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Fibroma of tendon sheath with bone involvement
FIBROMA
OF TENDON
SHEATH
WITH
BONE
INVOLVEMENT
G. J. SOUTHWICKandP. KARAMOSKOS From the Cabrini Medical Centre, Australia The case is reported of a 6%year-old man presenting with a fibroma of tendon sheath of the left little
finger with bone involvement. This is only the third-such case reported. A brief discmsion of this benign soft tissue tumour follows. Journal of Hand Surgery (British Volume, 1990) 15B: 373-375
Fibroma of tendon sheath is a benign soft tissue tumour and has been reported to involve bone in only two previous cases. This uncommon lesion predominantly affects the fingers and hand (Chung and Enzinger, 1979). The differential diagnosis includes ganglion, inclusion cyst and giant-cell tumour of tendon sheath (Greene and Strickland, 1984), with which it is often confused macroscopically.
Case report A 62-year-old right-handed engineer presented with a three-month history of a painless lump on his left hand. It had slowly increased in size interfering with his golf swing. There was no history of trauma. Examination revealed a 3 cm firm mass over the volar aspect of the base of the left little finger. The mass was mobile but not tender and did not interfere with joint movement. There was no motor or sensory disturbance nor was there any associated lymphadenopathy. Radiographs revealed gross erosion of the radial aspect of the base of the proximal phalanx of the little finger. The M.P. joint appeared normal (Fig. 1). Surgical excision of the mass was performed under regional brachial plexus anaesthesia and tourniquet control. A Bruner incision was made on the volar and ulnar aspects of the left palm, extending onto the base of the little finger. Dissection revealed a large grey/white encapsulated tumour mass in the soft tissue overlying the flexor tendons, displacing both neurovascular bundles. The tumour was dumb-bell shaped, one portion associated with the flexor tendon sheath and the other lying in the large cavity in the radial side of the base of the proximal phalanx. The central narrowed portion extended on the ulnar side of the lumbrical and interosseous muscles in the fourth intermetacarpal space. The flexor tendon sheath was dissected free and the large bony defect in the proximal phalanx (measuring 2 x 1 cm) was noted. The mass was easily removed in one piece from the defect using a Mitchell trimmer. The bony defect was packed with cancellous bone taken from the distal end of the left radius and the incision closed primarily. The post-operative course was uneventful. Six months later, there has been no recurrence and follow-up X-rays confirm good contouring of the grafted phalanx (Fig. 2). VOL. 15B No. 3 AUGUST
1990
Fig. 1 X-ray showing large erosion of the radial aspect of the base of the proximal phalanx.
Pathology The specimen consisted of a 26 x 17 x 15 mm fragment of resilient smooth-surfaced tissue. The cut surface was yellowish-white. Microscopic sections showed circumscribed nodular aggregates of spindle-shaped cells lying within a fibrous stroma (Fig. 3). Within the nodules, the cells showed large vesicular nuclei and occasional multinucleated cells (Fig. 4). The stroma was mucoid, in places hyalinised, and contained occasional scattered mononuclear cells. Moderate numbers of small blood vessels of capillary type with prominent endothelial cells were noted (Fig. 5). Cleft-like spaces were a common feature. 373
G. J. SOUTHWICK AND P. KARAMOSKOS
Fig. 3
Fig. 2 X-ray six months after bone graft to proximal phalanx.
Discussion Fibroma of tendon sheath was first reported in the literature in 1923, by Buxton, but the first authoritative description was in 1949 by Geschickter and Copeland. Since then there have been no further reports until Chung and Enzinger’s thorough review of 138 cases (Chung & Enzinger, 1979). This series revealed a predominance in males (75%) and involvement of the fingers (49x), although the lesion was infrequent in the ring and little 314
Nodular pattern of spindle-shaped (H&E, x 33).
cells in fibrous stoma.
fingers. Most were painless, with a median duration before presentation of five months. Bone involvement occurred in only two cases. Pathologically, the typical features are spindle-shaped fibroblast-like cells in a fibrous stroma with varying degrees of myxoid change and hyalinisation. The characteristic slit-like “vascul;ar channels”, as described by Chung and Enzinger, were also present in our patient. Bone involvement is due to pressure from the adjacent tumour. Smith et al. (1981) first described the ultra-structural characteristics. They refuted the idea that the slit-like channels were vascular, because of the absence of a basement membrane and the frequent absence of any cell cytoplasm bounding the edge of the collagen. The spaces were also devoid of red blood cells. In addition, they claimed that fibroblasts occurred rarely and that the majority of cells were actually myofibroblasts. Giant cell tumour of tendon sheath, also referred to as pigmented villonodular tenosynovitis, is macroscopically THE JOURNAL OF HAND SURGERY
FIBROMA
Fig. 4
OF TENDON
SHEATH WITH BONE INVOLVEMENT
Vesicular nuclei & multinucleated giant cell. Note also cleftlike spaces. (H&E, x 132).
Fig. 5
Capillary vessels with prominent endothelial cells well seen. Hyalinised stroma also demonstrated. (H&E, x 132).
References
similar in appearance to fibroma of tendon sheath but it can be easily distinguished microscopically. Although multinucleated giant cells are occasionally found in fibroma of tendon sheath, as in the present case, they contain none of the characteristic xanthoma cells nor siderophages as in giant cell tumour of tendon sheath. The recurrence rate has been reported as 24% (Chung and Enzinger, 1979). All of the recurrences were in the fingers or the hands and nearly all occurred between one and four months after excision.
BUXTON, St. J. D. (1923). Tumours of tendon and tendon sheath. British Joumalof Surgery, 10: 40: 469474. CHUNG, E. B. and ENZINGER, F. M. (r979). Fibroma of tendon sheath. Cancer, 44: 5: 1945-1954. GESCHICKTER, C. F. and COPELAND, M. M. 7’wnours ofBone, 3rd edn. Philadelphia, J. B. Lippincott, 1949: 693-695. GREENE, T. L. and STRICKLAND, J. W. (1984). Fibroma of tendon sheath. Journal of Hand Surgery, 9A : 5 : 758-760. SMITH, P. S., PIETERSE, A. S. and MCCLURE, J. (1981). Fibroma of tendon sheath. Journal of Clinical Pathology, 35: 8: 842-848.
Acknowkdgements
Accepted:20 December 1988 Mr. Graeme Southwick,Suite 19,Cabrini MedicalCentre, IsabellaStreet, M&em, Victoria, 3144,Australia.
The authors wish to thank the following for their valued assistance: Dr A. Dorevitch of Dorevitch &Associates, Pathology, Mr Michael Richmond for his photography and Mrs Pamela Lombard0 for preparing the manuscript.
VOL. 15B No. 3 AUGUST
1990
0 1990The
British Society for Surgery of the Hand
00267681/90/0015-0373/S10.00
375
OF TENDON
SHEATH
WITH
BONE
INVOLVEMENT
G. J. SOUTHWICKandP. KARAMOSKOS From the Cabrini Medical Centre, Australia The case is reported of a 6%year-old man presenting with a fibroma of tendon sheath of the left little
finger with bone involvement. This is only the third-such case reported. A brief discmsion of this benign soft tissue tumour follows. Journal of Hand Surgery (British Volume, 1990) 15B: 373-375
Fibroma of tendon sheath is a benign soft tissue tumour and has been reported to involve bone in only two previous cases. This uncommon lesion predominantly affects the fingers and hand (Chung and Enzinger, 1979). The differential diagnosis includes ganglion, inclusion cyst and giant-cell tumour of tendon sheath (Greene and Strickland, 1984), with which it is often confused macroscopically.
Case report A 62-year-old right-handed engineer presented with a three-month history of a painless lump on his left hand. It had slowly increased in size interfering with his golf swing. There was no history of trauma. Examination revealed a 3 cm firm mass over the volar aspect of the base of the left little finger. The mass was mobile but not tender and did not interfere with joint movement. There was no motor or sensory disturbance nor was there any associated lymphadenopathy. Radiographs revealed gross erosion of the radial aspect of the base of the proximal phalanx of the little finger. The M.P. joint appeared normal (Fig. 1). Surgical excision of the mass was performed under regional brachial plexus anaesthesia and tourniquet control. A Bruner incision was made on the volar and ulnar aspects of the left palm, extending onto the base of the little finger. Dissection revealed a large grey/white encapsulated tumour mass in the soft tissue overlying the flexor tendons, displacing both neurovascular bundles. The tumour was dumb-bell shaped, one portion associated with the flexor tendon sheath and the other lying in the large cavity in the radial side of the base of the proximal phalanx. The central narrowed portion extended on the ulnar side of the lumbrical and interosseous muscles in the fourth intermetacarpal space. The flexor tendon sheath was dissected free and the large bony defect in the proximal phalanx (measuring 2 x 1 cm) was noted. The mass was easily removed in one piece from the defect using a Mitchell trimmer. The bony defect was packed with cancellous bone taken from the distal end of the left radius and the incision closed primarily. The post-operative course was uneventful. Six months later, there has been no recurrence and follow-up X-rays confirm good contouring of the grafted phalanx (Fig. 2). VOL. 15B No. 3 AUGUST
1990
Fig. 1 X-ray showing large erosion of the radial aspect of the base of the proximal phalanx.
Pathology The specimen consisted of a 26 x 17 x 15 mm fragment of resilient smooth-surfaced tissue. The cut surface was yellowish-white. Microscopic sections showed circumscribed nodular aggregates of spindle-shaped cells lying within a fibrous stroma (Fig. 3). Within the nodules, the cells showed large vesicular nuclei and occasional multinucleated cells (Fig. 4). The stroma was mucoid, in places hyalinised, and contained occasional scattered mononuclear cells. Moderate numbers of small blood vessels of capillary type with prominent endothelial cells were noted (Fig. 5). Cleft-like spaces were a common feature. 373
G. J. SOUTHWICK AND P. KARAMOSKOS
Fig. 3
Fig. 2 X-ray six months after bone graft to proximal phalanx.
Discussion Fibroma of tendon sheath was first reported in the literature in 1923, by Buxton, but the first authoritative description was in 1949 by Geschickter and Copeland. Since then there have been no further reports until Chung and Enzinger’s thorough review of 138 cases (Chung & Enzinger, 1979). This series revealed a predominance in males (75%) and involvement of the fingers (49x), although the lesion was infrequent in the ring and little 314
Nodular pattern of spindle-shaped (H&E, x 33).
cells in fibrous stoma.
fingers. Most were painless, with a median duration before presentation of five months. Bone involvement occurred in only two cases. Pathologically, the typical features are spindle-shaped fibroblast-like cells in a fibrous stroma with varying degrees of myxoid change and hyalinisation. The characteristic slit-like “vascul;ar channels”, as described by Chung and Enzinger, were also present in our patient. Bone involvement is due to pressure from the adjacent tumour. Smith et al. (1981) first described the ultra-structural characteristics. They refuted the idea that the slit-like channels were vascular, because of the absence of a basement membrane and the frequent absence of any cell cytoplasm bounding the edge of the collagen. The spaces were also devoid of red blood cells. In addition, they claimed that fibroblasts occurred rarely and that the majority of cells were actually myofibroblasts. Giant cell tumour of tendon sheath, also referred to as pigmented villonodular tenosynovitis, is macroscopically THE JOURNAL OF HAND SURGERY
FIBROMA
Fig. 4
OF TENDON
SHEATH WITH BONE INVOLVEMENT
Vesicular nuclei & multinucleated giant cell. Note also cleftlike spaces. (H&E, x 132).
Fig. 5
Capillary vessels with prominent endothelial cells well seen. Hyalinised stroma also demonstrated. (H&E, x 132).
References
similar in appearance to fibroma of tendon sheath but it can be easily distinguished microscopically. Although multinucleated giant cells are occasionally found in fibroma of tendon sheath, as in the present case, they contain none of the characteristic xanthoma cells nor siderophages as in giant cell tumour of tendon sheath. The recurrence rate has been reported as 24% (Chung and Enzinger, 1979). All of the recurrences were in the fingers or the hands and nearly all occurred between one and four months after excision.
BUXTON, St. J. D. (1923). Tumours of tendon and tendon sheath. British Joumalof Surgery, 10: 40: 469474. CHUNG, E. B. and ENZINGER, F. M. (r979). Fibroma of tendon sheath. Cancer, 44: 5: 1945-1954. GESCHICKTER, C. F. and COPELAND, M. M. 7’wnours ofBone, 3rd edn. Philadelphia, J. B. Lippincott, 1949: 693-695. GREENE, T. L. and STRICKLAND, J. W. (1984). Fibroma of tendon sheath. Journal of Hand Surgery, 9A : 5 : 758-760. SMITH, P. S., PIETERSE, A. S. and MCCLURE, J. (1981). Fibroma of tendon sheath. Journal of Clinical Pathology, 35: 8: 842-848.
Acknowkdgements
Accepted:20 December 1988 Mr. Graeme Southwick,Suite 19,Cabrini MedicalCentre, IsabellaStreet, M&em, Victoria, 3144,Australia.
The authors wish to thank the following for their valued assistance: Dr A. Dorevitch of Dorevitch &Associates, Pathology, Mr Michael Richmond for his photography and Mrs Pamela Lombard0 for preparing the manuscript.
VOL. 15B No. 3 AUGUST
1990
0 1990The
British Society for Surgery of the Hand
00267681/90/0015-0373/S10.00
375