Villonodular plasma cell synovitis

VILLONODULAR LEO F.

PLASMA CELL SYNOVITIS*

BLEYER, M.D. AND K.

CARROLL,

M.D.

EVANSTON, ILLINOIS

T

HE

term “viIIonoduIar synovitis” first been introduced by Jaffe co-workers in 1941 to designate

has and pig-

FIG. I. X-ray picture of uInar Iesion.

mented Iesions of tumor-Iike appearance which occur in joints, bursae and tendon sheaths. A brief review of his articIe’ shaI1 precede the report of our own case. The authors state that in the past, often because of the baflling cytoIogic picture, many observers have overIooked the basic pathoIogic process and have named the Iesion according to some outstanding gross or microscopic manifestation. Thus among the names appIied to this condition are the foIIowing : chronic hemorrhagic viIIous synovitis, giant ceI1 fibrohemangioma, fibrohemosideric sarcoma and poIymorphoceIIuIar tumor of the synovium. The tota number of cases of pigmented viIIonoduIar synovitis at the time Jaffe’s articIe was pubIished was fifty-seven incIuding twenty

cases of his own study. He stated that the lesion appears aIways to be monarticular and to have been noted in the joints of the Iower extremity, more commonIy in the knee. Ages in his series varied between eighteen and forty-eight with a preference of the male sex. The interva1 between appearance of symptoms and medica consultation varied from one month to five years though the average was two to three years. A history of trauma was eIicited from onIy three of the author’s patients. It was found that x-ray contributed very IittIe to the diagnosis except to co&m the presence of Auid in the joint or of soft tissue sweIIing. The gross appearance of the Iesion varied greatIy. It was predominantIy villous, noduIar or represented a combination of the two. In many cases the villi or noduIes were fused and the whoIe joint cavity obIiterated by a soft tissue mass. One outstanding characteristic was pigmentation, the coIor of the Iesion varying from reddishbrown, to yeIIow. MicroscopicaIIy, the viIIous Iesions showed the viIIi to be covered by synovial ceIIs in one to three Iayers. The supporting connective tissue stroma of the viIIi was’f.IooseIy textured and composed of poIyhedra1 or spindIe-shaped ceIIs. ViIIi contained a considerabIe number of thinwaIIed vascuIar channeIs, an occasiona one of which was encircIed by a cuff of smaI1 Iymphocyte-Iike ceIIs. The outstanding histoIogica1 feature was the presence of brownish pigment granules; in addition, there were hemosiderin-bearing and Iipoidbearing fcam ceIIs and muItinucIear giant ceIIs. In the more compIex Iesions presenting a fused or matted viIIous appearance, the spaces between the viIIi were reduced to narrow cIefts Iined by synovia1 ceIIs.

* From the PathoIogicaI Department, St. Francis HospitaI, Evanston, III. 222

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FIG. 2. Low power view of joint. contents.

PuIp of the vi& consisted of cIoseIy packed poIyhedra1 and foam ceIIs with or without pigment. VariahIe numbers of multinucIear giant ceIIs were aIso present. The authors emphasize the variability of the microscopic pattern, different areas being dominated by one or another ceI1 type. Marked CoIIagenization and hyalinization of the stroma was seen in the older Iesions. The authors reject the idea that the Iesions represent a tumor in the true sense of the word, or that it is the resuIt of intraarticuIar hemorrhage or IocaI Iipoid imbaIante. They beIieve that it represents an inffammatory response to some as yet unknown agent. AIthough Jaffe’s pubIication presents a very exhaustive study of the subject, we fee1 justified to report another case of our own observation’ because of the reIative rarity of the fesion among surgical specimens in a genera1 hospita1 and certain deviations from the description of the lesion by Jaffe. CASE

REPORT

The patient was a forty-five year old white male, and bus driver by occupation. In May, 1944, he stated that he struck the ulnar aspect of his left wrist against the steering wheel of a bus. He had pain in the wrist for two or three days foliowed by swelling which increased

slowly but steadily in size. In July, 1945, he consuIted a physician who incised the sweIling, telling him that it was a “gangIion.” Some cIear amber coIored fluid was obtained. The wrist and arm were put in a cast for nine weeks. At the end of this time, the swelling was stiI1 present although the wound had healed. In January, 1946, he consulted another doctor who sent him to the hospital. The lesion was described as a lirm but not hard mass at the distal end of the left StIna, measuring 155 cm. in diameter. Except for this finding, physical examination was essentially negative. Laboratory studies were not contributory. X-rays of the wrist revealed a circumscribed area of decreased density at the distal end of the left ulna surrounded by a narrow zone of increased density with a fuzzy appearance. There appeared to be some involvement of the lateral side of the radius. Comparison with x-rays taken severa months earlier showed some increase in the size of the lesion. At operation, February I, 1946, the joint capsule was thickened and somewhat distended. Upon entering the joint, the synovium was found to be covered by a thick layer of soft, shaggy, grayish-white “granulation tissue.” There was a small amount of gelatinous, straw-cotored Auid in the joint. The distal end of the ulna was rough and irregular. The distal 3 cm. of the uIna were resected and the granulation tissue clipped away. The pathoIogica1 fIndings were as follows: Crossly, the contents of the ulnar-radial joint

224

American Journal of Surgery

BIeyer,

Carroll---Synovitis

FIG. 3.

FIG. 4.

FIG. 4. High

FIG. 3. High power view showing synovid viIli. power view showing extensive plasma-cell infiltration

resembled granulation tissue and were devoid of any characteristic pigmentation. Contrary to Jaffe’s statement that roentgenography is of little value in diagnosis except for confirming the soft tissue sweIIing, we found in the x-ray picture (Fig. I) a definite ragged corrosion of the distal end of the ulna. The appearance of the resected distal end wxs in accordance with the x-ray shadow. Microscopic sections (Figs. z to 4) were made from both, the bone and the joint contents. The bone sections were completely negative for any penetration of the synovial proliferative tissue. The structure of the joint contents presented viIIous processes separated by narrow channels and was composed of com-

of the villi.

pact sheets and masses of polygonal and polyhedral synovial ceIIs of fairly uniform size and equal staining power of the nucfei. There was a considerabIe amount of intervening, partially hyalinized connective tissue. Multinuclear giant ceIIs were present but these were very few in numbers. No pigment of any kind was discernible. Outstanding and partiaIIy obscuring the basic cytoIogic pattern was a heavy i&tration of the viIIi (Fig. 4) by cIusters and coIIections of pIasma cells intermingled with varying numbers of smaI1 Iymphocytes. Sections were sent for confirmation to Dr. Fred Stewart at the Memorial Hospital in New York City who classified Lhe lesion as villonodular synovitis.

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COMMENT

The basic structure of synovial cell sheets in viIIous and noduIar form is the finding by which our case conforms to the description in Jaffe’s series. There is, however, a conspicuous absence of pigment the occurrence of which is so much stressed as a typical feature in Jaffe’s cases. Even more prominent is the inff ammatory pIasma cell reaction. We find no mentioning of the

latter in Jaffe’s report. We are inclined to believe that the post-traumatic inff ammatory process was primary and set the synovial proliferation in motion. AIthough superficially of the bone, found.

corroding no deeper

the articufar penetration

surface could be

REFERENCE I. JAFFE, H. L., LICHTENSTEIN, L. and SL’TRO, C. J.

Pigmented villonodular synovitis, bursitis tenosynovitis. Arch. Path., 31: 731, 1g41.

IN cases of puruIent arthritis of the ankle-joint there is often a sympathetic effusion into the tendon sheaths. It is possible that suppurative tenosy,novitis may be confused with puruIent arthritis, but as the former condition is IikeIy to be confined to one set of the synovial tendon sheaths, the differentiar diagnosis is not usually difficult. From “Surgery of Modern Warfare” edited by Hamilton BaiIey (The WiIIiams & WiIkins Company).

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