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Background

The giant cell tumour of the tendon sheath (GCTTS) is a relatively common soft tissue neoplasm arising from the tendon sheath. It commonly occurs in the hands but has been identified in the foot as well. It is one of the most common neoplasm of the hand that can recur after excision. Recurrences may be difficult to manage. There are rare reports of malignant transformation.

OUTLINE

Epidemiology  
Disease Associations  
Pathogenesis  
Laboratory/Radiologic/
Other Diagnostic Testing
 
Gross Appearance and Clinical Variants  
Histopathological Features and Variants  
Special Stains/
Immunohistochemistry/
Electron Microscopy
 
Differential Diagnosis  
Prognosis  
Treatment  
Commonly Used Terms  
Internet Links  

 

EPIDEMIOLOGY CHARACTERIZATION
SYNONYMS Localized nodular tenosynovitis
INCIDENCE/
PREVALENCE
 
AGE  
Giant cell tumour of tendon sheath in a child: a case report.

Hulse N, Watson SJ.

Department of Plastic and Reconstructive Surgery, South Manchester University Hospitals, Wythenshawe, Manchester,
UK.
Hand Surg. 2005 Jul;10(1):97-100. Abstract quote  

Giant cell tumour of the tendon sheath is uncommon in children.

We describe this tumour arising from the right ring finger in an eight-year-old girl.

Plane radiographs showed a soft tissue mass with erosion of the distal phalanx.

The tumour was treated by surgical excision with good outcome.
SEX  
GEOGRAPHY  
EPIDEMIOLOGIC ASSOCIATIONS  

 

DISEASE ASSOCIATIONS CHARACTERIZATION

 

PATHOGENESIS CHARACTERIZATION
GENERAL  
Giant cell tumor of tendon sheath is a polyclonal cellular proliferation.

Vogrincic GS, O'Connell JX, Gilks CB.

Department of Pathology and Laboratory Medicine, Vancouver Hospital and Health Sciences Centre, British Columbia, Canada.
Hum Pathol. 1997 Jul;28(7):815-9. Abstract quote  

Giant cell tumor of tendon sheath (GCTTS) is a common soft tissue tumor. Immunophenotypical evidence suggests it is of synovial cell origin. There is controversy regarding the underlying nature of this lesion, specifically whether it is a neoplastic or nonneoplastic (ie, reactive or hyperplastic) process. Karyotypic abnormalities have been identified in GCTTS and interpreted as evidence of neoplasia, although the finding of similar karyotypic abnormalities in unequivocally nonneoplastic proliferations raises questions about using such findings to define a neoplasm.

In an attempt to resolve this uncertainty, a polymerase chain reaction (PCR)-based assay for methylation of the X-linked human androgen receptor gene (HUMARA) was used to assess whether GCTTS is a clonal or polyclonal proliferation. DNA was isolated from formalin-fixed, paraffin-embedded tissue blocks from eight cases of digital GCTTS in female subjects; two cases of hepatocellular carcinoma (HCC) were used as clonal controls. Seven of eight cases of GCTTS were informative, and each showed a polyclonal proliferation, whereas both cases of HCC were clonal.

Our results indicate that GCTTS is a nonneoplastic proliferation, if one accepts that a population of cells forming a tumorous mass must show clonality to be classified as a neoplasm. Our results emphasize that simple karyotypic abnormalities do not define a neoplasm. It remains to be determined whether GCTTS is a reactive or hyperplastic process.
CHROMOSOMAL ALTERATIONS  
Molecular cytogenetic mapping of recurrent chromosomal breakpoints in tenosynovial giant cell tumors.

Nilsson M, Hoglund M, Panagopoulos I, Sciot R, Dal Cin P, Debiec-Rychter M, Mertens F, Mandahl N.

Department of Clinical Genetics, University Hospital, 221 85 Lund, Sweden.
Virchows Arch. 2002 Nov;441(5):475-80. Epub 2002 Apr 13. Abstract quote  

Tenosynovial giant cell tumor (TGCT) is the most common benign tumor of synovium and tendon sheath. Cytogenetic data indicate that 1p11-13 is the region most frequently involved in structural rearrangements.

With the aim of eventually identifying the genes associated with TGCT development, we have investigated 1p11-13 breakpoints using fluorescence in situ hybridization (FISH) analysis, with a panel of yeast artificial chromosome (YAC) probes covering 1p11-21.

Twenty-six tumors were analyzed by G-banding, and 24 of these showed a breakpoint in 1p11-13. The cytogenetic findings add to previous observations that, among a variety of translocations involving 1p11-13, chromosome 2 is the most common translocation partner, with a breakpoint in 2q35-37. This aberration was found in eight cases. Other recurrent translocation partners, found in two or three cases, were 5q22-31, 11q11-12, and 8q21-22.

Material from 21 tumors was available for FISH analysis, which revealed that the breakpoints clustered to one region spanned by two YAC probes, 914F6 and 885F12 located in 1p13.2, in 18 cases. Bacterial artificial chromosome probes were used to map the recurrent breakpoint on chromosome 2.

In four of seven cases there was a breakpoint within the sequence covered by probe 260J21, where the RDC1 gene is located, a gene reported to fuse with HMGIC in lipomas with a 2;12 translocation.

 

LABORATORY/
RADIOLOGIC/
OTHER TESTS

CHARACTERIZATION
RADIOLOGIC  
MRI  
MR imaging for preoperative diagnosis and assessment of local tumor extent on localized giant cell tumor of tendon sheath.

Kitagawa Y, Ito H, Amano Y, Sawaizumi T, Takeuchi T.

Department of Orthopaedic Surgery, Nippon Medical School, 1-1-5 Sendagi, 113-8603 Bunkyo-ku, Tokyo, Japan.
Skeletal Radiol. 2003 Nov;32(11):633-8. Epub 2003 Sep 20. Abstract quote  

OBJECTIVE: The purpose of this study was to clarify the usefulness of MR imaging for preoperative diagnosis and evaluation of the extent of localized giant cell tumor of tendon sheath (GCTTS).

DESIGN AND PATIENTS: We retrospectively reviewed the MR images of 25 patients with surgically proved GCTTS (seven males and 18 females; mean age, 41 years) including five recurrences. T1- and T2-weighted imaging was carried out on 24 and 22 lesions, respectively. Gadolinium-enhanced images were obtained for 20 lesions. We evaluated the tumor extent around the phalanx (the degree of circumferential occupation by a tumor around the phalanx on an axial plane) and involvement of the bone, joint, and tenosynovial space by both MR imaging and surgery (gold standard).

RESULTS: MR signal intensities of the GCTTSs were consistently equal to those of skeletal muscle or between those of muscle and fat on T1-weighted images; on T2-weighted images, the signal intensities tended to be between those of muscle and fat. Most lesions were inhomogeneous due to low-signal-intensity areas, and enhanced following gadolinium administration. The tumor extent around the phalanx was 168.5 +/- 99.2 degrees (63-360 degrees). MR imaging did not identify the bone involvement (five lesions), but depicted the involvement of the joint in four of five lesions and the tenosynovial space in nine of ten lesions.

CONCLUSIONS: This study confirms that MR imaging is able to depict the characteristic internal signal of GCTTS. Moreover, it can accurately assess the tumor size and degree of extent around the phalanx, which can affect the type of surgical approach.
Pigmented villonodular synovitis and giant cell tumor of the tendon sheath: scintigraphic findings in 10 cases.

Mackie GC.

St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia.
Clin Nucl Med. 2003 Nov;28(11):881-5. Abstract quote  

The purpose of this report was to determine the pattern of thallium (T1-201) uptake in pigmented villonodular synovitis (PVNS) and giant cell tumor of the tendon sheath (GCTTS) and to evaluate for features that might help to distinguish these lesions from malignant disease.

Scintigraphic images from patients subsequently found to have pigmented villonodular synovitis confirmed by histopathologic analysis were assessed. The patients had been evaluated with T1-201 scintigraphy for a suspicious musculoskeletal lesion. All 6 patients with PVNS had significant T1-201 uptake on the early images with retention on the delayed images. The T1-201 activity was in a juxta-articular location and generally conformed to the synovial cavity with scattered irregular nodular components. Of 4 cases of giant cell tumor of the tendon sheath, all had T1-201 uptake on the early images, and 3 cases (75%) also had uptake on the delayed images. T1-201 uptake is observed almost invariably in pigmented villonodular synovitis on both early and delayed images and can simulate the findings of malignant disease.

Features that should raise suspicion of PVNS include close proximity to a joint, especially with distribution corresponding to that of the synovial cavity.

When T1-201 activity is detected in a lesion in the hand or foot, giant cell tumor of the tendon sheath should be considered. Magnetic resonance imaging will often aid in the differentiation by demonstrating features of hemosiderin degradation products.
ULTRASOUND  
Giant cell tumors of the tendon sheath: analysis of sonographic findings.

Middleton WD, Patel V, Teefey SA, Boyer MI.

The Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway, St. Louis, MO 63110, USA.
AJR Am J Roentgenol. 2004 Aug;183(2):337-9. Abstract quote  

OBJECTIVE: The purpose of this study was to analyze the sonographic characteristics of giant cell tumors of the tendon sheath.

CONCLUSION: Giant cell tumors of the hand typically appear as solid, homogeneous hypoechoic masses with detectable internal vascularity that are associated with the flexor tendons of the fingers.
LABORATORY MARKERS  

 

GROSS APPEARANCE/
CLINICAL VARIANTS
CHARACTERIZATION
GENERAL  
Giant cell tumor of tendon sheath.

Walsh EF, Mechrefe A, Akelman E, Schiller AL.

Department of Orthopaedics, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA.

Am J Orthop. 2005 Mar;34(3):116-21. Abstract quote  

Neoplasms of the hand are not common. Giant cell tumor of tendon sheath (GCTTS) is the most common primary tumor of the hand. Many different theories have recently been proposed as to whether GCTTS is a neoplasm or a localized reactive process.

We believe the evidence supports a neoplastic origin. Although the origin is still not proved, the presentation, diagnosis, and treatment of GCTTS have been clear for a long time.
Giant cell tumour of tendon sheath (localised nodular tenosynovitis): clinicopathological features of 71 cases.

Monaghan H, Salter DM, Al-Nafussi A.

Department of Pathology, Edinburgh University Medical School, Teviot Place, Edinburgh EH8 9AG, UK.
J Clin Pathol. 2001 May;54(5):404-7. Abstract quote  

AIMS/BACKGROUND: Giant cell tumour of the tendon sheath (GCTTS) is regarded as the most common neoplasm of the hand that can recur after excision. The objective of this study was to review a series of cases in our department and to determine any clinical or pathological features that might predict the likelihood of recurrence.

METHODS: Clinical data, obtained from pathology request forms and in patient notes, along with the gross and microscopic appearances of 71 cases of GCTTS were evaluated.

RESULTS: Clinical features and pathological features identified were similar to those of previous studies. In comparison with previous studies a higher mitotic count (range, 1-21 mitoses/10 high power fields (HPF); mean, 5/10 HPF) was noted in all cases, irrespective of recurrence and numerous apoptotic bodies (up to 30/10 HPF), mainly formed from osteoclast-like giant cells, were present.

CONCLUSIONS: GCTTS is a relatively rare soft tissue tumour of uncertain histiogenesis. Mitotic and apoptotic figures are a common feature and do not indicate clinical behaviour. Complete local excision is the treatment of choice.
INTRAOSSEOUS  
Intraosseous growth of giant cell tumors of the tendon sheath (localized nodular tenosynovitis) of the digits: report of 15 cases.

Uriburu IJ, Levy VD.

Department of Surgery, Buenos Aires University Hospital, Argentina.

J Hand Surg [Am]. 1998 Jul;23(4):732-6. Abstract quote  

Giant cell tumors of tendon sheath are common soft tissue lesions affecting the digits, sometimes causing pressure atrophy of an adjoining bone and rarely perforating the cortex to expand into the medullary canal.

One hundred thirty-three cases of giant cell tumors of tendon sheath were retrospectively reviewed; 15 (11%) showed cortical perforation and intraosseous expansion. Radiographic features, diagnoses, and surgical treatment are described.

The use of soft tissue radiographic techniques and mammographic films was an extremely valuable diagnostic tool, although computed tomography and magnetic resonance imaging may be necessary in some cases.

 

HISTOLOGICAL TYPES CHARACTERIZATION
CYTOLOGY  
Comparison of cytologic features of giant-cell tumor and giant-cell tumor of tendon sheath.

Gupta K, Dey P, Goldsmith R, Vasishta RK.

Department of Cytology and Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Diagn Cytopathol. 2004 Jan;30(1):14-8. Abstract quote  

The cytologic features in twelve cases of giant-cell tumor (GCT) and five cases of giant-cell tumor of tendon sheath (GCTTS) diagnosed by fine-needle aspiration cytology (FNAC) are described. All of these cases were histopathologically confirmed.

The aspirates of GCT are composed of a dual population of mononucleated spindle cell and multinucleated giant cells. The peripheral adherence of giant cells to the spindle cell is the feature of diagnostic significance in GCT. In GCTTS, the aspirate consists of a polymorphic population composed of mononuclear histiocyte-like cells, hemosiderin laden macrophages, foamy macrophages, and a few multinucleated giant cells.

FNAC can be used as a diagnostic tool for an early and accurate detection of these two giant cell-rich lesions, since the cytologic features when evaluated in conjunction with the clinical and radiologic features are sufficiently diagnostic.
MALIGNANT  
Malignant giant cell tumor of synovium and locally destructive pigmented villonodular synovitis: ultrastructural and immunohistochemical study and review of the literature.

Nielsen AL, Kiaer T.

Department of Pathology, University Hospital, Odense, Denmark.


Hum Pathol. 1989 Aug;20(8):765-71. Abstract quote  

The first reported case of an intraarticular malignant giant cell tumor of synovium studied with electron microscopic and immunohistochemical examination is presented, together with a case of diffuse intraarticular pigmented villonodular synovitis with extensive bone destruction.

The malignant case was dominated by uniform cells positive for histiocytic markers, the fine structure showing a gradual change from cells dominated by organelles serving a secretory function to cells with phagocytic activity.

The reported cases of giant cell tumor of the tendon sheath indicate that the pertinent histologic changes regarding malignancy are an increase in cell polymorphism and in the number of mitoses, and a decrease in the number of multinucleated giant cells.
Malignant giant cell tumor of tendon sheath. Report of a case.

Ushijima M, Hashimoto H, Tsuneyoshi M, Enjoji M, Miyamoto Y, Okue A.

Acta Pathol Jpn. 1985 May;35(3):699-709. Abstract quote

In a patient with pigmented villonodular synovitis of the right knee joint, there occurred a malignant giant cell tumor of tendon sheath. There was clinical evidence of metastasis after the second local recurrence and the recurrent tumors were studied enzyme cytochemically and electron microscopically.

Ultrastructurally, the malignant tumor consisted of three principal cell types; histiocyte-like cells, fibroblast-like cells, and intermediate cells, with unique attendance of myofibroblasts.

This may be the first report of the presence of myofibroblasts in malignant giant cell tumor of tendon sheath. Enzyme cytochemistry revealed various functional properties of histiocytes.

 

SPECIAL STAINS/
IMMUNOPEROXIDASE/
OTHER
CHARACTERIZATION
SPECIAL STAINS  
IMMUNOPEROXIDASE  
Giant cell tumors: inquiry into immunohistochemical expression of CD117 (c-Kit), microphthalmia transcription factor, tartrate-resistant acid phosphatase, and HAM-56.

Ramos RY, Haupt HM, Kanetsky PA, Donthineni-Rao R, Arenas-Elliott C, Lackman RD, Martin AM.

Department of Pathology, Pennsylvania Hospital, Philadelphia 19107, USA.

Arch Pathol Lab Med. 2005 Mar;129(3):360-5. Abstract quote  

CONTEXT: Osteoclast-like giant cells (GCs) in giant cell tumors (GCTs) are thought to derive from a monocyte-macrophage lineage. Microphthalmia transcription factor (MITF) is necessary for osteoclast gene expression and tartrate-resistant acid phosphatase (TRAP) activation; c-Kit plays a role in regulation of MITF.

OBJECTIVE: To gain insight into the differentiation of GCTs of bone (GCTBs) and GCTs tendon sheath (GCTTSs) by investigating immunohistochemical staining for c-Kit, MITF, TRAP, and HAM-56 in the GCs and stroma.

DESIGN: Immunoreactivity for CD117 (c-Kit), MITF, TRAP, and HAM-56 was studied in 35 GCTBs, 15 GCTTSs, and 5 foreign-body GC controls.

RESULTS: Across tumors, MITF and TRAP but not c-Kit were generally expressed in GCs; TRAP was variably expressed in stromal cells. The MITF was expressed more consistently in stromal cells of GCTTSs than GCTBs (P < .001). The GCTBs showed more intense MITF stromal (P < .001) and TRAP GC staining (P = .04) than GCTTSs. HAM-56 staining by stromal cells was associated with MITF stromal staining (r2 = 0.6, P < .001).

CONCLUSIONS: Results suggest that MITF and TRAP are expressed during osteoclast differentiation and that a proportion of mononuclear cells in GCTs express the macrophage marker HAM-56. Both GCTBs and GCTTSs show similar patterns of immunohistochemical expression.
Giant cell tumor of tendon sheath: immunohistochemical study of 20 cases.

Cavaliere A, Sidoni A, Bucciarelli E.

Institute of Pathological Anatomy and Histology, First Chair, Perugia University, Italy.
Tumori. 1997 Sep-Oct;83(5):841-6. Abstract quote  

AIMS AND BACKGROUND: Giant cell tumor of tendon sheath (GCTTS) is a common tumor occurring on the tendon sheaths of the fingers. The nature of this lesion is still controversial: some researchers consider it a reactive process arising from chronic inflammation while others regard it as a tumor of presumed synovial cell or monocytic macrophage system origin. In an effort to clarify the histogenesis we decided to further investigate the immunophenotypic profile of this tumor.

STUDY DESIGN: We studied 20 GCTTS of the fingers using a panel of 18 antibodies, 13 monoclonal and 5 polyclonal.

RESULTS: The immunohistochemical investigation revealed that the mononuclear cells of this lesion can be divided into two groups. The cells of the first and more numerous group were positive for vimentin, PG-M1 and KP1 but also for muscle actin (HHF35 monoclonal antibody) and neuron-specific enolase. A second population of mononuclear cells, usually arranged around the giant cells, were positive for PG-M1, KP1, LCA and occasionally for alpha-1-antitrypsin and alpha-1-antichymotrypsin. Multinucleated giant cells were also positive for KP1, PG-M1 and LCA monoclonal antibodies. A variable but usually weak positivity for alpha-1-antitrypsin, alpha-1-antichymotrypsin and lysozyme was also observed.

CONCLUSIONS: Our results suggest a synovial cell origin for GCTTS and do not support the hypothesis that it could be a neoplasm with a true histiocytic origin. The positivity of some cells for the HHF35 antibody, together with electron microscopic evidence of filament bundles with focal dense bodies, suggests that at least part of the mononuclear cells may have a myofibroblastic differentiation.
MICROPHTHALMIA-ASSOCIATED TRANSCRIPTION FACTOR  
Immunohistochemical evaluation of microphthalmia-associated transcription factor expression in giant cell lesions.

Seethala RR, Goldblum JR, Hicks DG, Lehman M, Khurana JS, Pasha TL, Zhang PJ.

University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
Mod Pathol. 2004 Dec;17(12):1491-6. Abstract quote  

Microphthalmia-associated transcription factor (Mitf), a member of the helix-loop-helix transcription factor subfamily, normally expressed in mononuclear and multinucleated osteoclasts, is involved in the terminal differentiation of osteoclasts. Dysfunction of osteoclast activity resulting from abnormal Mitf expression has been implicated in osteopetrosis. Numerous other giant cells of various types including osteoclast-like giant cells seen in various tumors, traditionally thought to be monocyte derived, are seen in a variety of bone and extraosseous lesions.

Using a monoclonal antibody with a standard immunohistochemical technique on paraffin sections, we evaluated expression of Mitf in 89 various giant cell lesions including giant cell tumor of bone (n26), giant cell tumor of tendon sheath/pigmented villonodular synovitis (n24), giant cell reparative granuloma (n3), aneurysmal bone cysts (n11), chondroblastomas (n7), foreign body giant cell reaction (n10), and sarcoidosis (n8). We also evaluated three cases of osteopetrosis and 27 various tissues without monocyte-derived giant cells (nine bone marrows, nine products of conception, seven lymph nodes with sinus histiocytosis, one granulation tissue and one thymus). Nuclear Mitf immunoreactivity was evaluated. Mitf was variably expressed in the monocyte-derived giant cells and/or the adjacent mononuclear cells/histiocytes in 23 (89%) giant cell tumors of the bone, 23 (96%) giant cell tumors of tendon sheath/pigmented villonodular synovitis, three (100%) giant cell reparative granuloma, eight (73%) aneurysmal bone cysts, five (71%) chondroblastomas, eight (80%) foreign-body giant cell reactions, and six (75%) sarcoidoses. No Mitf immunoreactivity was detected in cases of osteopetrosis and giant cells of nonmonocyte origin.

Mitf immunoreactivity is rare in tissues with rich mononuclear cells/histiocytes but no monocyte derived giant cells. These findings support the notion that giant cells in giant cell lesions are likely derived from adjacent mononuclear cells and Mitf might play a role in the multinucleation process of such cells.
ELECTRON MICROSCOPY  
Diffuse type of giant-cell tumor of tendon sheath: an ultrastructural study of two cases with cytogenetic support.

Ferrer J, Namiq A, Carda C, Lopez-Gines C, Tawfik O, Llombart-Bosch A.

Department of Pathology, Medical School, University of Valencia, Spain.

Ultrastruct Pathol. 2002 Jan-Feb;26(1):15-21. Abstract quote  

Two cases of the diffuse type of giant-cell tumor of the tendon sheath (GCTTS) are described. Both tumors arose in the vicinity of large joints of the lower extremity, showing similar clinical and radiological features.

Histologically, a proliferation of polygonal mononuclear cells was seen, together with osteoclastlike giant cells, foam cells, and siderophages. The tumors were poorly delineated, displaying an infiltrative pattern into the neighboring soft tissues.

Immunohistochemically, strong expression of vimentin, neuron-specific enolase, A1-antitrypsin, and CD68 was found in both mono- and multinucleated tumor cells. At the ultrastructural level, mononuclear cells revealed a diverse morphology, displaying features of histiocytelike and fibroblastlike cells, with the former being more numerous. Scarce neurosecretorylike granules, made up of electrondense membrane-bound material, were found in the cytoplasm of the mononuclear cells.

Cytogenetic analysis of one case shows the presence of a clonal population with 47 chromosomes and two different translocations, t(2;3) and der(8) t(8;12). Present findings provide further support regarding the neoplasic nature of this tumoral entity.

 

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES
AMYLOIDOMA  
Recurrent amyloidoma of soft tissue with exuberant giant cell reaction.

Mukhopadhyay S, Damron TA, Valente AL.

Department of Pathology, State University of New York Upstate Medical University, Syracuse, NY 13210, US
A.
Arch Pathol Lab Med. 2003 Dec;127(12):1609-11. Abstract quote  

Amyloidoma (localized tumorlike amyloidosis) in the soft tissues is rare. We present an instructive case of recurrent amyloidoma in the soft tissue of the ankle in a 45-year-old man with multiple surgical procedures and chronic osteomyelitis of the underlying bones.

The lesion evaded diagnosis because of a florid giant cell reaction that led to various misdiagnoses, including giant cell tumor of tendon sheath, foreign body reaction secondary to surgery, and pseudogout.

This case demonstrates the importance of considering the possibility of amyloidoma when a giant cell-rich lesion is encountered in the soft tissues.
INJURY, PAINT GUN  
High-pressure paint-gun injury of the finger simulating giant cell tumor of tendon sheath.

Stefanato CM, Turner MS, Bhawan J.

Department of Dermatology, Dermatopathology Section, Boston University School of Medicine, Boston, MA 02118-2515, USA.

J Cutan Pathol. 2005 Feb;32(2):179-83. Abstract quote  

High-pressure paint guns deliver paint at approximately 3000 pounds per square inch. At this pressure, paint will penetrate the skin and spread quickly through fascial planes and tendon sheaths. The present case is that of a lesion from the finger of a 35-year-old white male in whom a history was initially unavailable.

Histologic examination revealed diffuse fibrohistiocytic proliferation and giant cells, with numerous darkly pigmented, uniformly small-sized particles throughout the lesion. The initial impression was that of a giant cell tumor of tendon sheath. However, the pigment particles were negative for Perls stain, and polariscopic examination revealed clear refractile fragments. These findings raised the possibility that the lesion was the result of a traumatic event.

On further inquiry, it was revealed that the patient had sustained a high-pressure paint-gun injury 1 year earlier. The simulation, histopathologically, of a giant cell tumor of tendon sheath by a high-pressure paint-gun injury has not, to our knowledge, been reported previously, nor has the histologic finding of small, uniformly sized pigment particles and polarizable refractile fragments in this particular type of injury.

 

PROGNOSIS CHARACTERIZATION
PROLIFERATIVE ACTIVITY  
The effect of cellular proliferative activity on recurrence and local tumour extent of localized giant cell tumour of tendon sheath.

Kitagawa Y, Ito H, Yokoyama M, Sawaizumi T, Maeda S.

Department of Orthopaedic Surgery, Pathology and Surgical Pathology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
J Hand Surg [Br]. 2004 Dec;29(6):604-7. Abstract quote  

This study investigates whether the proliferative activity of giant cell tumour of tendon sheath is related to its recurrence rate and local aggressiveness.

The clinicopathological and immunohistochemical features of 30 localized giant cell tumours of tendon sheath were studied and the influence of the MIB-1 staining index on recurrence, tumour extent around the phalanx and involvement of the bone were evaluated. No significant difference in the MIB-1 staining index was found between the lesions which recurred and those which did not. Also there was no significant association between local aggressiveness and the MIB-1 staining index.

These results suggest that the proliferative activity of localized giant cell tumour of tendon sheath is not related to its high recurrence rate and local aggressiveness.
RECURRENCE  
Giant cell tumours of tendon sheath: classification and recurrence rate.

Al-Qattan MM.

Division of Plastic Surgery, King Khalid University Hospital, Saudi Arabia.

J Hand Surg [Br]. 2001 Feb;26(1):72-5. Abstract quote  

Forty-three consecutive cases of giant cell tumour of tendon sheath were included in a prospective study. The tumours were classified into two main types, depending on whether the entire tumour was, or was not, surrounded by one pseudocapsule as assessed by the surgeon during surgery.

Each type was then sub-classified according to the thickness of the capsule, lobulation of the tumour, the presence of satellite lesions, and the diffuse or multicenteric nature of the tumour: these factors were also assessed by the surgeon.

The mean follow-up period was 4 (range, 2-6) years. None of the type I tumours (n=30) recurred, but recurrence occurred in five out of 13 type II tumours. Second recurrences were seen with type II B and C, but not type II A tumours.

 

TREATMENT CHARACTERIZATION
GENERAL Complete excision
Giant cell tumor of tendon sheath, tenosynovial giant cell tumor, and pigmented villonodular synovitis: defining the presentation, surgical therapy and recurrence.

Martin RC 2nd, Osborne DL, Edwards MJ, Wrightson W, McMasters KM.

Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine and the James Graham Brown Cancer Center, Louisville, KY 40202, USA.

Oncol Rep. 2000 Mar-Apr;7(2):413-9. Abstract quote  

Giant cell tumor of the tendon sheath (GCTTS), tenosynovial giant cell tumor (TGCT), and pigmented villo-nodular synovitis (PVNS) are the common names for a group of rare proliferative disorders that involve synovial joints and tendon sheaths. Considerable confusion exists about the surgical treatment and diagnosis of these disorders.

This review evaluates the presentation, surgical therapy and recurrence of these three proliferative disorders. We retrospectively reviewed the clinical data from all cases of GCTTS, TGCT, and PVNS from 1985 to 1997. A total of 35 patients were identified: GCTTS (n=8), TGCT (n=1), and PVNS (n=26), there were 18 men and 17 women. The median age was 48 years (range 6-84 years). The most common site of involvement was the knee (15), followed by wrist (7), elbow (4), and hip (4). Seven patients had extra-articular involvement, and 19 were found incidentally at operations for other reasons. Among the 4 patients who developed recurrent disease, 2 had extra-articular disease at the time of their original diagnosis. None died, and none required major amputation. One patient was treated with adjuvant radiotherapy following resection of a recurrence.

It is important to distinguish between focal and diffuse forms of synovial involvement. If focal, simple surgical excision is appropriate. If diffuse, complete synovectomy is indicated for disease confined to the joint, and resection of all gross disease is indicated for extra-articular disease.

Radical resection with negative margins is not necessary in most instances. In rare aggressive cases, local recurrence may necessitate more extensive resection and radiation therapy.
Giant cell tumor of the tendon sheath: a retrospective study of 28 cases.

Rodrigues C, Desai S, Chinoy R.

Department of Pathology, Tata Memorial Hospital, Bombay, India.
J Surg Oncol. 1998 Jun;68(2):100-3. Abstract quote  

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

Kotwal PP, Gupta V, Malhotra R.

Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi.

J Bone Joint Surg Br. 2000 May;82(4):571-3. Abstract quote  

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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Examine an actual biopsy report to understand what each section means

Special Stains
Understand the tools the pathologist utilizes to aid in the diagnosis

How Accurate is My Report?
Pathologists actively oversee every area of the laboratory to ensure your report is accurate

Got Path?
Recent teaching cases and lectures presented in conferences


Internet Links

Pathologists Who Make A Difference
Search for a Physician Specialist


Last Updated August 23, 2005

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