Giant Cell Tumor of Tendon Sheath in the Hand and Wrist

Giant cell tumor of the tendon sheath (GCTTS) is the second most common soft tissue tumor of the hand following ganglion, accounting for 15 to 27.5% of the benign hand tumors. It is typically slow growing and originates from the synovial cells of the tendon sheaths. It could be nodular or diffuse. The earlier form is frequently found in the hand, whereas the latter variety is often found around the large joints. It is classified as types 1 and 2. The type 1 denotes single tumor which may be round or multilobulated. The type 2 is characterized by two or more distinct tumors which are not joined together.[1] [2] [3]

This prospective study aimed to evaluate the demographic and clinical presentation of GCTTS and the rate of early recurrence at 1 year following radical surgical excision. This study spanned over a period of 10 years and included all histologically confirmed cases of GCTTS. The patients were evaluated with history, examination, magnetic resonance imaging (MRI), and fine needle aspiration cytology (FNAC). The adult patients underwent excision under local anesthesia, whereas in case of children, general anesthesia was employed. All cases were operated under tourniquet control and with use of magnifying loupes. Radical surgical excision along with any satellite lesions was ensured. The excision margin included 1 mm of normal surrounding tissue. [Table 1] summarizes the entry variables and outcomes observed ([Figs. 1] [2]).

Table 1 Demographic, clinical variables and outcomes observed among the included patients (n = 27)

Characteristics/parameters	Number (%)
Age (y)	46.55 ± 15.50 (range: 7–65 years)
Gender
Female	19 (70.37)
Male	8 (29.62)
Duration (mo)	15.14 ± 7.1 (range: 7–48 months)
Affected side
Dominant	21 (77.77)
Nondominant	6 (22.22)
Digits affected
Index finger	6 (22.22)
Middle finger	6 (22.22)
Thumb	4 (14.81)
Ring finger	3 (11.11)
Little finger	3 (11.11)
Wrist	3 (11.11)
Palm	2 (7.40)
Aspect of digits, hand or wrist affected
Volar surface	19 (70.37)
Dorsal surface	8 (29.62)
Phalanx affected
Middle phalanx	12 (44.44)
Proximal phalanx	9 (33.33)
Distal phalanx	1 (3.70)
Wrist and palm	5 (18.51)
Presenting clinical complaint
Swelling	27 (100)
Tenderness on movement	3 (11.11)
Type of tumors
Type 1 tumor	18 (66.66)
Type 2 tumor	9 (33.33)
Recurrence	2 (7.40)
Postoperative complications	0
Mortality	0

Fig. 1 Intraoperative photograph of GCTTS involving the right middle finger. The tumor is attached to the flexor tendon sheath. GCTTS, giant cell tumor of the tendon sheath.

Fig. 2 The excision specimen of a GCTTS in another patient, displaying the characteristic appearance of the tumor. GCTTS, giant cell tumor of the tendon sheath.

The exact cause of the GCTTS continues to remain elusive. Some authorities declare it to be an inflammatory disease whereas others consider it to be a neoplastic entity.[1] [2] [3]

At the time of radical surgical excision, the surgeon is often faced with unique challenges. Being originating from the synovial sheaths, one has to be careful to dissect the entire tumor and at the same time, preserve the underlying tendons. Also one has strike a balance between excision and preserving any encased digital neurovascular structures. Where possible, en bloc excision of the entire pathologic tissue is performed. Satellite lesions are searched for in the vicinity and excised meticulously. If erosion of the bone cortices is observed, curettage of the involved cortical shell is performed. Likewise, the involved joint capsules are cleared of the tumor tissue. In case of recurrent tumors, surgical reexcision is still the primary treatment where there is an increased risk of neurovascular injury. Rarely, these have to be sacrificed to ensure complete excision.[1] [2] [3] [4] [5]

The low recurrence rate in this study is attributable to the routine employment of preoperative workup with MRI and FNAC, use of intraoperative loupe magnification, and meticulous surgical technique that ensured radical resection without missing any satellite lesions.

To conclude, GCTTS were predominantly found among females aged over 40 years. The tumors had a predilection for involving the radial digits including the index and middle fingers and the thumb. Radical surgical excision with removal of associated satellite nodules helped to reduce the recurrence rate to 7.40% at 1-year follow-up.

Ethical Approval

The study followed the ethical protocols as outlined by the Helsinki's Declaration-2013 revision. Anonymity of the participants was ensured. Written informed consents were obtained. The patients provided written informed consent for the publication and the use of their images.

Publication History

Article published online:
29 October 2020

• References

• 1 Fotiadis E, Papadopoulos A, Svarnas T, Akritopoulos P, Sachinis NP, Chalidis BE. Giant cell tumour of tendon sheath of the digits. A systematic review. Hand (N Y) 2011; 6 (03) 244-249
• 2 Al-Qattan MM. Giant cell tumours of tendon sheath: classification and recurrence rate. J Hand Surg [Br] 2001; 26 (01) 72-75
• 3 Ozben H, Coskun T. Giant cell tumor of tendon sheath in the hand: analysis of risk factors for recurrence in 50 cases. BMC Musculoskelet Disord 2019; 20 (01) 457
• 4 Ozalp T, Yercan H, Kurt C, Ozdemir O, Coşkunol E. [Giant-cell tumors of the tendon sheath involving the hand or the wrist: an analysis of 141 patients] (in Turkish). Acta Orthop Traumatol Turc 2004; 38 (02) 120-124
• 5 Williams J, Hodari A, Janevski P, Siddiqui A. Recurrence of giant cell tumors in the hand: a prospective study. J Hand Surg Am 2010; 35 (03) 451-456