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Intra-articular benign fibrous histiocytoma in the knee joint
The Knee 13 (2006) 48 – 50 www.elsevier.com/locate/knee
Intra-articular benign fibrous histiocytoma in the knee joint Manickam Rathinam *, David M. Wright, Juan A. Alonso, David H. Sochart North Manchester General Hospital, United Kingdom Received 23 March 2005; received in revised form 18 April 2005; accepted 31 May 2005
Abstract We report a rare case of benign fibrous histiocytoma presenting as an intra-articular tumor in the knee joint causing pain and limitation of movements. This is the first case reported with no attachment to tendinous or ligamentous structures. D 2005 Elsevier B.V. All rights reserved. Keywords: Benign fibrous histiocytoma; Knee; MR imaging; Arthroscopy
1. Introduction Benign fibrous histiocytoma (also called giant cell tumour of tendon sheath (GCTTS)) is a benign lesion usually occurring in the hands and feet, less commonly around the ankle and knee joints. A true benign fibrous histiocytoma developing inside the knee joint is rare. We report such a case of intra-articular benign fibrous histiocytoma causing chronic pain and limitation of movement in the knee.
2. Case report A 52 year old lady presented to our clinic with long standing discomfort of the right knee joint, more pronounced on climbing stairs. Physical examination of the knee revealed retropatellar tenderness and an extension lag of 10- with further flexion possible only to 70-. On delving into the history, the initial presentation was 5 years prior to this present consultation, following moderate trauma to her knee and persistent pain following this. She had undergone various investigations to diag* Corresponding author. 12, Lancashire House, Warrington Hospital, Lovely Lane, Warrington, WA5 1QG, United Kingdom. Tel.: +44 1925 662956; (MOB): +44 7958331950. E-mail address: [email protected] (M. Rathinam). 0968-0160/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2005.05.003
nose the cause of the pain. Radiographs of the knee were normal and so were all haematological investigations. MRI scans of the knee revealed mild effusion with an encysted portion of fluid behind the patella. This was not thought to be significant. She underwent various treatments in the form of physiotherapy and analgesics. When none of these achieved relief, she underwent a further MRI scan and a CT scan. The CT scan was essentially normal but the repeat MRI revealed a soft tissue mass interposed between the patella and the anteromedial femoral condyle giving out an intermediate signal on T1 weighted images and a high signal on T2 weighted images (Fig. 1). Arthroscopy revealed a pedunculated mass abutting the medial femoral condyle posterior to the patella, with the pedicle arising from the medial margin of the synovial lining of the medial femoral condyle (Fig. 2). The swelling was excised in-toto and sent for histopathological examination. No other villous proliferation or synovial hypertrophy was visible in the joint which was otherwise normal. There was no indentation or erosion of the underlying bone. Histopathological exam of the mass revealed fibrous tissue stroma containing a mixture of foamy cells, polygonal cells, round cells, occasional spindle cells and prominent multinucleated giant cells. The cells formed a concentric arrangement around a vascular network with the presence of focal haemosiderin deposition.
M. Rathinam et al. / The Knee 13 (2006) 48 – 50
Fig. 1. A cross section MR image of the knee in T1 phase clearly showing the pedicle attachment of the mass to the medial femoral condyle.
The postoperative course was uneventful with the patient having complete relief of symptoms and return to normal activity level in 3 weeks.
3. Discussion Solitary intra-articular tumours in the knee are rare. Reported lesions are lipomata, nodular fasciitis and other tenosynovial tumours [14]. Benign fibrous histiocytomas are slow growing benign tumours arising from the synovial lining of tendon sheaths and joints. The common age of incidence is in the 3rd and 4th decades of life and the patients typically present with painless masses seen predominantly the hands and feet. The majority of these are seen in extra-articular locations and in only 20% of cases inside the joint [5]. The occurrence of these lesions in the knee joint is rare. A few of the cases reported as benign fibrous histiocytoma of the knee have in fact been extra-articular in location [6]. Others were attached to the patellar tendon or the posterior cruciate ligament [79]. Our case is the fourth truly intra-articular benign fibrous histiocytoma reported in English literature and the first one not arising from a tendinous or ligamentous structure. There continues to be some confusion regarding aetiology with one school of thought being that it is inflammatory in origin and is a representation of a localised form of pigmented villonodular synovitis (PVNS) [10]. But the majority believe it to be of a neoplastic nature
49
though the cell of origin remains obscure. The pathological picture of GCTTS is quite similar to that of PVNS with numerous mononuclear cells and varying numbers of multinucleated giant cells. Haemosiderin deposition and collections of foamy macrophages as well as lymphoid cells may be present. Of the imaging modalities available, CT scans reveal a hypo- or isodense picture and may delineate the lesion better with contrast enhancement [12]. Magnetic resonance imaging best outlines the tumour and its relationship to adjacent neurovascular structures. The MRI appearances show that the lesions are typically iso- or hypointense to muscle on T1 weighted images, but can be hypo-, iso-, or hyperintense to muscle on T2 weighted images depending on the amount of haemosiderin present in the lesion [13,14]. This clearly differentiates it from the lipomatous lesions which have high signal intensity on both T1 and T2 images. Because of the lack of characteristic symptoms and the very rare occurrence, benign fibrocytic histiocytoma was unsuspected clinically, as in other reported cases. There have been studies that recommend that any patient with persistent unilateral knee pain lasting more than 6 weeks and a normal radiograph is a candidate for further imaging [11]. Our case highlights the need for MRI scan of the knee when there is a doubt regarding the diagnosis. MRI scans give a clear delineation of the tumour but still they do not have a pathognomonic appearance. Treatment for benign fibrocytic histiocytomas is surgical extirpation. There is a known recurrence rate which is typically 10% to 20% but may be higher in the more diffuse variety after an incomplete resection [5,10]. Follow up with further MRI evaluation for recurrence maybe necessary in the long term.
Fig. 2. Arthroscopic picture of the swelling abutting the medial femoral condyle.
50
M. Rathinam et al. / The Knee 13 (2006) 48 – 50
References [1] Yamamoto T, Nagira K, Noda M, Kurosaka M. Intra-articular nodular fasciitis. Arthroscopy 2001;17(9)(Nov – Dec):E38. [2] Soejima T, Murakami H, Tanaka N, Sato K, Nagata K., Sugita Y. Fasciitis-like proliferation in the knee joint. Arthroscopy 2003; 19(4)(April):E33. [3] Matsumoto K, Okabe H, Ishizawa M, Hiraoka S. Intra-articular lipoma of the knee joint. J Bone Jt Surg (American) 2001;83A (1)(Jan):101 – 5. [4] Marui T, Yamamoto T, Kimura T, Akisue T, Nagira K, Natakani T, et al. A true intra-articular lipoma of the knee in a girl. Arthroscopy 2002;18(5)(May – Jun):E24. [5] Moore JR, Weiland AJ, Curtis RM. Localized nodular tenosynovitis: experience with 115 cases. J Hand Surg 1984;9A(3)(May): 412 – 7. [6] Balsara ZN, Stainken BF, Martinez AJ. MR image of localized giant cell tumor of the tendon sheath involving the knee. J Comput Assist Tomogr 1989;13(1)(Jan – Feb):159 – 62. [7] Lu KH. Arthroscopic excision of juxta-articular giant-cell tumor arising from the patellar tendon sheath. Arthroscopy 2004;20(5)(May): eE35.
[8] Relwani J, Factor D, Khan F, Dutta A. Giant cell tumour of the patellar tendon sheathan unusual cause of anterior knee pain: a case report. Knee 2003;10(2)(Jun):145 – 8. [9] Sheppard DG, Kim EE, Yasko AW, Ayala A. Giant-cell tumor of the tendon sheath arising from the posterior cruciate ligament of the knee: a case report and review of the literature. Clin Imaging 1998;22 (6)(Nov – Dec):428 – 30. [10] Monaghan H, Salter DM, Al-Nafussi A. Giant cell Tumour of tendon sheath (localised nodular tenosynovitis): clinicopathological features of 71 cases. J Clin Pathol 2001;54(5)(May):404 – 7. [11] Dickinson F.L., Harper W.M., Finlay D.B.. Knee tumoursduration and nature of symptoms prior to investigation. Br J Radiol 1997;70: 635 – 7. [12] Machiels F, De Maeseneer M, Chaskis C, Bourgain C, Osteaux M. Deep benign fibrous histiocytoma of the knee: CT and MR features with pathologic correlation. Eur Radiol 1998;8(6):989 – 91. [13] Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AA, Malawer MM. Giant cell tumor of the tendon sheath: MR findings in nine cases. AJR Am J Roentgenol 1994;162(4)(Apr):919 – 22. [14] Murphey MD, Gross TM, Rosenthal HG, Neff JR. Magnetic resonance imaging of soft tissue and cystic masses about the knee. Top Magn Reson Imaging 1993;5(4):263 – 82.
Intra-articular benign fibrous histiocytoma in the knee joint Manickam Rathinam *, David M. Wright, Juan A. Alonso, David H. Sochart North Manchester General Hospital, United Kingdom Received 23 March 2005; received in revised form 18 April 2005; accepted 31 May 2005
Abstract We report a rare case of benign fibrous histiocytoma presenting as an intra-articular tumor in the knee joint causing pain and limitation of movements. This is the first case reported with no attachment to tendinous or ligamentous structures. D 2005 Elsevier B.V. All rights reserved. Keywords: Benign fibrous histiocytoma; Knee; MR imaging; Arthroscopy
1. Introduction Benign fibrous histiocytoma (also called giant cell tumour of tendon sheath (GCTTS)) is a benign lesion usually occurring in the hands and feet, less commonly around the ankle and knee joints. A true benign fibrous histiocytoma developing inside the knee joint is rare. We report such a case of intra-articular benign fibrous histiocytoma causing chronic pain and limitation of movement in the knee.
2. Case report A 52 year old lady presented to our clinic with long standing discomfort of the right knee joint, more pronounced on climbing stairs. Physical examination of the knee revealed retropatellar tenderness and an extension lag of 10- with further flexion possible only to 70-. On delving into the history, the initial presentation was 5 years prior to this present consultation, following moderate trauma to her knee and persistent pain following this. She had undergone various investigations to diag* Corresponding author. 12, Lancashire House, Warrington Hospital, Lovely Lane, Warrington, WA5 1QG, United Kingdom. Tel.: +44 1925 662956; (MOB): +44 7958331950. E-mail address: [email protected] (M. Rathinam). 0968-0160/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2005.05.003
nose the cause of the pain. Radiographs of the knee were normal and so were all haematological investigations. MRI scans of the knee revealed mild effusion with an encysted portion of fluid behind the patella. This was not thought to be significant. She underwent various treatments in the form of physiotherapy and analgesics. When none of these achieved relief, she underwent a further MRI scan and a CT scan. The CT scan was essentially normal but the repeat MRI revealed a soft tissue mass interposed between the patella and the anteromedial femoral condyle giving out an intermediate signal on T1 weighted images and a high signal on T2 weighted images (Fig. 1). Arthroscopy revealed a pedunculated mass abutting the medial femoral condyle posterior to the patella, with the pedicle arising from the medial margin of the synovial lining of the medial femoral condyle (Fig. 2). The swelling was excised in-toto and sent for histopathological examination. No other villous proliferation or synovial hypertrophy was visible in the joint which was otherwise normal. There was no indentation or erosion of the underlying bone. Histopathological exam of the mass revealed fibrous tissue stroma containing a mixture of foamy cells, polygonal cells, round cells, occasional spindle cells and prominent multinucleated giant cells. The cells formed a concentric arrangement around a vascular network with the presence of focal haemosiderin deposition.
M. Rathinam et al. / The Knee 13 (2006) 48 – 50
Fig. 1. A cross section MR image of the knee in T1 phase clearly showing the pedicle attachment of the mass to the medial femoral condyle.
The postoperative course was uneventful with the patient having complete relief of symptoms and return to normal activity level in 3 weeks.
3. Discussion Solitary intra-articular tumours in the knee are rare. Reported lesions are lipomata, nodular fasciitis and other tenosynovial tumours [14]. Benign fibrous histiocytomas are slow growing benign tumours arising from the synovial lining of tendon sheaths and joints. The common age of incidence is in the 3rd and 4th decades of life and the patients typically present with painless masses seen predominantly the hands and feet. The majority of these are seen in extra-articular locations and in only 20% of cases inside the joint [5]. The occurrence of these lesions in the knee joint is rare. A few of the cases reported as benign fibrous histiocytoma of the knee have in fact been extra-articular in location [6]. Others were attached to the patellar tendon or the posterior cruciate ligament [79]. Our case is the fourth truly intra-articular benign fibrous histiocytoma reported in English literature and the first one not arising from a tendinous or ligamentous structure. There continues to be some confusion regarding aetiology with one school of thought being that it is inflammatory in origin and is a representation of a localised form of pigmented villonodular synovitis (PVNS) [10]. But the majority believe it to be of a neoplastic nature
49
though the cell of origin remains obscure. The pathological picture of GCTTS is quite similar to that of PVNS with numerous mononuclear cells and varying numbers of multinucleated giant cells. Haemosiderin deposition and collections of foamy macrophages as well as lymphoid cells may be present. Of the imaging modalities available, CT scans reveal a hypo- or isodense picture and may delineate the lesion better with contrast enhancement [12]. Magnetic resonance imaging best outlines the tumour and its relationship to adjacent neurovascular structures. The MRI appearances show that the lesions are typically iso- or hypointense to muscle on T1 weighted images, but can be hypo-, iso-, or hyperintense to muscle on T2 weighted images depending on the amount of haemosiderin present in the lesion [13,14]. This clearly differentiates it from the lipomatous lesions which have high signal intensity on both T1 and T2 images. Because of the lack of characteristic symptoms and the very rare occurrence, benign fibrocytic histiocytoma was unsuspected clinically, as in other reported cases. There have been studies that recommend that any patient with persistent unilateral knee pain lasting more than 6 weeks and a normal radiograph is a candidate for further imaging [11]. Our case highlights the need for MRI scan of the knee when there is a doubt regarding the diagnosis. MRI scans give a clear delineation of the tumour but still they do not have a pathognomonic appearance. Treatment for benign fibrocytic histiocytomas is surgical extirpation. There is a known recurrence rate which is typically 10% to 20% but may be higher in the more diffuse variety after an incomplete resection [5,10]. Follow up with further MRI evaluation for recurrence maybe necessary in the long term.
Fig. 2. Arthroscopic picture of the swelling abutting the medial femoral condyle.
50
M. Rathinam et al. / The Knee 13 (2006) 48 – 50
References [1] Yamamoto T, Nagira K, Noda M, Kurosaka M. Intra-articular nodular fasciitis. Arthroscopy 2001;17(9)(Nov – Dec):E38. [2] Soejima T, Murakami H, Tanaka N, Sato K, Nagata K., Sugita Y. Fasciitis-like proliferation in the knee joint. Arthroscopy 2003; 19(4)(April):E33. [3] Matsumoto K, Okabe H, Ishizawa M, Hiraoka S. Intra-articular lipoma of the knee joint. J Bone Jt Surg (American) 2001;83A (1)(Jan):101 – 5. [4] Marui T, Yamamoto T, Kimura T, Akisue T, Nagira K, Natakani T, et al. A true intra-articular lipoma of the knee in a girl. Arthroscopy 2002;18(5)(May – Jun):E24. [5] Moore JR, Weiland AJ, Curtis RM. Localized nodular tenosynovitis: experience with 115 cases. J Hand Surg 1984;9A(3)(May): 412 – 7. [6] Balsara ZN, Stainken BF, Martinez AJ. MR image of localized giant cell tumor of the tendon sheath involving the knee. J Comput Assist Tomogr 1989;13(1)(Jan – Feb):159 – 62. [7] Lu KH. Arthroscopic excision of juxta-articular giant-cell tumor arising from the patellar tendon sheath. Arthroscopy 2004;20(5)(May): eE35.
[8] Relwani J, Factor D, Khan F, Dutta A. Giant cell tumour of the patellar tendon sheathan unusual cause of anterior knee pain: a case report. Knee 2003;10(2)(Jun):145 – 8. [9] Sheppard DG, Kim EE, Yasko AW, Ayala A. Giant-cell tumor of the tendon sheath arising from the posterior cruciate ligament of the knee: a case report and review of the literature. Clin Imaging 1998;22 (6)(Nov – Dec):428 – 30. [10] Monaghan H, Salter DM, Al-Nafussi A. Giant cell Tumour of tendon sheath (localised nodular tenosynovitis): clinicopathological features of 71 cases. J Clin Pathol 2001;54(5)(May):404 – 7. [11] Dickinson F.L., Harper W.M., Finlay D.B.. Knee tumoursduration and nature of symptoms prior to investigation. Br J Radiol 1997;70: 635 – 7. [12] Machiels F, De Maeseneer M, Chaskis C, Bourgain C, Osteaux M. Deep benign fibrous histiocytoma of the knee: CT and MR features with pathologic correlation. Eur Radiol 1998;8(6):989 – 91. [13] Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AA, Malawer MM. Giant cell tumor of the tendon sheath: MR findings in nine cases. AJR Am J Roentgenol 1994;162(4)(Apr):919 – 22. [14] Murphey MD, Gross TM, Rosenthal HG, Neff JR. Magnetic resonance imaging of soft tissue and cystic masses about the knee. Top Magn Reson Imaging 1993;5(4):263 – 82.