Giant cell tumour of the tendon sheath - recurrence

Case contributed by Dr Matt Skalski

Presentation

The patient reported multiple previous operations on her hand in a foreign country for a hand mass. Now presents with multiple enlarging hand masses.

Patient Data

Age: 25
Gender: Female

There are large soft tissue masses within the volar aspect of the hand, involving the thenar eminence and proximal fifth digit. No mineralization within the masses is observed. Subtle ossesous erosions are appreicated along the proximal metacarpals and proximal interphalangeal joint of the fifth digit. Because of the ventral and lateral locations of the erosions, there is suspicion of tumor spread to the dorsal comparments of the hand. 

There is a large T1 and STIR hypointense mass that involves the entire common flexor compartment tendon sheath, 5th digital tendon sheath, and flexor pollicis longus tendon sheath. The mass violates the dorsal aspect of these compartments to extend between the first, second and third metacarpals proximally. The mass is well-defined and lobular without peritumoral edema. There are multiple, small, mildly enhancing foci throughout the lesion, most prominently within the mass between the first and second metacarpals, and anterior to the fourth metacarpal. 

Case Discussion

The differential for hypointesne lesions on both T1 and T2 weighted images in the hand commonly includes: giant cell tumor of the tendon sheath (GCTTS) (aka: PVNS of the tendon sheath), gouty tophi, anything with calcification (i.e. synovial osteochondromatosis), rice bodies and chronic blood. GCTTS is T1 and T2 hypointense due to hemosiderin accumulation, similar to chronic blood products.

This case is unique because GCTTS usually presents with a focal mass that respects the boundaries of the enveloping tendon sheath. The history of "multiple surgeries" in this case explains the spread of the tumor to multiple tendon sheath compartments and beyond into the dorsum of the hand, because the sheath was violated at the time of surgery, likely seeding tissue in muliple locations and/or with incomplete removal of the inital mass(es).

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Case Information

rID: 27719
Case created: 16th Feb 2014
Last edited: 13th Mar 2016
Inclusion in quiz mode: Included

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