Giant Cell Tumor of Tendon Sheath

It is a common finding which is usually benign. The second most common soft-tissue tumour seen in the hand, following ganglion cyst. Chassaignac first described these benign soft-tissue masses in 1852, and he overstated their biologic potential in referring to them as cancers of the tendon sheath.

  •  Common in patients aged 30-50 years old
  •  Anatomic location
it is most common on the palmar surface of the thumb, index and middle fingers.

Presentation

Signs & Symptoms

  1. enlarging mass
  2. pain, worse with activity (or wearing shoes, for foot lesions)
  3. firm, nodular mass that does not transilluminate

The symptoms of these masses depend on which subtype you have. Some possible symptoms include the following:

• ‌Swelling that may be painless at first 
• ‌Warmth or tenderness around your joint
• ‌Locking, popping or catching when you move your affected joint
• ‌Unstable joint
 
Diffuse-type giant cell tumor (pigmented villonodular synovitis) can cause degeneration of your joints. It can also damage the bone and cartilage that surrounds your affected joint. If left untreated, it can cause chronic pain and deterioration of your joints.‌
 

Imaging

  • Plain radiographs
  • To help show the status of the bone underneath
  • Ultrasound
    able to demonstrate the relationship of the lesion with adjacent tendon
  • most have some internal vascularity
  • MRI
  • MRI may be helpful diagnostically
  

Other causes to consider?

  • Ganglion cyst  
  • cystic component
  • Pigmented villonodular synovitis (PVNS)  
  • histologically identical
  • involves larger joints
  • Desmoid tumour  
  • fibroma/fibrosarcoma
  • glomangioma

Treatment

Surgery

Surgery is the main treatment for tenosynovial giant cell tumors. Your doctor may remove some or all of the tumors, as well as the inflamed joint tissue. You may need another surgery if the tumorreturns.

Surgical procedure:

  • marginal excision
  • High recurrence rate     
  • more common if tumour extends into joints and deep to the volar plate
  • tendon involvement is associated with a high recurrence rate     
  • local recurrence is usually treated with repeat excision
  • the operative approach is dependent on the location and extent of the tumour

For Professionals

The incidence of local recurrence is high, ranging from 9% to 44%. Researchers have reported the following rates:

• Phalen et al, 9% recurrence rate in 56 cases
• Moore et al, 9% recurrence rate in 115 cases
• Jones et al, 17% recurrence rate in 95 cases
• Reilly et al, 27% recurrence rate in 70 cases
• Wright, 44% recurrence rate in 69 cases
 

The variability in rates probably reflects incomplete excision of the lesions, especially the satellite nodules. Risk factors for recurrence include the following:

• Presence of adjacent degenerative joint disease
• Injury at the DIP joint of the finger or the interphalangeal (IP) joint of the thumb
• Radiographic presence of osseous pressure erosions
• Goda et al have presented a new technique for the use of radiotherapy as an adjuvant modality to prevent local recurrence. For retrospective studies, see Rodrigues et al, Darwish and Haddad, and Messoudi et al.
• To the author’s knowledge, no cases of malignant degeneration of a benign GCT of the tendon sheath of the hand have been reported. These tumors also have no propensity to metastasize distally. A few sporadic cases of purported malignant GCTs have been reported; however, most authors doubt that these malignant tumours exist, because this diagnosis is difficult to confirm.