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CASE REPORT
Year : 2012  |  Volume : 39  |  Issue : 3  |  Page : 155-157

Giant cell tumour of extensor tendon sheath: Preventing recurrence


1 Department of Plastic Surgery, KIMS, Hubli, India
2 Orthopaedics, JNMC, Belgaum, India
3 Anaesthesia, JNMC Belgaum, India
4 Hospital Administrator, JNMC Belgaum, India

Date of Web Publication11-Jan-2013

Correspondence Address:
S S Shirol
Department of Plastic Surgery, KIMS, Hubli
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.105928

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  Abstract 

Giant Cell Tumour of tendon sheath is relatively rare tumour with an overall incidence of around 1 in 50,000 individuals. Marginal excision of giant cell tumour of the tendon sheath is the treatment of choice. It is also the commonest hand lesion to recur after excision. The incidence of local recurrence is high, ranging from 9-44%. Here we present a case report of a giant cell tumour of extensor tendon sheath in hand which was successfully treated with special emphasis on ways of prevention of recurrence.

Keywords: Extensor tendon sheath, giant cell tumour, hand, prevention of recurrence


How to cite this article:
Shirol S S, Jain A, Kedareshwar, Nimbaragi G. Giant cell tumour of extensor tendon sheath: Preventing recurrence. J Sci Soc 2012;39:155-7

How to cite this URL:
Shirol S S, Jain A, Kedareshwar, Nimbaragi G. Giant cell tumour of extensor tendon sheath: Preventing recurrence. J Sci Soc [serial online] 2012 [cited 2019 Jul 18];39:155-7. Available from: http://www.jscisociety.com/text.asp?2012/39/3/155/105928


  Introduction Top


Giant Cell Tumour (GCT) is a clinically a slow growing soft tissue tumour that develops over a period of months to years. It is the second commonest tumour of the hand. [1] Many factors are considered as causing recurrence, including proximity to distal joint, presence of degenerative joint disease, pressure erosion in the radiographs, increased mitotic activity and type 2 lesions described Al Qattan. [1],[2],[3],[4] The incidence of GCT in India has not been reported to the best of our knowledge.

Here we present a case of GCT of extensor tendon sheath which was successfully treated with special emphasis on prevention of recurrence.


  Case Report Top


A young 32 year old male software engineer presented with complaints of a painless swelling over the proximal third of left middle finger, progressively increasing in size since last eight months with no features suggestive of any infective pathology or malignancy.

Clinically there was a non-tender, firm to hard, solitary swelling over the dorso-medial aspect of left middle finger measuring 2 × 1 cms in size with restricted mobility in all directions, with no effect on joint mobility or distal neurovascular effect [Figure 1]. Plain X-ray of hand revealed no bony abnormality but only a un-mineralized soft tissue shadow [Figure 2]. Ultrasound of the swelling showed a semi solid, soft tissue density mass lesion in the subcutaneous plain with a small vascular pedicle with no underlying tendon involvement [Figure 3], and FNAC from the swelling showed round to oval cells with foci of osteoclastic giant cells with regular nuclei suggestive of a Giant cell tumour of tendon sheath.
Figure 1: The planned incision over the lesion

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Figure 2: X-ray revealing soft tissue shadow and no bony abnormality

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Figure 3: Ultrasonography of the lesion revealing its origin from the extensor tendon sheath

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Intra-operatively a glistening white ovoid mass with bony hard consistency and a smooth, regular surface was found arising from the tendon sheath of extensor tendon of the left middle finger [Figure 4]. The mass was completely excised, under magnification with loupes, without injury to the extensor tendon and sent for Histopathological examination which revealed a well delineated mass comprising of oval to spindle cells admixed with osteoclastic types of giant cells [Figure 5].Hand was mobilised from 2 nd postoperative day and the patient is on regular follow up with no functional debility. The patient is on follow up for last six months with no evidence of recurrence.
Figure 4: The tumour arising from the extensor tendon sheath

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Figure 5: Histological examination round to oval cells with foci of osteoclastic giant cells with regular nuclei

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  Discussion Top


Giant cell tumours of the tendon sheath are relatively uncommontumours in the hand; [5] Most commonly occur in patients aged 30-50 years, [6] with a peak incidence in those aged 40-50 years. Rarely are these tumours found in patients younger than 10 years or older than 60 years. The female-to-male ratio is 3:2.Antecedent trauma occurs in a variable number of these patients, but its association with these tumours is also probably coincidental. The aetiology of giant cell tumours of the tendon sheath is unknown. The most widely accepted theory, proposed by Jaffe et al., is that of a reactive or regenerative hyperplasia associated with an inflammatory process. [7],[8]

Marginal excision of giant cell tumour of the tendon sheath is the treatment of choice. Complete excision of the tumour is difficult sometimes, due to its close association with synovium of the joint or the tendon sheath. The incidence of local recurrence is high, ranging from 9-44%. [6],[9] Moore et al.[10] 9% reports recurrence rate in 115 cases while, Wright [11] 44% reportsrecurrence rate in 69 cases.

Various factors have been described predictive of recurrence. These include pressure erosion on radiographs, location at distal joints, presence of degenerative joint disease, diffuse form of the disease with satellite lesions, increased mitotic activity, type 2 lesions as described by Al Qattan. [8] In a nodular tumour, the tumour could be easily excised since there is a clear margin, where as in diffuse tumour excision is difficult due to infiltrating nature. [12],[13]

Pre-operative diagnosis with FNAC helps in pre-operative planning to prevent recurrence. [14] The use of tourniquet, microscopic excision with operating microscope or magnifying loupe, meticulous technique, and thorough exploration for satellite lesions are essential for the complete removal of the tumour. [1] It may sometimes necessitate tendon reconstruction when the continuity of the tendon is caused due to excision of the tumour. The involvement of the bone and bony erosions when associated, need to be managed with bony debridement and curettage. The involvement of the skin can occur in few cases which might either require an elliptical excision and primary closure or skin graft when the shin defect is larger. Radiotherapy may have a role in cases in which complete excision may not be possible. [3] Early mobilisation in post-operative period is essential to prevent the stiffness. No cases of malignant degeneration of a benign giant cell tumour of the tendon sheath of the hand have been reported. These tumours also have no propensity to metastasize distally.

Though six months is a short period to call it recurrence free, the patient is still on regular follow up and needs to be followed in future too.


  Conclusion Top


Though GCT of tendon sheaths are notoriously known for recurrence, the recurrence can be prevented by accurate pre-operative diagnosis with FNAC and use of magnification for complete excision with microsurgical skills.

 
  References Top

1.Al-Qattan M. Giant cell tumors of tendon sheath: Classification and recurrence rate. J Hand Surg 2001;26B: 72-5.  Back to cited text no. 1
    
2.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. 2
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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 2000;82B:571-3.  Back to cited text no. 3
    
4.Rao AS, Vigorita VJ. Pigmented villonodularsynovitis (Giant-Cell tumor of the tendon sheath and synovial membrane): A review of 81 cases. J Bone Joint Surg 1984;66A:76-94.  Back to cited text no. 4
    
5.Tumours and Tumorous conditions of the Hand.Campbell′s Operative Orthopaedics. In: Canale ST, Beaty JH, editors. 11 th edn, Vol. 4. Philadelphia: Elsevier Health Sciences; 2008. p. 4315.  Back to cited text no. 5
    
6.The Wrist and Hand. Turek′s Orthopaedics: Principles and Their Application. 6 th edn. Weinstein SL, Buckwalter JA, editors. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 437-8.  Back to cited text no. 6
    
7.Rodrigues C, Desai S, Chinoy R. Giant cell tumor of the tendon sheath: A retrospective study of 28 cases. J Surg Oncol 1998;68:100-3.  Back to cited text no. 7
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8.Jaffe HL, Lichtenstein HL, Elsutro CJ. Pigmented villonodularsynovitis, bursitis, and tenosynovitis. Arch Pathol 1941;31:731-65.  Back to cited text no. 8
    
9.Wheeless CR. Wheeless′ Textbook of Orthopaedics. Available from: http://www.wheelessonline.com/ortho/giant_cell_tumor_of_the_tendon_sheath. [Last accessed on 2012 Jul 22].  Back to cited text no. 9
    
10.Moore JR, Weiland AJ, Curtis RM. Localized nodular tenosynovitis: Experience with 115 cases. J Hand Surg 1984;9:412-7.  Back to cited text no. 10
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11.Wright CJ. Benign giant-cell synovioma; an investigation of 85 cases. Br J Surg 1951;38:257-71.  Back to cited text no. 11
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12.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;41:138-42.  Back to cited text no. 12
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13.Ozalp T, Yercan H, Kurt C, Ozdemir O, Coºkunol E. Giant cell tumor of tendon sheath of the hand. Acta Orthop Traumatol Turc 2004;38:120-4.  Back to cited text no. 13
    
14.Iyer KV, Kusum K, Kusum V. Fine-needle aspiration cytology of giant cell tumor of the tendon sheath. Diagn Cytopathol 2003;29:105-10.  Back to cited text no. 14
    


    Figures

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



 

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Discussion
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