Giant Cell Tumor of Tendon Sheath

  • Author: James R Verheyden, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Jul 07, 2016
 

Background

Giant cell tumors of the tendon sheath are the second most common tumors of the hand, with simple ganglion cysts being the most common.[1] 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.

Giant cell tumors of the soft tissue are classified into the following two types:

  • Localized (common)
  • Diffuse (rare)

The rare diffuse form is considered the soft-tissue counterpart of diffuse pigmented villonodular synovitis (PVNS) and typically affects the lower extremities.[2] Its anatomic distribution parallels that of PVNS, with lesions most commonly found around the knee, followed by the ankle and foot; however, it occasionally affects the hand. Typically, these lesions, like those of PVNS, occur in young patients; 50% of cases are diagnosed in patients younger than 40 years. The diffuse form is often locally aggressive, and multiple recurrences after excision are common.

Because of the similarities in age, tumor locations, clinical presentations, and symptoms for patients with PVNS and patients with the diffuse form of giant cell tumors of the tendon sheath, the diffuse form probably represents an extra-articular extension of a primary intra-articular PVNS process.

Findings from flow cytometric DNA analysis suggest that PVNS and giant cell tumors of the tendon sheath are histopathologically similar but clinically distinct lesions.[3, 4, 4] When the origin of these poorly confined soft-tissue masses is uncertain, Enzinger and Weiss[5] classify these tumors as the diffuse type of giant cell tumors of the tendon sheath, whether or not they involve the adjacent joint.[6]

This article focuses on the common localized form of giant cell tumors—that is, the giant cell tumors of the tendon sheath that are often found in the hands and feet.[7, 8, 9, 10, 11]

Next

Etiology

As is true for most soft-tissue tumors, the etiology of giant cell tumors of the tendon sheath is unknown. Pathogenetic theories have included trauma, disturbed lipid metabolism, osteoclastic proliferation, infection, vascular disturbances, immune mechanisms, inflammation, neoplasia, and metabolic disturbances.[12] Probably the most widely accepted theory, as Jaffe et al proposed,[13] is that of a reactive or regenerative hyperplasia associated with an inflammatory process.

Histochemical evidence shows that the mononuclear cells and giant cells present in these lesions resemble osteoclasts,[14, 15] and this resemblance suggests a bone marrow–derived monocyte/macrophage lineage for these tumors. Polymerase chain reaction (PCR) assays have shown that giant cell tumors of the tendon sheath are polyclonal proliferations,[16] which suggests that these masses are nonneoplastic proliferations, if one accepts the premise that a population of cells forming a tumorous mass must show clonality to be classified as a neoplasm.

Previous
Next

Epidemiology

Giant cell tumors of the tendon sheath are the second most common tumors in the hand; simple ganglion cysts are the most common. Giant cell tumors of the tendon sheath most commonly occur in patients aged 30-50 years, with a peak incidence in those aged 40-50 years. Rarely are these tumors found in patients younger than 10 years or older than 60 years. The female-to-male ratio is 3:2.

Giant cell tumors of the tendon sheath are associated with degenerative joint disease, especially in the distal interphalangeal (DIP) joint. Jones et al[17] noted degenerative joint disease in the joint from which a tumor arose or in the joint nearest to the mass in 46 of 91 cases in which radiographs were reviewed.

An occasional association with rheumatoid arthritis has been reported;[18] however, to the authors' knowledge, no pathogenetic relation between rheumatoid arthritis and giant cell tumor of the tendon sheath has been demonstrated, and their simultaneous occurrence may be coincidental. Antecedent trauma occurs in a variable number of these patients, but its association with these tumors is also probably coincidental.

Previous
Next

Prognosis

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

  • Phalen et al, [19] 9% recurrence rate in 56 cases
  • Moore et al, [20] 9% recurrence rate in 115 cases
  • Jones et al, [17] 17% recurrence rate in 95 cases
  • Reilly et al, [21] 27% recurrence rate in 70 cases
  • Wright, [22] 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.[23] For retrospective studies, see Rodrigues et al,[24] Darwish and Haddad,[25] and Messoudi et al.[26] For a significant study in children, see Gholve et al.[27]

To the authors' knowledge, no cases of malignant degeneration of a benign giant cell tumor 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 giant cell tumors have been reported; however, most authors doubt that these malignant tumors exist, because this diagnosis is difficult to confirm.

Previous
 
 
Contributor Information and Disclosures
Author

James R Verheyden, MD Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades

James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

Timothy A Damron, MD David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse

Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society for Experimental Biology and Medicine, Orthopaedic Research Society, Children's Oncology Group, Musculoskeletal Tumor Society, American College of Surgeons, American Medical Association, Connective Tissue Oncology Society

Disclosure: Received research grant from: National Institutes of Health NIAMS; Orthopaedic Research and Education Foundation; Stryker; Cempra; Wright Medical<br/>Received income in an amount equal to or greater than $250 from: Stryker, Inc (Educational travel to Stryker sponsored meetings)<br/>Received royalty from Lippincott, Williams, and Wilkins for editing/writing textbook; Received grant/research funds from Genentech for clinical research; Received grant/research funds from Orthovita for clinical research; Received grant/research funds from National Institutes of Health for clinical research; Received royalty from UpToDate for update preparation author; Received grant/research funds from Wright Medical, Inc. for clinical research.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Sean P Scully, MD 

Sean P Scully, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, Society of Surgical Oncology

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Additional Contributors

Timothy A Damron, MD David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse

Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society for Experimental Biology and Medicine, Orthopaedic Research Society, Children's Oncology Group, Musculoskeletal Tumor Society, American College of Surgeons, American Medical Association, Connective Tissue Oncology Society

Disclosure: Received research grant from: National Institutes of Health NIAMS; Orthopaedic Research and Education Foundation; Stryker; Cempra; Wright Medical<br/>Received income in an amount equal to or greater than $250 from: Stryker, Inc (Educational travel to Stryker sponsored meetings)<br/>Received royalty from Lippincott, Williams, and Wilkins for editing/writing textbook; Received grant/research funds from Genentech for clinical research; Received grant/research funds from Orthovita for clinical research; Received grant/research funds from National Institutes of Health for clinical research; Received royalty from UpToDate for update preparation author; Received grant/research funds from Wright Medical, Inc. for clinical research.

References
  1. Di Grazia S, Succi G, Fragetta F, Perrotta RE. Giant cell tumor of tendon sheath: study of 64 cases and review of literature. G Chir. 2013 May-Jun. 34(5-6):149-52. [Medline]. [Full Text].

  2. Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming DJ, Walker EA. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 2008 Sep-Oct. 28(5):1493-518. [Medline].

  3. Abdul-Karim FW, el-Naggar AK, Joyce MJ. Diffuse and localized tenosynovial giant cell tumor and pigmented villonodular synovitis: a clinicopathologic and flow cytometric DNA analysis. Hum Pathol. 1992 Jul. 23(7):729-35. [Medline].

  4. Mathews RE, Gould JS, Kashlan MB. Diffuse pigmented villonodular tenosynovitis of the ulnar bursa--a case report. J Hand Surg [Am]. 1981 Jan. 6(1):64-9. [Medline].

  5. Enzinger FM, Weiss SH. Benign tumors and tumorlike lesions of synovial tissue. In: Enzinger FM, Weiss SW, eds. Soft Tissue Tumors. St Louis, Mo: Mosby. 1995:735-55.

  6. Abimelec P, Cambiaghi S, Thioly D. Subungual giant cell tumor of the tendon sheath. Cutis. 1996 Oct. 58(4):273-5. [Medline].

  7. Choudhury M, Jain R, Nangia A. Localized tenosynovial giant cell tumor of tendon sheath. A case report. Acta Cytol. 2000 May-Jun. 44(3):463-6. [Medline].

  8. Ciattaglia G, Filosa G, Bugatti L. Giant cell tumor of tendon sheath. J Am Acad Dermatol. 1991 Oct. 25(4):728-9. [Medline].

  9. LaRussa LR, Labs K, Schmidt RG. Giant cell tumor of tendon sheath. J Foot Ankle Surg. 1995 Nov-Dec. 34(6):541-6. [Medline].

  10. Schleicher SM. Giant cell tumor of tendon sheath. Cutis. 1997 Mar. 59(3):133-4. [Medline].

  11. Wu NL, Hsiao PF, Chen BF, et al. Malignant giant cell tumor of the tendon sheath. Int J Dermatol. 2004 Jan. 43(1):54-7. [Medline].

  12. Hosaka M, Hatori M, Smith R, Kokubun S. Giant cell formation through fusion of cells derived from a human giant cell tumor of tendon sheath. J Orthop Sci. 2004. 9(6):581-4. [Medline].

  13. Jaffe HL, Lichtenstein HL, Elsutro CJ. Pigmented villonodular synovitis, bursitis, and tenosynovitis. Arch Pathol. 1941. 31:731-65.

  14. Darling JM, Goldring SR, Harada Y. Multinucleated cells in pigmented villonodular synovitis and giant cell tumor of tendon sheath express features of osteoclasts. Am J Pathol. 1997 Apr. 150(4):1383-93. [Medline].

  15. Wood GS, Beckstead JH, Medeiros LJ. The cells of giant cell tumor of tendon sheath resemble osteoclasts. Am J Surg Pathol. 1988 Jun. 12(6):444-52. [Medline].

  16. Vogrincic GS, O''Connell JX, Gilks CB. Giant cell tumor of tendon sheath is a polyclonal cellular proliferation. Hum Pathol. 1997 Jul. 28(7):815-9. [Medline].

  17. Jones FE, Soule EH, Coventry MB. Fibrous xanthoma of synovium (giant-cell tumor of tendon sheath, pigmented nodular synovitis). A study of one hundred and eighteen cases. J Bone Joint Surg Am. 1969 Jan. 51(1):76-86. [Medline].

  18. Reginato A, Martinez V, Schumacher HR. Giant cell tumour associated with rheumatoid arthritis. Ann Rheum Dis. 1974 Jul. 33(4):333-41. [Medline].

  19. Phalen GS, McCormack LJ, Gazale WJ. Giant-cell tumor of tendon sheath (benign synovioma) in the hand. Evaluation of 56 cases. Clin Orthop. 1959. 15:140-51. [Medline].

  20. Moore JR, Weiland AJ, Curtis RM. Localized nodular tenosynovitis: experience with 115 cases. J Hand Surg [Am]. 1984 May. 9(3):412-7. [Medline].

  21. Reilly KE, Stern PJ, Dale JA. Recurrent giant cell tumors of the tendon sheath. J Hand Surg [Am]. 1999 Nov. 24(6):1298-302. [Medline].

  22. Wright CJE. Benign giant-cell synovioma; an investigation of 85 cases. Br J Surg. 1951 Jan. 38(151):257-71. [Medline].

  23. Goda JS, Patil P, Krishnappan C, Elangovan D. Giant cell tumor of the tendon sheath treated by brachytherapy (surface mold) technique-A technical illustration. Brachytherapy. 2008 Oct 22. [Medline].

  24. Rodrigues C, Desai S, Chinoy R. Giant cell tumor of the tendon sheath: a retrospective study of 28 cases. J Surg Oncol. 1998 Jun. 68(2):100-3. [Medline].

  25. Darwish FM, Haddad WH. Giant cell tumour of tendon sheath: experience with 52 cases. Singapore Med J. 2008 Nov. 49(11):879-82. [Medline].

  26. Messoudi A, Fnini S, Labsaili N, Ghrib S, Rafai M, Largab A. [Giant cell tumors of the tendon sheath of the hand: 32 cases]. Chir Main. 2007 Jun. 26(3):165-9. [Medline].

  27. Gholve PA, Hosalkar HS, Kreiger PA, Dormans JP. Giant cell tumor of tendon sheath: largest single series in children. J Pediatr Orthop. 2007 Jan-Feb. 27(1):67-74. [Medline].

  28. Briët JP, Becker SJ, Oosterhoff TCh, Ring D. Giant cell tumor of tendon sheath. Arch Bone Jt Surg. 2015 Jan. 3 (1):19-21. [Medline].

  29. Suresh SS, Zaki H. Giant cell tumor of tendon sheath: case series and review of literature. J Hand Microsurg. 2010 Dec. 2(2):67-71. [Medline]. [Full Text].

  30. Garg B, Kotwal PP. Giant cell tumour of the tendon sheath of the hand. J Orthop Surg (Hong Kong). 2011 Aug. 19(2):218-20. [Medline].

  31. Hamdi MF, Touati B, Zakhama A. Giant cell tumour of the flexor tendon sheath of the hand: analysis of 27 cases. Musculoskelet Surg. 2011 Jun 15. [Medline].

  32. Findling J, Lascola NK, Groner TW. Giant cell tumor of the flexor hallucis longus tendon sheath: a case study. J Am Podiatr Med Assoc. 2011 Mar-Apr. 101(2):187-9. [Medline].

  33. Stewart MJ. Benign giant-cell synovioma and its relation to "xanthoma". JBJS. 1948. 30B:522-7.

  34. Jelinek JS, Kransdorf MJ, Shmookler BM. Giant cell tumor of the tendon sheath: MR findings in nine cases. AJR Am J Roentgenol. 1994 Apr. 162(4):919-22. [Medline].

  35. Bancroft LW, Peterson JJ, Kransdorf MJ. Imaging of soft tissue lesions of the foot and ankle. Radiol Clin North Am. 2008 Nov. 46(6):1093-103. [Medline].

  36. Wang Y, Tang J, Luo Y. The value of sonography in diagnosing giant cell tumors of the tendon sheath. J Ultrasound Med. 2007 Oct. 26(10):1333-40. [Medline].

  37. Agarwal PK, Gupta M, Srivastava A. Cytomorphology of giant cell tumor of tendon sheath. A report of two cases. Acta Cytol. 1997 Mar-Apr. 41(2):587-9. [Medline].

  38. Iyer VK, Kapila K, Verma K. Fine-needle aspiration cytology of giant cell tumor of tendon sheath. Diagn Cytopathol. 2003 Aug. 29(2):105-10. [Medline].

 
Previous
Next
 
Image in a 44-year-old right hand–dominant man who presented with a mass on the volar radial aspect of his left index finger. The mass was painless and had been slowly growing for 1.5 years.
Radiograph demonstrates cortical erosion from the pressure effect of the adjacent mass on the radial aspect of the proximal phalanx.
Radiograph demonstrates the bony erosion associated with some giant cell tumors of the tendon sheath and shows the unmineralized soft-tissue shadow of the mass.
Radiograph demonstrates cortical erosion from the pressure effect of the overlying giant cell tumor of the tendon sheath. This apple-core effect is indicative of a primary soft-tissue mass that is causing external erosion, which should not be confused with a primary bone process such as periosteal chondroma.
Radiograph demonstrates cortical erosion from the pressure effect of the overlying giant cell tumor of the tendon sheath.
Histologic findings of a giant cell tumor of the tendon sheath.
High-power photomicrograph depicts the histologic findings of a giant cell tumor of the tendon sheath.
Typical T2-weighted MRI appearance of a giant cell tumor of the tendon sheath. Most of the tumor has intermediate signal intensity, and portions of the tumor have low signal intensity; the latter finding likely reflects signal attenuation due to hemosiderin deposition.
Typical T1-weighted MRI appearance of a giant cell tumor of the tendon sheath. Portions of the tumor have decreased signal intensity.
Typical T1-weighted MRI findings in a giant cell tumor of the tendon sheath overlying the metacarpophalangeal joint. Note the low-signal-intensity areas.
Corresponding T2-weighted MRI findings in the tumor shown in the image above. Note the areas of low signal intensity.
Intraoperative excision of the giant cell tumor of the tendon sheath, which has the typical golden-yellow color secondary to hemosiderin deposition. The radial digital nerve is dissected free and slightly volar to the mass.
After excision, the bone is curetted, leaving the exposed radial aspect of the proximal phalanx, as shown here.
Giant cell tumor of the tendon sheath after marginal excision.
Typical microscopic appearance of a giant cell tumor of the tendon sheath. Sheets of rounded or polygonal cells blend with hypocellular collagenized zones; variable numbers of giant cells are present.
High-power photomicrograph of giant cell tumor of the tendon sheath shows occasional numerous mononuclear cells, scattered giant cells, and hemosiderin-containing xanthoma cells.
An 11-year-old girl presented with this firm nonfluctuant mass over her posterior medial left ankle that had been present for 5 months and had not increased in size. The mass was not transilluminating. Findings on frozen section were consistent with a benign giant cell tumor of the tendon sheath. The mass was marginally excised.
Giant cell tumor of the tendon sheath after marginal excision from an 11-year-old girl who presented with a firm nonfluctuant mass over her posterior medial left ankle that had been present for 5 months and had not increased in size.
 
Medscape Consult
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.