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Laterosubungual giant cell tumor of the tendon sheath: An unusual location
Laterosubungual giant cell tumor of the tendon sheath: An unusual location Berkrand Richert, MD,a and Josette André, MDb Liège and Brussels, Belgium Giant cell tumor of the tendon sheath is the second most frequent nonepithelial benign tumor of the hand after ganglion cyst. Although it is recognized as a condition that may involve the distal digit, there has been only 1 report of periungual involvement. We describe a second case at that site in this article. (J Am Acad Dermatol 1999;41:347-8.)
CASE REPORT A 37-year-old man presented with a 10-year history of a lesion located beneath and lateral to the nail of the middle finger of the dominant hand. There was no history of preceding trauma, although radiotherapy had been given to the thumb, index finger and thenar eminence for a tuberous angioma 25 years ago. Examination revealed a firm subcutaneous mass lifting the overlying nail plate, which was short, thinned, and split, failing to reach the distal end of the nail bed (Fig 1). There was no pain, tenderness, or loss of function. X-ray results were normal. Partial nail avulsion revealed a very firm yellow-orange pea-size nodular lesion, filling the proximal two thirds of the lateral nailfold and a part of the underlying pulp. Histology confirmed the diagnosis of giant cell tumor of the tendon sheath (GCTTS) that was well-defined and partially surrounded by a fibrous capsule. It consisted of clusters of histiocyte-like cells with vesicular nuclei, some with foamy cytoplasm and all set in a dense hyalinized stroma. Hemosiderin and scattered giant cells were present. The latter had eosinophilic cytoplasm and contained a variable number of haphazardly distributed nuclei (Fig 2).
Fig 1. Laterosubungual tumor pushing overlying nail plate, which is thinned, split, and shortened.
DISCUSSION Despite its relatively frequent occurrence, GCTTS is rarely reported in the dermatological literature, perhaps because it is mainly dealt with by hand surgeons. Its pathogenesis remains unclear.1,2 A true neoplasm arising from either sesamoid bones, synovium, or primitive mesenchymal cells has been pro-
This supplement is made possible through an educational grant from Ortho Dermatological to the American Academy of Dermatology. From the Dermatology Units of the University of Liègea and the Brussels Free University,b Belgium. Reprint requests: B. Richert, MD, Dermatology Unit, CHU Brull, 45 Quai Kurth, 4020 Liège, Belgium. E-mail: [email protected] Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/4/96949
Fig 2. Histiocyte-like cells and osteoclastic giant cell in dense hyalinized stroma.
posed, but most authors favor the hypothesis that it may be a reactive inflammatory process. The tumor is primarily on the fingers: the index finger, thumb, and middle fingers in descending order of frequency and showing no preference for either hand.1,3,4 Involvement of the toes is rare.2 Typically, the tumor 347
348 Richert and André
produces no symptoms and presents as a well-circumscribed, lobulated firm mass with normal overlying skin at any point around an interphalangeal joint. Differential diagnosis of GCTTS includes myxoid cyst, epidermal cyst, lipoma, fibroma, rheumatoid nodule, reticulohistiocytoma, sarcomas, and metastasis.1,3 Granuloma annulare and erythema elevatum diutinum should also be considered.5 Only 20% to 30% of GCTTS are diagnosed clinically before surgery.1 Although the condition is routinely benign, malignant degeneration has been reported in exceptional cases.6,7 No spontaneous regression has been recorded and the treatment is surgery. The reported recurrence rate of 17% to 48% is probably due to the lobulated nature of the tumor, with occult extension around the tendon sheath. Failure to make the correct diagnosis and to dissect out the tumor to its full extent may increase the chance of relapse. We wish to thank David de Berker, MD, for his help and constructive advice in the revision of the manuscript.
J AM A C A D D ERMATOL A UGUST 1999
REFERENCES 1. Sapra S, Prokopetz R, Murray AH. Giant cell tumor of tendon sheath. Int J Dermatol 1989;28:587-90. 2. Ciattaglia G, Filosa G, Bugatti L. Giant cell tumor of the tendon sheath. J Am Acad Dermatol 1991;25:728-9. 3. Abimelec PH, Cambiaghi S, Thioly D, Moulonguet I, Dumontier Ch. Subungual giant cell tumor of the tendon sheath. Cutis 1996;58:273-5. 4. Norton LA. Tumors. In: Scher RK, Daniel CR, editors. Nails: therapy, diagnosis, surgery. Philadelphia: WB Saunders; 1990. p. 206. 5. Baran R, Haneke E. Tumours of the nail apparatus and adjacent tissues. In: Baran R, Dawber RPR, editors. Diseases of the nails and their management. Oxford: Blackwell Scientific Publications; 1994. p. 470-1. 6. Noordanus RP, Hage JJ, Van der Valk P.”Borderline” giant cell tumor of the tendon sheath in the hand: to amputate or not? Scand J Plast Reconstr Surg Hand Surg 1995;29:73-6. 7. Tiuriaeva EI, Kolosov AE, Kochnev VA, Zagol’skaia VN. A rare case of the malignant degeneration of a giant cell tumor of the tendon sheaths of the hand.Vestnik Khirurgii Imeni 1994;152:57-8.
CASE REPORT A 37-year-old man presented with a 10-year history of a lesion located beneath and lateral to the nail of the middle finger of the dominant hand. There was no history of preceding trauma, although radiotherapy had been given to the thumb, index finger and thenar eminence for a tuberous angioma 25 years ago. Examination revealed a firm subcutaneous mass lifting the overlying nail plate, which was short, thinned, and split, failing to reach the distal end of the nail bed (Fig 1). There was no pain, tenderness, or loss of function. X-ray results were normal. Partial nail avulsion revealed a very firm yellow-orange pea-size nodular lesion, filling the proximal two thirds of the lateral nailfold and a part of the underlying pulp. Histology confirmed the diagnosis of giant cell tumor of the tendon sheath (GCTTS) that was well-defined and partially surrounded by a fibrous capsule. It consisted of clusters of histiocyte-like cells with vesicular nuclei, some with foamy cytoplasm and all set in a dense hyalinized stroma. Hemosiderin and scattered giant cells were present. The latter had eosinophilic cytoplasm and contained a variable number of haphazardly distributed nuclei (Fig 2).
Fig 1. Laterosubungual tumor pushing overlying nail plate, which is thinned, split, and shortened.
DISCUSSION Despite its relatively frequent occurrence, GCTTS is rarely reported in the dermatological literature, perhaps because it is mainly dealt with by hand surgeons. Its pathogenesis remains unclear.1,2 A true neoplasm arising from either sesamoid bones, synovium, or primitive mesenchymal cells has been pro-
This supplement is made possible through an educational grant from Ortho Dermatological to the American Academy of Dermatology. From the Dermatology Units of the University of Liègea and the Brussels Free University,b Belgium. Reprint requests: B. Richert, MD, Dermatology Unit, CHU Brull, 45 Quai Kurth, 4020 Liège, Belgium. E-mail: [email protected] Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/4/96949
Fig 2. Histiocyte-like cells and osteoclastic giant cell in dense hyalinized stroma.
posed, but most authors favor the hypothesis that it may be a reactive inflammatory process. The tumor is primarily on the fingers: the index finger, thumb, and middle fingers in descending order of frequency and showing no preference for either hand.1,3,4 Involvement of the toes is rare.2 Typically, the tumor 347
348 Richert and André
produces no symptoms and presents as a well-circumscribed, lobulated firm mass with normal overlying skin at any point around an interphalangeal joint. Differential diagnosis of GCTTS includes myxoid cyst, epidermal cyst, lipoma, fibroma, rheumatoid nodule, reticulohistiocytoma, sarcomas, and metastasis.1,3 Granuloma annulare and erythema elevatum diutinum should also be considered.5 Only 20% to 30% of GCTTS are diagnosed clinically before surgery.1 Although the condition is routinely benign, malignant degeneration has been reported in exceptional cases.6,7 No spontaneous regression has been recorded and the treatment is surgery. The reported recurrence rate of 17% to 48% is probably due to the lobulated nature of the tumor, with occult extension around the tendon sheath. Failure to make the correct diagnosis and to dissect out the tumor to its full extent may increase the chance of relapse. We wish to thank David de Berker, MD, for his help and constructive advice in the revision of the manuscript.
J AM A C A D D ERMATOL A UGUST 1999
REFERENCES 1. Sapra S, Prokopetz R, Murray AH. Giant cell tumor of tendon sheath. Int J Dermatol 1989;28:587-90. 2. Ciattaglia G, Filosa G, Bugatti L. Giant cell tumor of the tendon sheath. J Am Acad Dermatol 1991;25:728-9. 3. Abimelec PH, Cambiaghi S, Thioly D, Moulonguet I, Dumontier Ch. Subungual giant cell tumor of the tendon sheath. Cutis 1996;58:273-5. 4. Norton LA. Tumors. In: Scher RK, Daniel CR, editors. Nails: therapy, diagnosis, surgery. Philadelphia: WB Saunders; 1990. p. 206. 5. Baran R, Haneke E. Tumours of the nail apparatus and adjacent tissues. In: Baran R, Dawber RPR, editors. Diseases of the nails and their management. Oxford: Blackwell Scientific Publications; 1994. p. 470-1. 6. Noordanus RP, Hage JJ, Van der Valk P.”Borderline” giant cell tumor of the tendon sheath in the hand: to amputate or not? Scand J Plast Reconstr Surg Hand Surg 1995;29:73-6. 7. Tiuriaeva EI, Kolosov AE, Kochnev VA, Zagol’skaia VN. A rare case of the malignant degeneration of a giant cell tumor of the tendon sheaths of the hand.Vestnik Khirurgii Imeni 1994;152:57-8.