Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 211-214  

Bilateral giant cell tumor of tendon sheath of tendoachilles


1 Department of Pathology, Burdwan Medical College, Burdwan, West Bengal, India
2 Department of Orthopedics, Burdwan Medical College, Burdwan, West Bengal, India
3 Department of Physiology, Burdwan Medical College, Burdwan, West Bengal, India
4 Department of Anesthesiology, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication4-Feb-2014

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan-713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.126349

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  Abstract 

Giant cell tumor of tendon sheath arises from the synovium of tendon sheaths, joints, or bursae, mostly affects adults between 30 and 50 years of age, and is slightly more common in females. We report the case of a 32-years-old male presenting with pain in both ankles without any history of trauma. On clinical examination, tenderness on both tendoachilles and local thickening were observed. Ultrasonography showed thickening of local tendinous area with increase in anteroposterior diameter, and Doppler demonstrated increased flow in peritendinous area. MRI findings showed that most of the tumor had intermediate signal intensity and portions of the tumor had low signal intensity. Fine needle aspiration cytology confirmed the diagnosis of giant cell tumor of tendon sheath. Excision biopsy was done with no recurrence on five month follow-up. Review of literature did not reveal any similar result; so, bilateral giant cell tumor of tendon sheath of tendoachilles is a rare presentation.

Keywords: Giant cell tumor of tendon sheath, nodular and diffuse, tenosynovitis.


How to cite this article:
Datta S, Ghosh S, Chaudhuri A, Moulik SG. Bilateral giant cell tumor of tendon sheath of tendoachilles. Med J DY Patil Univ 2014;7:211-4

How to cite this URL:
Datta S, Ghosh S, Chaudhuri A, Moulik SG. Bilateral giant cell tumor of tendon sheath of tendoachilles. Med J DY Patil Univ [serial online] 2014 [cited 2019 Nov 19];7:211-4. Available from: http://www.mjdrdypu.org/text.asp?2014/7/2/211/126349


  Introduction Top


Giant cell tumor of tendon sheath (GCTTS) arises from the synovium of tendon sheaths, joints, or bursae, mostly affecting female subjects between 30 and 50 years of age. [1] The lesions consist of proliferation of polyhedral and spindle cell in fibrous stroma, exhibiting a capacity for phagocytosis of hemosidrin and lipid and a proclivity to form multinucleated giant cells. [2],[3] Diffuse-type GCT (Dt-GCT) is characterized by a striking vascularization pattern composed of densely arranged thin-walled, partly slit-like and partly hyalinized small blood vessels within the papillary synovial frond and can cause erosion of bone. [2],[3],[4] The fibrohistiocytic tumor cells probably cause considerable compression or destruction of the small vessels, which might be responsible for an increased blood deposition and massive hemosiderosis. Accompanying multinucleated osteoclast-like giant cells are recruited from circulating blood monocytes. [2],[3],[4]

Patients typi­cally present with a painless mass in the digits or large joints. The GCTTS can be divided into two groups according to the anatomic location, the first occurring in the digits, and the second in the larger joints. The lesions are usually well-circumscribed and localized, and infrequently erode or infiltrate the nearby bone. In large joints, the symptoms are non-specific and few; thus, the diagnosis is difficult to make. Plain radiographs are usually not helpful in the diagnosis of the disease. Bone erosions or soft tissue swelling is occasionally found in plain radiographs. [5],[6],[7],[8]

Magnetic resonance imaging (MRI) is an effective and highly sensitive tool for diagnosis. Typically, MRI features T1- (T1WI) and T2-weighted (T2WI) images, which may present with a homogeneous low signal intensity in GCTTS. [5],[6],[7] The reason for this is that tumors contain dense collagen and hemosiderin-laden macrophages. These tumors should be regarded as benign, but locally aggressive, neoplasms that are prone to recurrence when inadequately excised. [6],[7],[8] Microscopically, the GCTTS in both groups consisted of a mixture of abundant histiocyte-like, foam, and multinucleated giant cells of the osteoclast type. However, worthy of special mention are the large clefts or wide pseudoglandular spaces lined by synovial cells and that are more striking in the large joint group than in the conventional digit group. The component cells have functional properties of macrophages. Electron microscopically, the tumors consist essentially of histiocyte-like, fibroblast-like, and intermediate cells, together with myofibroblasts. [5],[6],[7],[8]

Treatment for giant cell tumor is local excision. Care must be taken to preserve the flexor tendons, extensor tendons, arteries, and nerves if possible. Rather than opening the entire site, satellite lesions can often be removed using a teasing technique, which utilizes gentle, slow dissection. If erosion of the bone has occurred, curettage to remove the cortical shell is advised. Flexor and extensor tendons invaded by the tumor should be repaired. [9]

Recurrence is a major concern in GCTTS, with rates of up to 44% being reported. In the case of recurrence, marginal excision of the tumor should be repeated. Radiotherapy has been indicated as an adjuvant therapy for the prevention of recurrence. Garg and Kotwal reported dramatic reductions in recurrence rates, with total recurrence rates of 0% and 4%, respectively, with the use of radiotherapy after surgery. [10],[11] Sharbat et al. [12] reported 0% recurrence in 10 cases (knee and ankle) after excision and intra-articular injection of 90 Yttrium on 76 months follow-up.

Arthroscopy is a safe and effective procedure for the treatment of these tumors with faster recovery. The results of clinical and radiographic follow-up of nine patients for 1 to 10 years after operation (knee) by Zang et al. [13] were satisfactory. Clinical symptoms disappeared; range of motion and X-ray findings were normal. There was no recurrent case found. Camilleri C et al. [14] reported 0% recurrence (popliteal fossa). Tumor wide resection and debriding the channel which tumor passed through are the key point to prevent the recurrence after operation.


  Case Report Top


A 32-year-old male presented with pain while walking, climbing stairs, and cycling, without any history of trauma. On examination, tenderness over back of both ankles with gross thickening was found. There was no history of fever or systemic illness. Routine hematological and biochemical tests were within normal limits. Ultrasonography showed heterogenous echogenicity with increase in anteroposterior diameter of tendon. Color Doppler showed increased flow in peritendinous area. MRI findings showed most of the tumor had intermediate signal intensity, and portions of the tumor had low signal intensity. On fine needle cytology, multinucleated giant cells with macrophage and round to spindled cells were seen. The excised masses were globular, measuring about 1.9 and 2.1 cm in diameters, firm with grey-white surfaces [Figure 1]. On microscopy, fibrous tissue with histiocytes having ill-defined eosinophilic cytoplasm, vacuolation, macrophages with multinucleated giant cells and fibroblasts were observed. Surface lining of flattened synovial cells were visualized [Figure 2]. The case was diagnosed as bilateral giant cell tumor of tendon sheath of tendoachilles.
Figure 1: Excised tumor

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Figure 2: Histopathology of giant cell tumor of tendon sheath showing histiocytes, some foamy, macrophage, fibroblast, and numerous multinucleated giant cells.

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Operative Procedure: Operation was done with patient in prone posture under spinal anesthesia, and tourniquet was applied. Posteromedial longitudinal incision of about 6 cm was made about 1 cm medial to the tendocalcaneus around the lesion. Incision was made through skin, subcutaneous tissues, and tendon sheath exposing the affected lesion, which was carefully dissected while keeping the tendon intact. Wound was closed in layers. Bilateral below knee anterior Plaster of Paris slab was applied. Stitches were removed after two weeks, and slab was removed after four weeks. The patient was allowed weight-bearing in the lower limbs with the help of walker. The walker was discarded after a month showing resultant full range of knee and ankle movement. Post-operative recovery was smooth and uneventful. During the five month follow-up period, there was no evidence of local tumor recurrence.


  Discussion Top


The present case of giant cell tumor of tendon sheath was a rare presentation affecting both tendoachilles of lower extremity. Single lesions are more frequently detected than multiple, but the latter were associated with a higher recurrence rate. [6],[7],[8] The diffuse form of tenosynovial giant cell tumor tends to affect a slightly younger age group than does the localized form. Ninety percent of intra-articular Dt-GCT (pigmented villonodular synovitis) involves the knee and hip, with the ankle involved to a much lesser extent. [6],[7],[8] Toe and midfoot involvement has been reported. Nearly 20% of cases involved the foot and ankle. Patients with GCTTS commonly present with articular or peri-articular pain and swelling with decreased range of motion. [5],[6],[7],[8] Hemarthrosis, degenerative osteochondral findings, and bone invasion are expected findings. These tumors should be regarded as benign, but locally aggressive, neoplasms that are prone to recurrence when inadequately excised. [8]

GCTTS arises from the synovium of a joint, bursa or tendon sheath, and 85% of the tumors occur in the fingers. The most widely accepted pathogenic hypothesis is reactive or regenerative hyperplasia associated with an inflammatory process. GCTTS was initially regarded as an inflammatory disease; however, the finding of aneuploidy in certain cases and the demonstration of clonal chromosomal abnormalities strongly support a neoplastic origin. [5],[6],[7]

In review of literature on treatment of GCTTS, the following data was found:

Arthroscopic resection of diseased tissue is preferred by some investigators. Complete resection is more likely with this approach when the disease is relatively localized. Although arthroscopic surgery offers the ability to resect disease with minimal loss of function and faster rehabilitation times, these advantages must be balanced against the possibility that diseased tissue may not be resected completely with this approach. [13],[24],[25],[26]

Lee et al. [24] reported recurrence following arthroscopic surgery in five cases, among which one case involving left knee had arthroscopic excision thrice and one case involving right knee had arthroscopic excision twice. Open synovectomy with electro-cauterization was done latter done in these cases with no recurrence on follow-up.

Open arthrotomy with synovectomy increases the likelihood of complete resection of disease, but usually requires immobilization and a longer recovery. Open synovectomy may be augmented by applying a cryosurgical surface spray to all non-articular surfaces at the time of surgery. Radiation therapy may be used as the primary treatment for Dt-GCT, but it is best used to augment surgery following the incomplete resection of disease. Clinical control of disease has been reported in as many as 98% of patients following external radiation therapy. External beam irradiation is usually employed after an incomplete resection of disease. [24],[25],[26]

In conclusion, in single lesions, complete excision of the mass by using magnifying glasses with or without radiotherapy provides good results. [5],[6],[7],[8]



 
  References Top

1.Brandal P, Bjerkehagen B, Heim S. Molecular cytogenetic characterization of tenosynovial giant cell tumors. Neoplasia 2004;6:578-583.   Back to cited text no. 1
    
2.Ruffolo PR, Kirkman H. Malignant, transplantable, giant cell tumors of peri-articular connective tissues in Syrian golden hamsters (Mesocricetus auratus). Br J Cancer 1965;19:573-80.   Back to cited text no. 2
    
3.Fletcher AG, Horn RC. Giant cell tumors of tendon sheath origin; A consideration of bone involvement and report of 2 cases with extensive bone destruction. Ann Surg 1951;133:374-85.   Back to cited text no. 3
    
4.Gould N, Korson R. Stenosing tenosynovitis of the pseudosheath of the tendo Achilles. Foot Ankle 1980;1:179-87.  Back to cited text no. 4
    
5.Sun C, Sheng W, Huiming YU, Han J. Giant cell tumor of the tendon sheath: A rare case in the left knee of a 15-year-old boy. Oncol Lett 2012;3:718-20.  Back to cited text no. 5
    
6.Elias FE, Alexis PA, Theodoros ST, Panagiotis AP, Sachinis NP, Chalidis BE. Giant cell tumour of tendon sheath of the digits: A systematic review. Hand 2011;6:244-9.  Back to cited text no. 6
    
7.Ushijima M, Hashomoto H, Tsuneyoshi M, Enjoji M. Giant cell tumor of tendon sheath (nodular tenosynovitis): A study of 207 cases to compare large joint group with common digit group. Cancer 1986;57:875-84.  Back to cited text no. 7
    
8.Bakotic BW. Tumors of the Soft Tissue of the Lower Extremity. In: Levy LA, Hetherington VJ, editors. Principles and Practice of Podiatric Medicine. vol. 17, 2 nd ed. USA: Data Trace Publishing Company; 2009. p. 1-75.  Back to cited text no. 8
    
9.Adams EL, Yoder EM, Kasdan ML. Giant cell tumor of the tendon sheath: Experience with 65 cases. Eplasty 2012;12:e50.   Back to cited text no. 9
    
10.Garg B, Kotwal PP. Giant cell tumour of the tendon sheath of the hand. J Orthop Surg (Hong Kong) 2011;19:218-20.   Back to cited text no. 10
    
11.Kotwal PP, Gupta V, Malhotra R. Giant-cell tumour of the tendon sheath. J Bone Joint Surg Br 2000;82:571-3.  Back to cited text no. 11
    
12.Shabat S, Kollender Y, Merimsky O, Isakov J, Flusser GM, Nyska M, et al. The use of surgery and yttrium 90 in the management of extensive and diffuse pigmented villonodular synovitis of large joints. Rheumatology 2002;41:1113-8.   Back to cited text no. 12
    
13.Zhang WG, Wang LD, Li J, Zhang YF, Liu Y, Wang FS. Arthroscopic treatment of the giant cell tumor of tendon sheath in knee joint. Zhonghua Wai Ke Za Zhi 2006;44:258-9.  Back to cited text no. 13
    
14.Camillieri G, Sanzo VD, Ferretti M, Calderaro C, Calvisi V. Intra-articular tenosynovial giant cell tumor arising from the posterior cruciate ligament. Orthopedics 2012;35:e1116-8.   Back to cited text no. 14
    
15.Uriburu IJ, Levy VD. Intraosseous growth of giant cell tumors of the tendon sheath (localized nodular tenosynovitis) of the digits: report of 15 cases. J Hand Surg Am 1998;23:732-6.   Back to cited text no. 15
    
16.Grover R, Grobbelaar AO, Richman PI, Smith PJ. Measurement of invasive potential provides an accurate prognostic marker for giant cell tumour of tendon sheath. J Hand Surg Br 1998;23:728-31.   Back to cited text no. 16
    
17.Reilly KE, Stern PJ, Dale JA. Recurrent giant cell tumors of the tendon sheath. J Hand Surg Am 1999;24:1298-302.   Back to cited text no. 17
    
18.Al-Qattan MM. Giant cell tumours of tendon sheath: classification and recurrence rate. J Hand Surg Br 2001;26:72-5.   Back to cited text no. 18
    
19.Ozalp T, Yercan H, Kurt C, Ozdemir O, Coºkunol E. Giant-cell tumors of the tendon sheath involving the hand or the wrist: an analysis of 141 patients. Acta Orthop Traumatol Turc 2004;38:120-4.  Back to cited text no. 19
    
20.Kitagawa Y, Ito H, Yokoyama M, Sawaizumi T, Maeda S. The effect of cellular proliferative activity on recurrence and local tumour extent of localized giant cell tumour of tendon sheath. J Hand Surg Br 2004;29:604-7.  Back to cited text no. 20
    
21.Ikeda K, Osamura N, Tomita K. Giant cell tumour in the tendon sheath of the hand: importance of the type of lesion. Scand J Plast Reconstr Surg Hand Surg 2007;41:13  Back to cited text no. 21
    
22.Darwish FM, Haddad WH. Giant cell tumour of tendon sheath: Experience with 52 cases. Singapore Med J 2008;49:879-82.  Back to cited text no. 22
    
23.Williams J, Hodari A, Janevski P, Siddiqui A. Recurrence of giant cell tumors in the hand: a prospective study. J Hand Surg Am 2010;35:451-6.  Back to cited text no. 23
    
24.Lee M, Lee SH, Suh JS, Yang WI, Shin KH. Outcomes of Diffuse-Type Pigmented Villonodular Synovitis (PVNS) after Open Total Synovectomy. J Korean Bone Joint Tumor Soc 2010;166:27-36.  Back to cited text no. 24
    
25.Ottaviani S, Ayral X, Dougados M, Gossec L. Pigmented villonodular synovitis: A retrospective single-center study of 122 cases and review of the literature. Semin Arthritis Rheum 2011;40:539-46.  Back to cited text no. 25
    
26.Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming DJ, Walker EA. Pigmented villonodular synovitis: Radiologic-pathologic correlation. RadioGraphics 2008;28:1493-518.  Back to cited text no. 26
    


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