- Email: [email protected]
Tenosynovial giant-cell tumor arising from the anterior cruciate ligament of the knee
Case Report
Tenosynovial Giant-Cell Tumor Arising From the Anterior Cruciate Ligament of the Knee Yutaka Otsuka, M.D., Hiroshi Mizuta, M.D., Eiichi Nakamura, M.D., Satoshi Kudo, M.D., Seiichi Inoue, M.D., and Katsumasa Takagi, M.D.
Summary: The localized form of tenosynovial giant-cell tumor is rarely located intraarticularly, especially in the large weight-bearing joints. We report the first case of localized, intraarticular tenosynovial giant-cell tumor arising from the anterior cruciate ligament of a knee in which locking and effusion had occurred. After arthroscopic removal of this tumor, the patient became asymptomatic. Key Words: Tenosynovial giant-cell tumor--Intra-articular tumor--Anterior cruciate ligament--Knee joint--Extension limit--Arthroscopic removal.
umors arising from the synovium of the knee joint are rare.l Because of this and the lack of characteristic symptoms, their presence is usually unsuspected during clinical diagnosis. I We report the first case of localized, intraarticular tenosynovial giant-cell tumor arising from the anterior cruciate ligament of a knee in which locking and effusion had occurred.
T
CASE REPORT A 33-year-old woman with a 6-month history of catching was admitted. Two days before admission, pain and limitation of extension in the right knee had occurred while playing volleyball. She denied any antecedent trauma of the knee. Physical examination of the knee showed joint effusion, and the range of motion was limited to 5 ° to 120 °. Thirty milliliters of joint effusion with blood were aspirated. There was no palpable mass nor crepitus on
From The lnoue Orthopaedic Hospital and Department of Orthopaedic Surgery, Kumamoto University School of Medicine, Kumamoto, Japan. Address correspondence and reprint requests to Yutaka Otsuka, M.D., Department of Orthopaedic Surgery Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto 860, Japan. © 1996 by the Arthroscopy Association of North America 0749-8063/96/1204-146053.00/0
496
motion. Roentogenograms of the knee showed no abnormality. Laboratory examination, including platelet count, prothrombin time, bleeding time, and total cholesterol, were all within normal limits. Magnetic resonance images were obtained using a Gyroscan (1.5 tesla). Coronal and sagittal T 1-weighted images demonstrated that the soft tissue mass was isointense to muscle and was clearly displacing the anteromedial of the anterior cruciate ligament. On T2weighted images, the mass was more inhomogenous, and its signal intensity was slightly higher than that of skeletal muscle. Arthroscopic examination under spinal anesthesia was performed on the right knee through the lateral infrapatellar portal. There was no ligamentous, meniscal, or cartilage injury, but a discoidal, circumscribed mass was found in the intercondylar notch. We confirmed that it originated with a peduncle from the synovium of the anterior cruciate ligament (Fig 1). The patchy area of reddish-brown color at the inferior pole of the mass suggested hemorrhage. The mass was excised carefully under arthroscopic control and removed from the medial infrapatellar portal. The tumor was well encapsulated and lobulated, and its size was approximately 25 × 20 x 7 mm (Fig 2). The basic color was pinkish gray, mottled with yellow blotches. A multinodular growth pattern with thin layers of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 12, No 4 (August), 1996: pp 496-499
TENOSYNOVIAL GIANT-CELL TUMOR OF THE KNEE
497
A f
.,1 J
FIG 1. (A) Arthroscopic appearance of the tumor. (B) A discoidal, circumscribed, and pedunculated soft tissue mass was attached to the synovium of the anterior cruciate ligament. (C) The mass impinged between the femoral trochlea and anterior tibial plateau at the knee extension.
fibrous tissue was also visible microscopically. Microscopic features varied in different parts of the tumor, and the cellular composition was polymorphic. The basic cellular component of this tumor was a welldefined polygonal mononuclear cell with a scanty, faintly eosinophilic cytoplasm and a large oval nucleus (Fig 3A). Mitotic figures were rarely seen in the hypercellular areas, and they were never numerous. These areas contained foamy cells, with abundant cytoplasm and vacuoles (Fig 3B). Multinucleated giant cells were present even in the less cellular areas (Fig 3C). They had abundant eosinophilic cytoplasm and contained six
or more nuclei. In some areas, there were broad bands or sheets of amorphous collagen, which consisted of thick and hyalinized fibrous connective tissue (Fig 3D). There was no villous projection of the synovium either macroscopically or microscopically. Based on these histological findings, a diagnosis of tenosynovial giantcell tumor arising from the anterior cruciate ligament was made. Postoperative rehabilitation was started the day after surgery, and the patient became asymptomatic within 3 weeks. The patient was followed in the outpatient clinic for 7 months, with no sign of local recurrence.
498
Y. OTSUKA ET AL.
DISCUSSION
FIG 2. Gross appearance of the excised mass. The size of the mass was approximately 25 X 20 x 7 mm. The tumor was well encapsulated and lobulated.
A m o n g the various benign tumors and tumorlike lesions that arise from the tendon sheath and synovium, the giant-cell tumor is the most common. 2 This tumor was first described in 1852 by Chassiagnac 3 as " c a n c e r of the tendon sheath," but whether it differs from pigmented villonodular synovitis is controversial. The earliest investigators4-6 considered that giant-cell tumor and pigmented villonodular synovitis represented different manifestations of the same process, according to the c o m m o n histological features. Subsequent write r s 2'7-9 defined giant-cell tumor as a separate clinical enity because its growth pattern is different. Ushijima et al. 7 demonstrated that lesions without villous projections of the s y n o v i u m are not pigmented villonodular synovitis but giant-cell tumor. In our case, the lesions did not show this projection, either macroscopically or microscopically, and therefore it is properly described as a giant-cell tumor.
FIG 3. Microscopic appearance of the tumor, (A) The basic cellular component was polygonal mononuclearcells. (B) In some areas, foam cells were dominated with abundant cytoplasm and vacuoles. (C) Even in the less cellular areas, multinucleatedgiant cells were present. (D) A hyalinized fibrous connected tissue with sheets of amorphous collagens (H&E, original magnification x200).
TENOSYNOVIAL
GIANT-CELL
Enzinger and Weiss 2 called this tumor tenosynovial giant-cell tumor because of its basic nature and origin, and divided it into localized and diffused forms. The former mostly affected the digits, whereas the latter often affected the large weight-bearing joints. The localized tenosynovial giant-cell tumor rarely located intraarticularly, especially in the large weight-bearing joints. We have found in the literature only two cases of localized tenosynovial giant-cell tumor that arose in the articular knee cavity, one ~° from the posterior cruciate ligament, and the other 1~ attached to the s y n o v i u m of the anterior horn of the medial meniscus. Ours is the first case arising from the anterior cruciate ligament of the knee. Localized tenosynovial giant-cell tumor has a dense collagenous capsule, but its reccurrence rate after incomplete excision is reported to be higher than 10%. 2 Although our patient is currently asymptomatic, a longer follow-up examination is needed.
TUMOR
3. 4.
5.
6.
7.
8.
9.
REFERENCES 10. 1. Coventry MB, Harrison EG, Martin JF. Benign synovial tumor of the knee: A diagnostic problem. J Bone Joint Surg Am 1966; 48:1350-1358. 2. Enzinger FM, Weiss SW. Benign tumors and tumor-like lesions
11.
OF THE KNEE
499
ofsynovial tissue. Ed 3. Soft Tissue Tumors. St. Louis: Mosby, 1994;735-755. Chassaignac CME. Cancer de la gaine des tendons. Gas Hosp Civ Milit 1852;47:185-190. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis, and tenosynovitis:A discussion of the synovial and bursal equivalents of the tenosynovial lesions commonly denoted as xanthoma, xanthogranuloma,giant cell tumor or myeloplaxoma of the tendon sheath, with some consideration of this tendon sheath lesion itself. Arch Pathol 1941;31:731-765. Jones FE, Soule EH, Coventry MB. Fibrous xanthoma of the synovium (Giant-cell tumor of tendon sheath, Pigmented nodular synovitis): A study of one hundred and eighteen cases. J Bone Joint Surg Am 1969;51:76-86. Rao AS, Vigorita VJ. Pigmented villonodular synovitis (Giantcell tumor of the tendon sheath and synovial membrane): A review of eighty-one cases. J Bone Joint Surg Am 1984;66:7694. 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 large joint group with the common digit group. Cancer 1986;57:875-884. Madewell JE, Sweet DE. Tumor and tumor-like lesions in or about joints. In: Resnick D, Niwayama G, eds. Diagnosis of bone and joint disorders. Philadelphia: W.B. Saunders, 1981; 2733-2735. SpjutHJ, Dorfman HD, Fechner RE, Ackerman LV. Tumors of bone and cartilage. Washington, DC: Armed Forces Institute of Pathology, 1983;400-410. Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AA, Malawer MM. Giant cell tumor of the tendon sheath: MR findings in nine cases. Am J Roentogenol 1994;162:919-922. Kim SJ, Choi NH, Lee SC. Tenosynovial giant-cell tumor in the knee joint. Arthroscopy 1995;11:213-215.
Tenosynovial Giant-Cell Tumor Arising From the Anterior Cruciate Ligament of the Knee Yutaka Otsuka, M.D., Hiroshi Mizuta, M.D., Eiichi Nakamura, M.D., Satoshi Kudo, M.D., Seiichi Inoue, M.D., and Katsumasa Takagi, M.D.
Summary: The localized form of tenosynovial giant-cell tumor is rarely located intraarticularly, especially in the large weight-bearing joints. We report the first case of localized, intraarticular tenosynovial giant-cell tumor arising from the anterior cruciate ligament of a knee in which locking and effusion had occurred. After arthroscopic removal of this tumor, the patient became asymptomatic. Key Words: Tenosynovial giant-cell tumor--Intra-articular tumor--Anterior cruciate ligament--Knee joint--Extension limit--Arthroscopic removal.
umors arising from the synovium of the knee joint are rare.l Because of this and the lack of characteristic symptoms, their presence is usually unsuspected during clinical diagnosis. I We report the first case of localized, intraarticular tenosynovial giant-cell tumor arising from the anterior cruciate ligament of a knee in which locking and effusion had occurred.
T
CASE REPORT A 33-year-old woman with a 6-month history of catching was admitted. Two days before admission, pain and limitation of extension in the right knee had occurred while playing volleyball. She denied any antecedent trauma of the knee. Physical examination of the knee showed joint effusion, and the range of motion was limited to 5 ° to 120 °. Thirty milliliters of joint effusion with blood were aspirated. There was no palpable mass nor crepitus on
From The lnoue Orthopaedic Hospital and Department of Orthopaedic Surgery, Kumamoto University School of Medicine, Kumamoto, Japan. Address correspondence and reprint requests to Yutaka Otsuka, M.D., Department of Orthopaedic Surgery Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto 860, Japan. © 1996 by the Arthroscopy Association of North America 0749-8063/96/1204-146053.00/0
496
motion. Roentogenograms of the knee showed no abnormality. Laboratory examination, including platelet count, prothrombin time, bleeding time, and total cholesterol, were all within normal limits. Magnetic resonance images were obtained using a Gyroscan (1.5 tesla). Coronal and sagittal T 1-weighted images demonstrated that the soft tissue mass was isointense to muscle and was clearly displacing the anteromedial of the anterior cruciate ligament. On T2weighted images, the mass was more inhomogenous, and its signal intensity was slightly higher than that of skeletal muscle. Arthroscopic examination under spinal anesthesia was performed on the right knee through the lateral infrapatellar portal. There was no ligamentous, meniscal, or cartilage injury, but a discoidal, circumscribed mass was found in the intercondylar notch. We confirmed that it originated with a peduncle from the synovium of the anterior cruciate ligament (Fig 1). The patchy area of reddish-brown color at the inferior pole of the mass suggested hemorrhage. The mass was excised carefully under arthroscopic control and removed from the medial infrapatellar portal. The tumor was well encapsulated and lobulated, and its size was approximately 25 × 20 x 7 mm (Fig 2). The basic color was pinkish gray, mottled with yellow blotches. A multinodular growth pattern with thin layers of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 12, No 4 (August), 1996: pp 496-499
TENOSYNOVIAL GIANT-CELL TUMOR OF THE KNEE
497
A f
.,1 J
FIG 1. (A) Arthroscopic appearance of the tumor. (B) A discoidal, circumscribed, and pedunculated soft tissue mass was attached to the synovium of the anterior cruciate ligament. (C) The mass impinged between the femoral trochlea and anterior tibial plateau at the knee extension.
fibrous tissue was also visible microscopically. Microscopic features varied in different parts of the tumor, and the cellular composition was polymorphic. The basic cellular component of this tumor was a welldefined polygonal mononuclear cell with a scanty, faintly eosinophilic cytoplasm and a large oval nucleus (Fig 3A). Mitotic figures were rarely seen in the hypercellular areas, and they were never numerous. These areas contained foamy cells, with abundant cytoplasm and vacuoles (Fig 3B). Multinucleated giant cells were present even in the less cellular areas (Fig 3C). They had abundant eosinophilic cytoplasm and contained six
or more nuclei. In some areas, there were broad bands or sheets of amorphous collagen, which consisted of thick and hyalinized fibrous connective tissue (Fig 3D). There was no villous projection of the synovium either macroscopically or microscopically. Based on these histological findings, a diagnosis of tenosynovial giantcell tumor arising from the anterior cruciate ligament was made. Postoperative rehabilitation was started the day after surgery, and the patient became asymptomatic within 3 weeks. The patient was followed in the outpatient clinic for 7 months, with no sign of local recurrence.
498
Y. OTSUKA ET AL.
DISCUSSION
FIG 2. Gross appearance of the excised mass. The size of the mass was approximately 25 X 20 x 7 mm. The tumor was well encapsulated and lobulated.
A m o n g the various benign tumors and tumorlike lesions that arise from the tendon sheath and synovium, the giant-cell tumor is the most common. 2 This tumor was first described in 1852 by Chassiagnac 3 as " c a n c e r of the tendon sheath," but whether it differs from pigmented villonodular synovitis is controversial. The earliest investigators4-6 considered that giant-cell tumor and pigmented villonodular synovitis represented different manifestations of the same process, according to the c o m m o n histological features. Subsequent write r s 2'7-9 defined giant-cell tumor as a separate clinical enity because its growth pattern is different. Ushijima et al. 7 demonstrated that lesions without villous projections of the s y n o v i u m are not pigmented villonodular synovitis but giant-cell tumor. In our case, the lesions did not show this projection, either macroscopically or microscopically, and therefore it is properly described as a giant-cell tumor.
FIG 3. Microscopic appearance of the tumor, (A) The basic cellular component was polygonal mononuclearcells. (B) In some areas, foam cells were dominated with abundant cytoplasm and vacuoles. (C) Even in the less cellular areas, multinucleatedgiant cells were present. (D) A hyalinized fibrous connected tissue with sheets of amorphous collagens (H&E, original magnification x200).
TENOSYNOVIAL
GIANT-CELL
Enzinger and Weiss 2 called this tumor tenosynovial giant-cell tumor because of its basic nature and origin, and divided it into localized and diffused forms. The former mostly affected the digits, whereas the latter often affected the large weight-bearing joints. The localized tenosynovial giant-cell tumor rarely located intraarticularly, especially in the large weight-bearing joints. We have found in the literature only two cases of localized tenosynovial giant-cell tumor that arose in the articular knee cavity, one ~° from the posterior cruciate ligament, and the other 1~ attached to the s y n o v i u m of the anterior horn of the medial meniscus. Ours is the first case arising from the anterior cruciate ligament of the knee. Localized tenosynovial giant-cell tumor has a dense collagenous capsule, but its reccurrence rate after incomplete excision is reported to be higher than 10%. 2 Although our patient is currently asymptomatic, a longer follow-up examination is needed.
TUMOR
3. 4.
5.
6.
7.
8.
9.
REFERENCES 10. 1. Coventry MB, Harrison EG, Martin JF. Benign synovial tumor of the knee: A diagnostic problem. J Bone Joint Surg Am 1966; 48:1350-1358. 2. Enzinger FM, Weiss SW. Benign tumors and tumor-like lesions
11.
OF THE KNEE
499
ofsynovial tissue. Ed 3. Soft Tissue Tumors. St. Louis: Mosby, 1994;735-755. Chassaignac CME. Cancer de la gaine des tendons. Gas Hosp Civ Milit 1852;47:185-190. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis, and tenosynovitis:A discussion of the synovial and bursal equivalents of the tenosynovial lesions commonly denoted as xanthoma, xanthogranuloma,giant cell tumor or myeloplaxoma of the tendon sheath, with some consideration of this tendon sheath lesion itself. Arch Pathol 1941;31:731-765. Jones FE, Soule EH, Coventry MB. Fibrous xanthoma of the synovium (Giant-cell tumor of tendon sheath, Pigmented nodular synovitis): A study of one hundred and eighteen cases. J Bone Joint Surg Am 1969;51:76-86. Rao AS, Vigorita VJ. Pigmented villonodular synovitis (Giantcell tumor of the tendon sheath and synovial membrane): A review of eighty-one cases. J Bone Joint Surg Am 1984;66:7694. 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 large joint group with the common digit group. Cancer 1986;57:875-884. Madewell JE, Sweet DE. Tumor and tumor-like lesions in or about joints. In: Resnick D, Niwayama G, eds. Diagnosis of bone and joint disorders. Philadelphia: W.B. Saunders, 1981; 2733-2735. SpjutHJ, Dorfman HD, Fechner RE, Ackerman LV. Tumors of bone and cartilage. Washington, DC: Armed Forces Institute of Pathology, 1983;400-410. Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AA, Malawer MM. Giant cell tumor of the tendon sheath: MR findings in nine cases. Am J Roentogenol 1994;162:919-922. Kim SJ, Choi NH, Lee SC. Tenosynovial giant-cell tumor in the knee joint. Arthroscopy 1995;11:213-215.