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Localized giant cell tumor of tendon sheath of upper back
Brief clinical reports Localized giant cell tumor of tendon sheath of upper back Lora Thaxton, MS, All F. AbuRahma, MD, Ho-Huang Chang, MD, and James P. Boland, MD, Charleston, W.V. From the Department of Surgery, Charleston Area Medical Center, West Virginia University, Charleston, W. V.
G t ~ r CELI.TUMORSof the t e n d o n s h e a t h (GCTTS) were first described in 18521 a n d have b e e n a subject o f extensive investigation since Jaffe's 2 classic description in 1941. T h e pathogenesis o f this disease r e m a i n s obscure. T r a u m a , neuroplasia, i n f l a m m a t i o n , h e m o r r h a g e , abn o r m a l lipid metabolism, infection, a n d degenerative j o i n t disease have all b e e n suggested as possible causes.S, 4 G C T T S is o n e o f the most c o m m o n t u m o r s o f the hands, e x c e e d e d in f r e q u e n c y only by ganglia. 5 I n a M e d l i n e review of the English literature several h u n d r e d cases o f G C T r S in the hands, feet, a n d m a j o r j o i n t s have b e e n reported; however, n o n e have b e e n r e p o r t e d in the u p p e r back. 1-4
CASE REPORT A 26-year-old woman noticed a mass on the fight upper lateral back that slowly increased in size during a 6-month period. The mass was firm, not tender, and not freely mobile or attached to the skin. A radiographic study showed a circumscribed soft tissue mass with no bone involvement. Computed tomography scan showed a probable neurogenic tumor (Fig. 1). The mass was widely excised with the patient under general anesthesia. In operation the mass appeared to originate in the seventh posterior intercostal space with questionable attachment to the periosteum. The mass appeared to be fairly well encapsulated. A frozen section was taken and the result was inconclusive. The pathology examination showed a wellencapsulated tumor measuring 2 x 1.2 x 1.0 cm, with a glistening light-yellow to tan cut surface. Microscopically, the tumor was found to originate from the tendon sheath, which conmined multinucleated giant cells, old hemorrhage, and hemosiderin in the cytoplasm of some of the histiocytes and in the interstitium (Fig. 2 A). The lesion appeared to be somewhat lobulated but surrounded by a rather thin layer of residual tendon sheath. An increase in mitotic activity (5 per Accepted tor publication Feb. 21, 1995. Reprint requests~Ali F. AbuRahma, MD, Suite 603, 3100 MacCorkle Ave., SE, Charleston, WV 25304. SUR~;~;RV1995;118:901-3. Copyright 9 1995 by Mosby-YearBook, Inc. 0039-6060/$5.00 + 0 11/57/65400
10 higher power field) was noted. Because of the presence of pigment and to rule out melanoma, immunoperoxidase studies were done. The tumor cells did not stain with HMB-45 stain (Fig. 2, B). Vimentin studies were positive, which supported the diagnosis (Fig. 2, C). The diagnosis was also independently confirmed by pathologists from the Armed Forces Institute of Pathology. After operation the patient did well, with no recurrence at 8 months follow-up.
DISCUSSION T h e most significant c o n t r i b u t i o n to the u n d e r s t a n d i n g o f giant cell t u m o r s was m a d e byJaffe et al. z T h e r e is n o c o n s e n s u s as to w h e t h e r these lesions are neoplastic or reactive. In favor o f the reactive theory are the facts that a b o u t o n e half of the patients have e x p e r i e n c e d a n t e c e d e n t t r a u m a a n d that all lesions c o n t a i n inflammatory e l e m e n t s . Moreover, similar lesions have b e e n i n d u c e d e x p e r i m e n t a l l y by i n t r a a r t i c u l a r injections of b l o o d 6 a n d have b e e n observed in the j o i n t s o f h e m o philiacs as a result of r e p e a t e d h e m o r r h a g e . 7 However, this theory lacks the e x p l a n a t i o n o f the p r e s e n c e o f intense m o n o n u c l e a r cell proliferation that typifies the giant cell t u m o r . T h e r e was n o history of t r a u m a in this patient. I n favor o f the neoplastic theory is the fact that these lesions are capable of a certain d e g r e e o f a u t o n o m o u s growth a n d the likelihood of local r e c u r r e n c e if n o t adequately excised. Moreover, there are exceedingly rare cases o f giant cell t u m o r s that have given rise to metastatic disease. 8 For these reasons the t e r m giant cell tumor has b e e n p r e f e r r e d over m a n y o t h e r terms in the literature, a n d the t u m o r s are divided into localized a n d diffuse forms, d e p e n d i n g o n their growth characteristics. T h e localized form primarily affects the digits, a n d the diffuse form occurs in areas a d j a c e n t to large weight-bearing joints, such as the k n e e a n d the ankle. O n pathologic e x a m i n a t i o n these localized giant cell t u m o r s are c i r c u m s c r i b e d l o b u l a t e d masses that are usually small, r a n g i n g in size f r o m 0.5 to 4.0 c m in diameter. O n cut section they have a m o t d e d a p p e a r a n c e o f a d e e p gray b a c k g r o u n d flecked with yellow o r brown, SURGERY
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Fig. 1. Computed tomography scan of chest shows tumor mass. Note location of tumor (7")in relation to rib and tip of scapula (S).
Fig. 2. A, Giant cell tumor of tendon sheath (• with hematoxylin-eosin stain. Note giant cells and fibrous histiocytes. B, Fibrous histiocytes with hemosiderin pigments (• with iron stain. C, Fibrous histiocytes and giant cells strongly positive with vimentin stain (• d e p e n d i n g on the amounts of lipid a n d hemosiderin. Microscopically, the a p p e a r a n c e o f the giant cell t u m o r varies d e p e n d i n g on the p r o p o r t i o n of m o n o n u c l e a r cells, giant cells, a n d x a n t h o m a cells a n d on the d e g r e e o f collagenization. Most tumors are moderately cellular
a n d are c o m p o s e d o f sheets o f r o u n d e d or polygonal cells that b l e n d with hypoceilular collagenized zones in which the cells a p p e a r slightly spindled. Multinucleated giant cells are scattered r a n d o m l y t h r o u g h o u t the lesion. The presence of mitotic figures occasionally
Surgery Volume 118, Number 5
leads to a m i s t a k e n diagnosis o f malignancy, w h i c h m a y indicate an actively g r o w i n g lesion that is likely to recur. T e n d o n s h e a t h t u m o r s can o c c u r at any age b u t d o so m o r e o f t e n in w o m e n b e t w e e n the ages o f 30 a n d 50 years. 9 T h e y are f o u n d p r e d o m i n a n t l y o n t h e h a n d b u t can be p r e s e n t in the feet, ankle, o r knee. 1~ Radiog r a p h i c studies usually d o c u m e n t a c i r c u m s c r i b e d soft tissue mass in a b o u t o n e h a l f o f the patients. Giant cell t u m o r s are generally b e n i g n lesions that possess the capacity for local r e c u r r e n c e a n d a r e m o t e p o t e n t i a l for malignancy, which occurs in a b o u t 10% to 20% o f the cases. 9 R e c u r r e n c e seems to d e v e l o p m o r e often in very cellular lesions with i n c r e a s e d mitoses a n d in patients w h o have simple e n u c l e a t i o n s . C o m p l e t e surgical excision with a small cuff o f n o r m a l tissue is usually c o n s i d e r e d a d e q u a t e therapy, e v e n for those lesions with i n c r e a s e d cellularity a n d mitotic activity. REFERENCES 1. Chassaignac CMEI Cancer de la gaine des tendons. Gazette Hopitaux Civils Militaires 1852;47:185-6.
Thaxton et al.
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2. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis and tenosynovitis. Arch Pathol 1941;31:731-65. 3. Byers PD, Cotton RE, Deacon OW, et al. The diagnosis and treatment of pigmented villonodular synovitis.J Bone Joint Surg Am 1968;50B:290-305. 4. Ushijima M, Hashimoto H, Tsuneyoshi M, Enjoji M. Giant cell tumor of the tendon sheath (nodular tenosynovitis): a study of 207 cases to compare the largejoint group with the common digit group. Cancer 1986;57:875-84. 5. Oyemade GAA,Abioye AA. A clinicopathologic review of benign giant cell tumors of tendon sheaths in Ibadan, Nigeria. AmJ Surg 1977;134:392-5. 6. Granowitz SP, D'AntonioJ, Mankin HL. The pathogenesis and long-term end results of pigmented villonodular synovitis. Clin Orthop 1976;114:335-51. 7. Hoaglund FT. Experimental hemarthrosis.J BoneJoint SurgAm 1967;49A:285-98. 8. Atmore WG, Dahlin DC, Ghormley RK. Pigmented villonodular synovitis: a clinical and pathologic study. Minn Med 1956;39:1962O2. 9. Castens HP, Howell RS. Malignant giant cell tumor of tendon sheath. Virchows Arch A Pathol Anat Histopathol 1979;382:23% 43. 10. Savage RC, Mustafa EB. Giant cell tumor of tendon sheath (localized nodular tenosynovitis). Ann Plast Surg 1984;13:205-10.
B O U N D VOLUMES AVAILABLE T O SUBSCRIBERS
Bound volumes of SURGERYare available to subscribers (only) for the 1995 issues from the publisher at a cost of $74.00 for domestic, $100.58 for Canadian, and $94.00 for international subscribers for Vol. 117 (January to J u n e ) and Vol. 118 (July to December). Shipping charges are included. Each b o u n d volume contains a subject index and an author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the JOURNAl. name, volume number, and year stamped in gold on the spine. Subscriptions must be in force to qualify. B o u n d volumes are not available in place of a regular j o u r n a l subscription. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; p h o n e (800)325-4177, ext. 4351, or (314)4534351.
G t ~ r CELI.TUMORSof the t e n d o n s h e a t h (GCTTS) were first described in 18521 a n d have b e e n a subject o f extensive investigation since Jaffe's 2 classic description in 1941. T h e pathogenesis o f this disease r e m a i n s obscure. T r a u m a , neuroplasia, i n f l a m m a t i o n , h e m o r r h a g e , abn o r m a l lipid metabolism, infection, a n d degenerative j o i n t disease have all b e e n suggested as possible causes.S, 4 G C T T S is o n e o f the most c o m m o n t u m o r s o f the hands, e x c e e d e d in f r e q u e n c y only by ganglia. 5 I n a M e d l i n e review of the English literature several h u n d r e d cases o f G C T r S in the hands, feet, a n d m a j o r j o i n t s have b e e n reported; however, n o n e have b e e n r e p o r t e d in the u p p e r back. 1-4
CASE REPORT A 26-year-old woman noticed a mass on the fight upper lateral back that slowly increased in size during a 6-month period. The mass was firm, not tender, and not freely mobile or attached to the skin. A radiographic study showed a circumscribed soft tissue mass with no bone involvement. Computed tomography scan showed a probable neurogenic tumor (Fig. 1). The mass was widely excised with the patient under general anesthesia. In operation the mass appeared to originate in the seventh posterior intercostal space with questionable attachment to the periosteum. The mass appeared to be fairly well encapsulated. A frozen section was taken and the result was inconclusive. The pathology examination showed a wellencapsulated tumor measuring 2 x 1.2 x 1.0 cm, with a glistening light-yellow to tan cut surface. Microscopically, the tumor was found to originate from the tendon sheath, which conmined multinucleated giant cells, old hemorrhage, and hemosiderin in the cytoplasm of some of the histiocytes and in the interstitium (Fig. 2 A). The lesion appeared to be somewhat lobulated but surrounded by a rather thin layer of residual tendon sheath. An increase in mitotic activity (5 per Accepted tor publication Feb. 21, 1995. Reprint requests~Ali F. AbuRahma, MD, Suite 603, 3100 MacCorkle Ave., SE, Charleston, WV 25304. SUR~;~;RV1995;118:901-3. Copyright 9 1995 by Mosby-YearBook, Inc. 0039-6060/$5.00 + 0 11/57/65400
10 higher power field) was noted. Because of the presence of pigment and to rule out melanoma, immunoperoxidase studies were done. The tumor cells did not stain with HMB-45 stain (Fig. 2, B). Vimentin studies were positive, which supported the diagnosis (Fig. 2, C). The diagnosis was also independently confirmed by pathologists from the Armed Forces Institute of Pathology. After operation the patient did well, with no recurrence at 8 months follow-up.
DISCUSSION T h e most significant c o n t r i b u t i o n to the u n d e r s t a n d i n g o f giant cell t u m o r s was m a d e byJaffe et al. z T h e r e is n o c o n s e n s u s as to w h e t h e r these lesions are neoplastic or reactive. In favor o f the reactive theory are the facts that a b o u t o n e half of the patients have e x p e r i e n c e d a n t e c e d e n t t r a u m a a n d that all lesions c o n t a i n inflammatory e l e m e n t s . Moreover, similar lesions have b e e n i n d u c e d e x p e r i m e n t a l l y by i n t r a a r t i c u l a r injections of b l o o d 6 a n d have b e e n observed in the j o i n t s o f h e m o philiacs as a result of r e p e a t e d h e m o r r h a g e . 7 However, this theory lacks the e x p l a n a t i o n o f the p r e s e n c e o f intense m o n o n u c l e a r cell proliferation that typifies the giant cell t u m o r . T h e r e was n o history of t r a u m a in this patient. I n favor o f the neoplastic theory is the fact that these lesions are capable of a certain d e g r e e o f a u t o n o m o u s growth a n d the likelihood of local r e c u r r e n c e if n o t adequately excised. Moreover, there are exceedingly rare cases o f giant cell t u m o r s that have given rise to metastatic disease. 8 For these reasons the t e r m giant cell tumor has b e e n p r e f e r r e d over m a n y o t h e r terms in the literature, a n d the t u m o r s are divided into localized a n d diffuse forms, d e p e n d i n g o n their growth characteristics. T h e localized form primarily affects the digits, a n d the diffuse form occurs in areas a d j a c e n t to large weight-bearing joints, such as the k n e e a n d the ankle. O n pathologic e x a m i n a t i o n these localized giant cell t u m o r s are c i r c u m s c r i b e d l o b u l a t e d masses that are usually small, r a n g i n g in size f r o m 0.5 to 4.0 c m in diameter. O n cut section they have a m o t d e d a p p e a r a n c e o f a d e e p gray b a c k g r o u n d flecked with yellow o r brown, SURGERY
901
902
Thaxton et aL
Surgery November 1995
Fig. 1. Computed tomography scan of chest shows tumor mass. Note location of tumor (7")in relation to rib and tip of scapula (S).
Fig. 2. A, Giant cell tumor of tendon sheath (• with hematoxylin-eosin stain. Note giant cells and fibrous histiocytes. B, Fibrous histiocytes with hemosiderin pigments (• with iron stain. C, Fibrous histiocytes and giant cells strongly positive with vimentin stain (• d e p e n d i n g on the amounts of lipid a n d hemosiderin. Microscopically, the a p p e a r a n c e o f the giant cell t u m o r varies d e p e n d i n g on the p r o p o r t i o n of m o n o n u c l e a r cells, giant cells, a n d x a n t h o m a cells a n d on the d e g r e e o f collagenization. Most tumors are moderately cellular
a n d are c o m p o s e d o f sheets o f r o u n d e d or polygonal cells that b l e n d with hypoceilular collagenized zones in which the cells a p p e a r slightly spindled. Multinucleated giant cells are scattered r a n d o m l y t h r o u g h o u t the lesion. The presence of mitotic figures occasionally
Surgery Volume 118, Number 5
leads to a m i s t a k e n diagnosis o f malignancy, w h i c h m a y indicate an actively g r o w i n g lesion that is likely to recur. T e n d o n s h e a t h t u m o r s can o c c u r at any age b u t d o so m o r e o f t e n in w o m e n b e t w e e n the ages o f 30 a n d 50 years. 9 T h e y are f o u n d p r e d o m i n a n t l y o n t h e h a n d b u t can be p r e s e n t in the feet, ankle, o r knee. 1~ Radiog r a p h i c studies usually d o c u m e n t a c i r c u m s c r i b e d soft tissue mass in a b o u t o n e h a l f o f the patients. Giant cell t u m o r s are generally b e n i g n lesions that possess the capacity for local r e c u r r e n c e a n d a r e m o t e p o t e n t i a l for malignancy, which occurs in a b o u t 10% to 20% o f the cases. 9 R e c u r r e n c e seems to d e v e l o p m o r e often in very cellular lesions with i n c r e a s e d mitoses a n d in patients w h o have simple e n u c l e a t i o n s . C o m p l e t e surgical excision with a small cuff o f n o r m a l tissue is usually c o n s i d e r e d a d e q u a t e therapy, e v e n for those lesions with i n c r e a s e d cellularity a n d mitotic activity. REFERENCES 1. Chassaignac CMEI Cancer de la gaine des tendons. Gazette Hopitaux Civils Militaires 1852;47:185-6.
Thaxton et al.
903
2. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis and tenosynovitis. Arch Pathol 1941;31:731-65. 3. Byers PD, Cotton RE, Deacon OW, et al. The diagnosis and treatment of pigmented villonodular synovitis.J Bone Joint Surg Am 1968;50B:290-305. 4. Ushijima M, Hashimoto H, Tsuneyoshi M, Enjoji M. Giant cell tumor of the tendon sheath (nodular tenosynovitis): a study of 207 cases to compare the largejoint group with the common digit group. Cancer 1986;57:875-84. 5. Oyemade GAA,Abioye AA. A clinicopathologic review of benign giant cell tumors of tendon sheaths in Ibadan, Nigeria. AmJ Surg 1977;134:392-5. 6. Granowitz SP, D'AntonioJ, Mankin HL. The pathogenesis and long-term end results of pigmented villonodular synovitis. Clin Orthop 1976;114:335-51. 7. Hoaglund FT. Experimental hemarthrosis.J BoneJoint SurgAm 1967;49A:285-98. 8. Atmore WG, Dahlin DC, Ghormley RK. Pigmented villonodular synovitis: a clinical and pathologic study. Minn Med 1956;39:1962O2. 9. Castens HP, Howell RS. Malignant giant cell tumor of tendon sheath. Virchows Arch A Pathol Anat Histopathol 1979;382:23% 43. 10. Savage RC, Mustafa EB. Giant cell tumor of tendon sheath (localized nodular tenosynovitis). Ann Plast Surg 1984;13:205-10.
B O U N D VOLUMES AVAILABLE T O SUBSCRIBERS
Bound volumes of SURGERYare available to subscribers (only) for the 1995 issues from the publisher at a cost of $74.00 for domestic, $100.58 for Canadian, and $94.00 for international subscribers for Vol. 117 (January to J u n e ) and Vol. 118 (July to December). Shipping charges are included. Each b o u n d volume contains a subject index and an author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the JOURNAl. name, volume number, and year stamped in gold on the spine. Subscriptions must be in force to qualify. B o u n d volumes are not available in place of a regular j o u r n a l subscription. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; p h o n e (800)325-4177, ext. 4351, or (314)4534351.