography cannot be used to make a definitive diagnosis, it is useful in showing bony erosion and is widely available. Magnetic resonance imaging is the most definitive imaging study;24 however, it is generally not obtained due to the ubiquity and cost-effectiveness of radiography and ultrasound.


Treatment
Treatment for giant cell tumor is local excision. Care must be taken to preserve the flexor tendons, extensor tendons, digital arteries, and nerves if possible. Because of the usual presence of a pseudocapsule, the tumor can often be removed en bloc. All surrounding tissues should be examined for satellite lesions, and such lesions and connections to these lesions should be excised. Rather than opening the entire site, satellite lesions can often be removed using a teasing technique,15 which utilizes gentle, slow dissection. If erosion of the bone has occurred, curettage to remove the cortical shell is advised.3 Flexor and extensor tendons invaded by the tumor should be repaired.

Recurrence is a major concern in GCTTS, with rates of up to 44% being reported.6 In the case of recurrence, marginal excision of the tumor should be repeated. Functionality of the involved digit should be considered and may result in the decision to amputate for large tumors that interfere with function.

Radiotherapy has been indicated as an adjuvant therapy for the prevention of recurrence. Garg and Kotwal16 reported dramatic reductions in recurrence rates, with total recurrence rates of 0% and 4%, respectively, with the use of radiotherapy after surgery.23

Giant Cell Tumor of the Tendon Sheath: Experience With 65 Cases

Background and Objectives: Giant cell tumor of the tendon sheath (GCTTS) is a lesion of uncertain etiology. To better interpret pathogenesis and aid in the differentiation of GCTTS from other similar pathological processes we reviewed the literature and analyzed the available information.



Methods

We retrospectively studied clinicopathologic findings in 28 cases of GCTTS on the basis of anatomic location and histologic appearance of the lesion.



Results

The GCTTS could be divided into those involving the common digits (20 cases) and larger joint group (8 cases) based on anatomic location. Grossly the digit tumors were small, multiple, surrounded by a thin fibrous capsule, and had a variegated appearance, while the large joint tumors were relatively large and covered by one or more layers of synovium. Microscopically both groups consisted of a mixture of round to polygonal histiocytes, foam cells, hemosiderin laden macrophages, and multinucleated giant cells. The giant cells seemed more abundant in the digit tumors, while the pseudoglandular spaces lined by synovial cells were more striking in the large joint group.



Conclusions

Local excision was the treatment of choice in the majority of the patients. Eight patients had local recurrence. J. Surg. Oncol. 1998;68:100–103. © 1998 Wiley-Liss, Inc.

Callista Rodrigues

Papers

Giant cell tumor of the tendon sheath: A retrospective study of 28 cases