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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Post traumatic Tenosynovial giant cell tumor in the foot
Post traumatic Tenosynovial giant cell tumor in the foot
Contributed by: Ankita Rani
Contributed by: Ankita Rani
Clinical profile:
Clinical profile:
A 49 year old man presented with the complaints of pain and swelling over dorsum of left foot since three months. There was history of trauma to left foot four to five months back following which the patient noticed a small swelling over the local site and dismissed it to be post traumatic swelling. There had been progressive increase in the size of the swelling since then. The swelling is soft and rubbery swelling (Fig. 1). There were normal movements of the tarsometatarsal and metatarsophalangeal joints. There were no signs of inflammation.
A 49 year old man presented with the complaints of pain and swelling over dorsum of left foot since three months. There was history of trauma to left foot four to five months back following which the patient noticed a small swelling over the local site and dismissed it to be post traumatic swelling. There had been progressive increase in the size of the swelling since then. The swelling is soft and rubbery swelling (Fig. 1). There were normal movements of the tarsometatarsal and metatarsophalangeal joints. There were no signs of inflammation.
Fig. 1 The swelling over dorsum of left foot
Radiological findings:
Radiological findings:
A plain radiograph of left foot (Fig. 2) with Dorsoplantar and medial oblique projections show a well defined homogenous soft tissue swelling over medial aspect of first metatarsal. There is erosion of underlying cortex of medial aspect of first metatarsal at tarsometatarsal joint. No calcifications are seen in the swelling.
A plain radiograph of left foot (Fig. 2) with Dorsoplantar and medial oblique projections show a well defined homogenous soft tissue swelling over medial aspect of first metatarsal. There is erosion of underlying cortex of medial aspect of first metatarsal at tarsometatarsal joint. No calcifications are seen in the swelling.
Grey scale sonographic images (Fig. 3) of dorsum of left foot show a heterogeneously hypoechoic, well defined solid lesion adjacent to extensor tendon overlying and extending into first tarsometatarsal joint space with erosion of base of first metatarsal.
Grey scale sonographic images (Fig. 3) of dorsum of left foot show a heterogeneously hypoechoic, well defined solid lesion adjacent to extensor tendon overlying and extending into first tarsometatarsal joint space with erosion of base of first metatarsal.
There are no cystic regions or calcifications .
There are no cystic regions or calcifications .
Colour and spectral Doppler of the swelling show good internal vascularity with arterial flow.
Colour and spectral Doppler of the swelling show good internal vascularity with arterial flow.
A contrast enhanced MRI was performed for further evaluation (Fig. 4) .
A contrast enhanced MRI was performed for further evaluation (Fig. 4) .
MRI shows a well defined, T1 hypointense and T2/STIR heterogeneously hypointense lesion measuring 3.6x2.2x3.8cm in the subcutaneous plane over left 1st tarso-metatarsal joint. The lesion is seen extending into the 1st tarso-metatarsal joint & causing medial cortical erosion. The insertion of tibialis anterior tendon at the base of 1st metatarsal is not seen separately from the lesion.
MRI shows a well defined, T1 hypointense and T2/STIR heterogeneously hypointense lesion measuring 3.6x2.2x3.8cm in the subcutaneous plane over left 1st tarso-metatarsal joint. The lesion is seen extending into the 1st tarso-metatarsal joint & causing medial cortical erosion. The insertion of tibialis anterior tendon at the base of 1st metatarsal is not seen separately from the lesion.
Similar lesions are also seen in the intermuscular plane of adductor hallucis muscle along the lateral aspect of the first tarsometatarsal joint and communicating with the above mentioned lesion inferiorly. There is bony erosion of lateral aspect of 1st metatarsal and medial cuneiform.
Similar lesions are also seen in the intermuscular plane of adductor hallucis muscle along the lateral aspect of the first tarsometatarsal joint and communicating with the above mentioned lesion inferiorly. There is bony erosion of lateral aspect of 1st metatarsal and medial cuneiform.
The rest of the bones of foot are normal.
The rest of the bones of foot are normal.
The neurovascular bundle is normal.
The neurovascular bundle is normal.
Radiological diagnosis:
Radiological diagnosis:
Gian cell tumor of the tendon sheath ; synovial cell sarcoma
Gian cell tumor of the tendon sheath ; synovial cell sarcoma
Figure 2: Radiograph of left foot with Dorsoplantar and medial oblique projections:
A well defined homogenous soft tissue swelling over medial aspect of first metatarsal. There is erosion of underlying cortex of medial aspect of first metatarsal at tarsometatarsal joint.
Figure 3: Sonographic images of dorsum of left foot show a heterogeneously hypoechoic, well defined, solid lesion adjacent to extensor tendon overlying and extending into first tarsometatarsal joint space with cortical erosions of base of first metatarsal and periosteal elevation. There are no cystic regions, calcifications . Colour Doppler of the swelling shows good central vascularity.
Figure 4: T1 cor, T2 trans and PD FS sag images show a well defined T1 hypointense and T2/STIR heterogeneously hypointense lesion of size 3.6x2.2x3.8cm in the subcutaneous plane over left 1st tarso-metatarsal joint. The lesion is seen extending into the 1st tarso-metatarsal joint & causing medial cortical erosion. The insertion of tibialis anterior tendon at the base of 1st metatarsal is not seen separately from the lesion. Satellite lesions are also seen in intermuscular plane of adductor hallucis muscle along lateral aspect of first tarsometatarsal joint causing pressure erosion of 1st metatarsal and medial cuneiform. Post contrast sagittal sections show heterogenous enhancement of the lesion.
Treatment:
Treatment:
The patient underwent surgical resection of the mass.
The patient underwent surgical resection of the mass.
Gross specimen shows a well circumscribed yellowish red mass with a lobulated appearance.
Gross specimen shows a well circumscribed yellowish red mass with a lobulated appearance.
Figure 5 Shows a well circumscribed yellowish red mass with a lobulated appearance.
Fig. 6 Shows sheets of mononuclear cells composed of large epitheloid to oval cells admixed with scattered osteoclast like giant cells. The larger epitheloid cells show moderate cytoplasm and vesicular nuclei. The intervening stroma shows hyalinisation and aggregates of foamy histiocytes.
Pathological Diagnosis:
Pathological Diagnosis:
Histopathological examination shows sThe meets of mononuclear cells composed of large epitheloid to oval cells admixed with scattered osteoclast like giant cells. The larger epitheloid cells show moderate cytoplasm and vesicular nuclei. The intervening stroma shows hyalinisation and aggregates of foamy histiocytes. Pigment deposition noted, stained by Prussian blue stain highlighting hemosiderin granules. The features are consistent with
Histopathological examination shows sThe meets of mononuclear cells composed of large epitheloid to oval cells admixed with scattered osteoclast like giant cells. The larger epitheloid cells show moderate cytoplasm and vesicular nuclei. The intervening stroma shows hyalinisation and aggregates of foamy histiocytes. Pigment deposition noted, stained by Prussian blue stain highlighting hemosiderin granules. The features are consistent with
Tenosynovial giant cell tumor (giant cell tumor of tendon sheath)
Tenosynovial giant cell tumor (giant cell tumor of tendon sheath)
Discussion:
Discussion:
Giant cell tumors of tendon sheath (GCTTS) is also known as localized nodular tenosynovitis. These are painless benign soft tissue tumors that frequently present as a firm, slow-growing, multilobulated, non-tender mass located adjacent to the tendon sheath synovium.
Giant cell tumors of tendon sheath (GCTTS) is also known as localized nodular tenosynovitis. These are painless benign soft tissue tumors that frequently present as a firm, slow-growing, multilobulated, non-tender mass located adjacent to the tendon sheath synovium.
The tumor usually affects young individuals aged 30–50 years with slight female predominance.
The tumor usually affects young individuals aged 30–50 years with slight female predominance.
Major etiological factors linked to its occurrence could be traumatic, inflammatory, metabolic or neoplastic disease.
Major etiological factors linked to its occurrence could be traumatic, inflammatory, metabolic or neoplastic disease.
GCTTS occurs in two different clinical presentations:
GCTTS occurs in two different clinical presentations:
L-GCTTS (Localized) on fingers and toes
L-GCTTS (Localized) on fingers and toes
D-GCTTS (Diffuse)that primarily occurs around large joints.
D-GCTTS (Diffuse)that primarily occurs around large joints.
The localised form is the most common and occurs most frequently in the hand, particularly in the volar aspect of the first three fingers (80% of cases).
The localised form is the most common and occurs most frequently in the hand, particularly in the volar aspect of the first three fingers (80% of cases).
It is the second most common soft tissue tumour of the hand after ganglion cyst. The second most frequent site of occurrence is the ankle–foot region.
It is the second most common soft tissue tumour of the hand after ganglion cyst. The second most frequent site of occurrence is the ankle–foot region.
Imaging features:
Imaging features:
It typically presents as a well-defined mass eccentrically located in association with or partially/completely enveloping a tendon.
It typically presents as a well-defined mass eccentrically located in association with or partially/completely enveloping a tendon.
Radiographs show a soft tissue mass with pressure erosion of underlying bone.
Radiographs show a soft tissue mass with pressure erosion of underlying bone.
On ultrasonography, the diagnosis should be strongly considered whenever a solid-appearing, hypoechoic mass with detectable blood flow is identified adjacent to tendon sheath. The pattern of vascularity may be central or peripheral. Posterior acoustic enhancement can be seen in about 33%.
On ultrasonography, the diagnosis should be strongly considered whenever a solid-appearing, hypoechoic mass with detectable blood flow is identified adjacent to tendon sheath. The pattern of vascularity may be central or peripheral. Posterior acoustic enhancement can be seen in about 33%.
The tumour does not move with the tendon during flexion and extension, as it arises from the tendon sheath and not the tendon itself.
The tumour does not move with the tendon during flexion and extension, as it arises from the tendon sheath and not the tendon itself.
Sonography can detect whether tumor is solid or cystic, and to note if there are satellite lesions. It also describes the relationship of the lesion to the surrounding structures. Underlying bony erosions may also be visualized on US.
Sonography can detect whether tumor is solid or cystic, and to note if there are satellite lesions. It also describes the relationship of the lesion to the surrounding structures. Underlying bony erosions may also be visualized on US.
It can also provide information about the extent of contact and circumferential involvement of the tendon that can be helpful for surgical planning.
It can also provide information about the extent of contact and circumferential involvement of the tendon that can be helpful for surgical planning.
In localised GCTTS, which is the major clinical differential to ganglion cyst for palpable masses along the flexor tendons of the fingers, US may be useful to distinguish between them by showing the typically cystic appearance of ganglion cyst.
In localised GCTTS, which is the major clinical differential to ganglion cyst for palpable masses along the flexor tendons of the fingers, US may be useful to distinguish between them by showing the typically cystic appearance of ganglion cyst.
MRI:
MRI:
MR imaging features of GCTTS reflect the histological characteristics
MR imaging features of GCTTS reflect the histological characteristics
of this group of lesions. The presence of haemosiderin-laden tissue exerts a paramagnetic effect that shortens T1 and T2 relaxation times, resulting in low to
of this group of lesions. The presence of haemosiderin-laden tissue exerts a paramagnetic effect that shortens T1 and T2 relaxation times, resulting in low to
intermediate signal intensity on T1- and T2-weighted sequences.
intermediate signal intensity on T1- and T2-weighted sequences.
Gradient echo sequences show blooming artifact due to increased magnetic
Gradient echo sequences show blooming artifact due to increased magnetic
susceptibility. The presence of abundant collagenous proliferation also contributes to the characteristically low signal intensity.
susceptibility. The presence of abundant collagenous proliferation also contributes to the characteristically low signal intensity.
Typically, lesions show moderate enhancement following intravenous gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA). Foci of haemosiderin deposits are seen as tiny areas of low signal intensity on all sequences, including post-Gd-DTPA sequences. Joint or tendon sheath effusion is a typical finding in diffuse disease but is uncommon with localised GCTTS.
Typically, lesions show moderate enhancement following intravenous gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA). Foci of haemosiderin deposits are seen as tiny areas of low signal intensity on all sequences, including post-Gd-DTPA sequences. Joint or tendon sheath effusion is a typical finding in diffuse disease but is uncommon with localised GCTTS.
Localised GCTTS typically shows a well defined mass eccentrically located in relation to a tendon or partially/completely enveloping it. The lesion is usually well demarcated by a low signal intensity capsule as a result of fibrosis or hemosiderin.
Localised GCTTS typically shows a well defined mass eccentrically located in relation to a tendon or partially/completely enveloping it. The lesion is usually well demarcated by a low signal intensity capsule as a result of fibrosis or hemosiderin.
The diffuse form of GCTTS appear as soft tissue mass with homogeneous, predominantly low signal intensity on both T1- and T2-weighted images, with homogeneous enhancement seen after contrast administration.
The diffuse form of GCTTS appear as soft tissue mass with homogeneous, predominantly low signal intensity on both T1- and T2-weighted images, with homogeneous enhancement seen after contrast administration.
MR imaging is currently the optimal modality for preoperative assessment of tumour size, extent and invasion of adjacent joint and tenosynovial space.
MR imaging is currently the optimal modality for preoperative assessment of tumour size, extent and invasion of adjacent joint and tenosynovial space.
Computed tomography
Computed tomography
GCTTS appear as soft tissue mass lesions of high attenuation in comparison to surrounding muscles, depending on the amount of hemosiderin content. Underlying bone erosions not visible on radiographs can be well appreciated.
GCTTS appear as soft tissue mass lesions of high attenuation in comparison to surrounding muscles, depending on the amount of hemosiderin content. Underlying bone erosions not visible on radiographs can be well appreciated.
Contrast enhancement is typically present due to their hypervascular nature. CT-guided biopsies can be performed for precise localisation and accurate sampling
Contrast enhancement is typically present due to their hypervascular nature. CT-guided biopsies can be performed for precise localisation and accurate sampling
with low patient morbidity .
with low patient morbidity .
Histopathological diagnosis:
Histopathological diagnosis:
Composed of variable proportions of mononuclear cells, osteoclast-like giant cells, foamy histiocytes and hemosiderin laden histiocytes, stained by Prussian blue stain.
Composed of variable proportions of mononuclear cells, osteoclast-like giant cells, foamy histiocytes and hemosiderin laden histiocytes, stained by Prussian blue stain.
Differential diagnosis:
Differential diagnosis:
Includes soft tissue tumours and tumour-like lesions that affect the extremities, including ganglion cyst, lipoma, haemangioma, nerve sheath tumour, foreign body granuloma and synovial sarcoma. They typically display high signal intensity on T2-weighted images, unlike the low/intermediate signal intensity usually seen in GCTTS.
Includes soft tissue tumours and tumour-like lesions that affect the extremities, including ganglion cyst, lipoma, haemangioma, nerve sheath tumour, foreign body granuloma and synovial sarcoma. They typically display high signal intensity on T2-weighted images, unlike the low/intermediate signal intensity usually seen in GCTTS.
Treatment:
Treatment:
Surgery is curative, although recurrence after resection may be seen
Surgery is curative, although recurrence after resection may be seen
in about 7%–44%. Incomplete excision and leaving behind satellite nodules is considered as the most important factor deciding recurrence pattern.
in about 7%–44%. Incomplete excision and leaving behind satellite nodules is considered as the most important factor deciding recurrence pattern.
References:
References:
1. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR Am J Roentgenol. 2004 Aug;183(2):337-9. doi: 10.2214/ajr.183.2.1830337. PMID: 15269021.
1. Middleton WD, Patel V, Teefey SA, Boyer MI. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR Am J Roentgenol. 2004 Aug;183(2):337-9. doi: 10.2214/ajr.183.2.1830337. PMID: 15269021.
2. Wang, C., Song, R. R., Kuang, P. D., Wang, L. H., & Zhang, M. M. (2017). Giant cell tumor of the tendon sheath: Magnetic resonance imaging findings in 38 patients. Oncology letters, 13(6), 4459–4462. https://doi.org/10.3892/ol.2017.6011
2. Wang, C., Song, R. R., Kuang, P. D., Wang, L. H., & Zhang, M. M. (2017). Giant cell tumor of the tendon sheath: Magnetic resonance imaging findings in 38 patients. Oncology letters, 13(6), 4459–4462. https://doi.org/10.3892/ol.2017.6011
3. Asaad SK, Bapir R, Salh AM, Abdullah AM, Tahir SH, Mikael TM, Kakamad FH, Hassan HA, Abdullah HO, Mohammed SH. Giant cell tumor of the tendon sheath in a 5-year-old child; A case report. Ann Med Surg (Lond). 2021 Jul 26;69:102599. doi: 10.1016/j.amsu.2021.102599. PMID: 34429941; PMCID: PMC8371222.
3. Asaad SK, Bapir R, Salh AM, Abdullah AM, Tahir SH, Mikael TM, Kakamad FH, Hassan HA, Abdullah HO, Mohammed SH. Giant cell tumor of the tendon sheath in a 5-year-old child; A case report. Ann Med Surg (Lond). 2021 Jul 26;69:102599. doi: 10.1016/j.amsu.2021.102599. PMID: 34429941; PMCID: PMC8371222.
4. Wan JM, Magarelli N, Peh WC, Guglielmi G, Shek TW. Imaging of giant cell tumour of the tendon sheath. Radiol Med. 2010 Feb;115(1):141-51. English, Italian. doi: 10.1007/s11547-010-0515-2. PMID: 20077044.
4. Wan JM, Magarelli N, Peh WC, Guglielmi G, Shek TW. Imaging of giant cell tumour of the tendon sheath. Radiol Med. 2010 Feb;115(1):141-51. English, Italian. doi: 10.1007/s11547-010-0515-2. PMID: 20077044.
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6. De Beuckeleer L, De Schepper A, De Belder F, Van Goethem J, Marques MC, Broeckx J, Verstraete K, Vermaut F. Magnetic resonance imaging of localized giant cell tumour of the tendon sheath (MRI of localized GCTTS). Eur Radiol. 1997;7(2):198-201. doi: 10.1007/s003300050134. PMID: 9038114.
6. De Beuckeleer L, De Schepper A, De Belder F, Van Goethem J, Marques MC, Broeckx J, Verstraete K, Vermaut F. Magnetic resonance imaging of localized giant cell tumour of the tendon sheath (MRI of localized GCTTS). Eur Radiol. 1997;7(2):198-201. doi: 10.1007/s003300050134. PMID: 9038114.
7. 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 Apr;162(4):919-22. doi: 10.2214/ajr.162.4.8141018. PMID: 8141018.
7. 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 Apr;162(4):919-22. doi: 10.2214/ajr.162.4.8141018. PMID: 8141018.
Acknowledgements:
Acknowledgements:
We are grateful to the Departments of Surgery and Pathology at our institution for providing the operative and histopathology images and their descriptions.
We are grateful to the Departments of Surgery and Pathology at our institution for providing the operative and histopathology images and their descriptions.
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