Giant Cell Tumor of the Tendon Sheath Treatment & Management

  • Author: James R Verheyden, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Feb 6, 2012
 

Surgical Therapy

Marginal excision of giant cell tumor of the tendon sheath is the treatment of choice (see the images below). Complete excision can be difficult, as the mass is frequently associated with the tendon sheath or synovial joint. Often, partial excision of the joint capsule or tendon sheath is necessary for complete removal of the tumor. Meticulous dissection and exploration are essential because satellite lesions are common. A Freer elevator or other blunt probe is often helpful in teasing these satellite lesions from beneath the surrounding tendons or other structures. Avoid puncturing these lesions because seeding of adjacent soft-tissue structures may be possible. Occasionally, bony debridement with a curette or rongeur is necessary if adjacent bony erosion is present.

An 11-year-old girl presented with this firm nonflAn 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 marginGiant 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.

Jones et al[11] noted an association between these lesions and arthritis at the DIP joint. If such arthritis is present, debridement or fusion may be necessary to completely eradicate the process. If the tumor involves the skin, consider the excision of an elliptical area of skin along with the mass. Skin excision may necessitate secondary skin grafting. Rarely, tendon reconstruction may be necessary if tumor excision compromises the associated tendon. Even with careful dissection, reported recurrence rates are 9-44%.

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Intraoperative Details

The tumor may involve the tendon sheath, volar plate, capsular ligaments, and joints. Dorsal sites frequently involve the joints or tendinous attachments to bone. Volar sites are more frequently present near the joints, presumably because the fibrous flexor-tendon sheath is thinner at the level of the joints. In a review of 115 cases, 20% had extra-articular joint involvement. In the digits, these tumors are often intimately associated with the flexor or extensor tendon. If no intimate association exists, a stalk of tissue often connects the tumor to the tendon sheath. If the mass is relatively large, smaller satellite lesions extending into the surrounding tendon sheath and synovium may be found.

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Outcome and Prognosis

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

  • Phalen et al,[28] 9% recurrence rate in 56 cases
  • Moore et al,[29] 9% recurrence rate in 115 cases
  • Jones et al,[11] 17% recurrence rate in 95 cases
  • Reilly et al,[30] 27% recurrence rate in 70 cases
  • Wright,[31] 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 presence of adjacent degenerative joint disease; an injury at the DIP joint of the finger or the interphalangeal joint of the thumb; and the 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.[32] For retrospective studies, see Rodrigues et al,[33] Darwish and Haddad,[34] and Messoudi et al.[35] For a significant study in children, see Gholve et al.[36]

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.

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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, and 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, American College of Surgeons, American Medical Association, Children's Oncology Group, Connective Tissue Oncology Society, Musculoskeletal Tumor Society, Orthopaedic Research Society, and Society for Experimental Biology and Medicine

Disclosure: Lippincott, Williams, and Wilkins Royalty Editing/writing textbook; Genentech Grant/research funds Clinical research; Orthovita Grant/research funds Clinical research; National Institutes of Health Grant/research funds Clinical research

Specialty Editor Board

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, American College of Surgeons, American Medical Association, Children's Oncology Group, Connective Tissue Oncology Society, Musculoskeletal Tumor Society, Orthopaedic Research Society, and Society for Experimental Biology and Medicine

Disclosure: Lippincott, Williams, and Wilkins Royalty Editing/writing textbook; Genentech Grant/research funds Clinical research; Orthovita Grant/research funds Clinical research; National Institutes of Health Grant/research funds Clinical research

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

Disclosure: Medscape Salary Employment

Sean P Scully, MD, PhD  Professor, Department of Orthopedics, University of Miami

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

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

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

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, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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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.
 
 
 
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