Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 82-84  

Giant cell tumor of tendon sheath in palmar region-cytological aspect of an uncommon tumor


1 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Rashmi Patnayak
Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197906

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  Abstract 

Giant cell tumor of tendon sheath (GCTTS) is a benign soft tissue neoplasm. It is the second most common tumor of the hand after ganglion. The pathogenesis of GCTTS is not known. This tumor is known to recur after excision. We present a case of GCTTS in the palmar aspect of the right hand of a 41-year-old female. Ultrasonography of hand revealed a well-defined hypoechoic lesion in the subcutaneous plane with focal areas of calcification. She underwent fine-needle aspiration (FNA). The FNA smears showed the characteristic presence of stromal cells and multinucleated osteoclast-like giant cells. This is an uncommon case of GCTTS present in the palmar aspect of hand diagnosed by FNA.

Keywords: Benign soft tissue neoplasm of hand, fine-needle aspiration cytology of giant cell tumor, giant cell tumor of tendon sheath


How to cite this article:
Rekha YC, Patnayak R, Bodagala V, Jena A, Mutheeswaraiah Y, Asha T. Giant cell tumor of tendon sheath in palmar region-cytological aspect of an uncommon tumor. Med J DY Patil Univ 2017;10:82-4

How to cite this URL:
Rekha YC, Patnayak R, Bodagala V, Jena A, Mutheeswaraiah Y, Asha T. Giant cell tumor of tendon sheath in palmar region-cytological aspect of an uncommon tumor. Med J DY Patil Univ [serial online] 2017 [cited 2019 Dec 6];10:82-4. Available from: http://www.mjdrdypu.org/text.asp?2017/10/1/82/197906


  Introduction Top


Giant cell tumor of tendon sheath (GCTTS) is a firm, nontender, slow growing, benign soft tissue neoplasm. It is the second most common tumor of the hand after ganglion.[1],[2] Its peak incidence is in the third and fifth decades with a slight female predominance.[1],[2] The origin and pathogenesis of the lesion remain undetermined. Several hypotheses have been proposed in this regard that include metabolic, neoplastic and inflammatory processes as probable etiological factors.[1] Although GCTTS most commonly presents in a digit of the hand, it may also present in the palm, wrist, foot, knee, ankle, elbow, and hip.[1],[2]

The reported local recurrence of GCTTS after excision is up to 45%.[2],[3] Fine-needle aspiration (FNA) cytology helps in making an early, accurate preoperative pathological diagnosis.[1],[4],[5]


  Case Report Top


A 41-year-old female presented with complaints of swelling over the palmar aspect of right hand since 2 years. The swelling was associated with complaints of occasional pricking type of pain. It was gradually increasing in size since then. She was sweeper by occupation and gave a history of excision of similar type swelling 3 years ago, at the same site, details of which were not available. On examination, a firm swelling was noted in between fourth and fifth metacarpal spaces over the palmar aspect of right hand measuring 2.5 cm × 2 cm. Skin over the swelling was thickened with a healed scar [Figure 1]. X-ray revealed a localized soft tissue swelling noted in the palmar aspect overlapping the fourth metacarpal with normal joint spaces, and there was no evidence of periarticular erosions [Figure 2]. Further, she was evaluated with ultrasonography (USG) which revealed a well-defined hypoechoic lesion noted in the subcutaneous plane measuring 2.8 cm × 2.5 cm, showing few areas of calcifications [Figure 3]. There was no evidence of bony origin. With a differential diagnosis of ganglion and GCTTS the patient was referred for FNA. FNA of the swelling yielded 0.3 ml of brown colored fluid. The cytology smears were moderately cellular. They revealed predominantly stromal cells and giant cells. The stromal cells were oval to elongated spindle-shaped cells with many showing bipolar cytoplasmic processes and tapering ends. These cells were arranged in tiny clusters and discretely along with multinucleated osteoclast-like giant cells admixed with few macrophages [Figure 4] and [Figure 5].
Figure 1: Swelling between fourth and fifth metacarpal spaces over the palmar aspect of right hand

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Figure 2: X-ray right hand showing focal soft tissue swelling noted overlapping the fourth metacarpal bone on the palmar aspect

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Figure 3: Ultrasound showing lobulated hypoechoic lesion surrounding the flexor tendon of fourth finger (black circle)

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Figure 4: Cytosmear showing multinucleated giant cell (white arrow), stromal cells (arrow head) and macrophages (black arrow) (papanicolouae stain, ×100)

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Figure 5: Osteoclastic type multinucleated giant cell (white arrow), stromal cells (arrow head) and macrophages (Black arrow) (May-Grunwald giemsa stain, ×400)

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  Discussion Top


GCTTS is a benign tumor usually noted in the hand of females in third to fifth decades of life.[1] The most common site is hand, but it can also occur in other parts of the body such as the spine, ankle, knee and feet.[6]

Imaging modalities like sonography helps to detect the solid or cystic nature of the tumor and presence of satellite lesions. It also describes the relationship of the lesion to the surrounding structures.[7],[8] This has been particularly been important in our case as the X-ray could conclude it only as soft tissue swelling whereas USG done could rule out the bony origin of the tumor. USG described the extent of the tumor in the subcutaneous plane with a possible origin from the tendon sheath.

Diagnosis of GCTTS is possible preoperatively with an FNA, some authors even have advocated image-guided FNA as a diagnostic tool.[4],[5],[9]

The aspiration smears of GCTTS usually show high cellularity. They have a predominant uniform population of spindled to polygonal stromal cells admixed with multinucleated osteoclastic type giant cells. Other cell types frequently present include hemosiderin-laden macrophages and foamy histiocytes. Nuclear grooves or intranuclear pseudo-inclusions are infrequently described in stromal cells. Mitosis and necrosis are typically not seen in GCTTS.[4],[5]

Our patient was a middle-aged female with a firm swelling in the palmar aspect. She gave the history of recurrent swelling that was previously operated. However, she did not have details of either the operation or the diagnosis.

The various differential diagnoses of (GCTTS) includes benign conditions such as ganglion, synovial cyst, fibrous histiocytoma, and nodular fasciitis and malignant neoplasms such as synovial sarcoma, malignant fibrous histiocytoma, and clear cell sarcoma. However, the characteristic cytology features with the help of clinical and radiological findings helped to arrive at the diagnosis of GCTTS.[10]

Treatment of GCTTS of hand is challenging. The treatment requires a balance between extensive dissections for excision versus the risk of recurrence. A study by Williams et al. shows that chance of recurrence is high if there is direct involvement of the extensor tendons, flexor tendons, or joint capsule by the tumor.[11] The goal of the surgeon dealing with GCTTS is to excise the tumor with minimal disruption to adjacent structures. The recurrence rate of GCTTS varies from 0% to 44%.[1],[3],[7] Recurrence is attributed to incomplete excision of the tumor or satellite lesions. To minimize recurrence, complete marginal excision should be performed.[1]

The patient should be counseled in the preoperative period with regard to the probability of recurrence. Complete surgical excision remains the mainstay of treatment, assisted either with an operating microscope or a magnifying loupe. Radiotherapy has been suggested after inadequate excision and in patients with high mitotic activity to prevent recurrence.[10]


  Conclusion Top


Diagnostic accuracy of GCTTS can be increased with a thorough clinical history, detail physical examination, and radiologic correlation. FNA can provide reliable early, accurate preoperative diagnosis in addition to clinical and radiological findings. This is an additional case of GCTTS highlighting the cytological aspect.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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. 1
    
2.
Fotiadis E, Papadopoulos A, Svarnas T, Akritopoulos P, Sachinis NP, Chalidis BE. Giant cell tumour of tendon sheath of the digits. A systematic review. Hand (NY) 2011;6:244-9.  Back to cited text no. 2
    
3.
Kotwal PP, Gupta V, Malhotra R. Giant-cell tumour of the tendon sheath. Is radiotherapy indicated to prevent recurrence after surgery? J Bone Joint Surg Br 2000;82:571-3.  Back to cited text no. 3
    
4.
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. 4
    
5.
Batra VV, Jain S, Singh DK, Kumar N. Cytomorphologic spectrum of giant cell tumor of tendon sheath. Acta Cytol 2008;52:152-8.  Back to cited text no. 5
    
6.
Briët JP, Becker SJ, Oosterhoff TC, Ring D. Giant cell tumor of tendon sheath. Arch Bone Jt Surg 2015;3:19-21.  Back to cited text no. 6
    
7.
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;34:149-52.  Back to cited text no. 7
    
8.
Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: Analysis of sonographic findings. AJR Am J Roentgenol 2004;183:337-9.  Back to cited text no. 8
    
9.
Ho CY, Maleki Z. Giant cell tumor of tendon sheath: Cytomorphologic and radiologic findings in 41 patients. Diagn Cytopathol 2012;40(Suppl 2):E94-8.  Back to cited text no. 9
    
10.
Cherla D, Hahn E Jr, Datiashvilli R. Meticulous surgical excision of a localized giant cell tumor of the tendon sheath. Eplasty 2013;13:ic36.  Back to cited text no. 10
    
11.
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. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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