Tenosynovial giant cell tumors are usually benign lesions that arise from the tendon sheath. It is unclear whether these lesions represent neoplasms or merely reactive masses. On imaging, these lesions are commonly demonstrated as localized, solitary, subcutaneous soft tissue nodules, with low T1 and T2 signal and moderate enhancement.
Tenosynovial giant cell tumor is the term used in the latest (2013) World Health Organization classification 10,11. They have previously been known as giant cell tumors of the tendon sheath (GCTTS), pigmented villonodular tumor of the tendon sheath (PVNTS), extra-articular pigmented villonodular tumor of the tendon sheath or localized or focal nodular synovitis 11.
Typically, they present in the 3rd to 5th decades and have a slight female predilection with an F:M ratio of 1.5-2.1:1 4. They are the second most common soft tissue mass of the hand and wrist.
Clinically these masses generally present in the hand (although they are found elsewhere also) as localized swelling with or without pain. They are slow-growing.
Tenosynovial giant cell tumors can cause pressure erosion of adjacent bone, or rarely can invade the bone mimicking an intraosseous lesion 8.
Tenosynovial giant cell tumors have been divided macroscopically into localized or diffuse forms and appear as rubbery multinodular masses that are well circumscribed. They have an enveloping fibrous capsule, and the transected surface of the specimen is variably colored depending on the relative proportions of fibrous tissue, hemosiderin, and pigmented foam cells 2.
The tumor is histologically identical to pigmented villonodular synovitis (PVNS) and is composed of fibroblasts and multinucleated giant cells, foamy histiocytes, and inflammatory cells on a background fibrous matrix 1,2.
As these masses arise from tendons, commonly of the hand, they may cause pressure erosions on the underlying bone in 10-20% of cases. More commonly these masses arise from the palmar tendons. The mass itself is of soft tissue density. Periosteal reaction and calcification are uncommon 4,5.
Ultrasound is useful as it allows not only the characterization of the lesion but also is able to demonstrate the relationship with the adjacent tendon. On the dynamic scan, there is free movement of the tendon within the lesion. Typically they appear as:
- associated with the volar surface of the digits
- does not move with flexion or extension of adjacent tendons
- usually homogeneously hypoechoic, although some heterogeneity may be seen in echotexture in a minority of cases 1
- most will have some internal vascularity
Not surprisingly, given the histological similarity to PVNS, giant cell tumors of the tendon sheaths also share the same finding on MRI, mainly on account of hemosiderin accumulation.
- T1: low signal
- T2: low signal
- T1 C+ (Gd): often show moderate enhancement 6
- GE: low and may demonstrate blooming
Treatment and prognosis
Tenosynovial giant cell tumors are usually benign and local surgical excision usually suffices, with local recurrence (seen in 10-20% of cases) requiring more extensive surgery with or without radiotherapy being uncommon 1. Locally aggressive and malignant tenosynovial giant cell tumors can occur 11. Metastases can occur, most commonly to lymph nodes and lung 4.
General imaging differential considerations include:
- cystic component
- attached to underlying joint capsule or tendon sheath 7
- if previously ruptured may appear similar 1
pigmented villonodular synovitis (PVNS)
- histologically identical
- involves larger joints
- desmoid tumor
- fibroma of the tendon sheath
- rheumatoid arthritis nodules
If in the hand consider:
- glomangioma: has high T2 signal on MRI
- 1. Middleton WD, Patel V, Teefey SA et-al. Giant cell tumors of the tendon sheath: analysis of sonographic findings. AJR Am J Roentgenol. 2004;183 (2): 337-9. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Ly JQ, Carlson CL, Lagatta LM et-al. Giant cell tumor of the peroneus tendon sheath. AJR Am J Roentgenol. 2003;180 (5): 1442. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Jelinek JS, Kransdorf MJ, Shmookler BM et-al. Giant cell tumor of the tendon sheath: MR findings in nine cases. AJR Am J Roentgenol. 1994;162 (4): 919-22. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Murphey MD, Rhee JH, Lewis RB et-al. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 28 (5): 1493-518. doi:10.1148/rg.285085134 - Pubmed citation
- 5. Peh WC, Shek TW, Ip WY. Growing wrist mass. Ann. Rheum. Dis. 2001;60 (6): 550-3. doi:10.1136/ard.60.6.550 - Pubmed citation
- 6. Bassetti E, Candreva R, Santucci E. Giant cell tumor of the flexor tendon of the wrist: US and MRI evaluation. Case report. J Ultrasound. 2011;14 (1): 37-9. doi:10.1016/j.jus.2010.12.001 - Free text at pubmed - Pubmed citation
- 7. Gude W, Morelli V. Ganglion cysts of the wrist: pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med. 2008;1 (3-4): 205-11. doi:10.1007/s12178-008-9033-4 - Free text at pubmed - Pubmed citation
- 8. Wang CS, Duan Q, Xue YJ et-al. Giant cell tumour of tendon sheath with bone invasion in extremities: analysis of clinical and imaging findings. Radiol Med. 2015;120 (8): 745-52. doi:10.1007/s11547-015-0520-6 - Pubmed citation
- 9. Wang Y, Tang J, Luo Y. The value of sonography in diagnosing giant cell tumors of the tendon sheath. J Ultrasound Med. 2008;26 (10): 1333-40. Pubmed citation
- 10. Christopher D. M. Fletcher. WHO Classification of Tumours of Soft Tissue and Bone. (2018) ISBN: 9789283224341
- 11. Plotkin B, Sampath SC, Sampath SC, Motamedi K. MR Imaging and US of the Wrist Tendons. (2016) Radiographics : a review publication of the Radiological Society of North America, Inc. 36 (6): 1688-1700. doi:10.1148/rg.2016160014 - Pubmed
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