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Radiologic-Pathologic Conference of Wilford Hall Medical Center |
1 Department of Radiology, Wilford Hall Medical Center, 2200 Bergquist Dr., Ste.
1, Lackland AFB, TX 78236-5300.
2 Department of Radiology, Brooke Army Medical Center, 3851 Roger Brooke Dr.,
Fort Sam Houston, TX 78234-6200.
3 Department of Pathology, Wilford Hall Medical Center, Lackland AFB, TX
78236-5300.
4 Department of Radiology, Uniformed Services University of the Health Sciences,
4301 Jones Bridge Rd., Bethesda, MD 20814-4799.
Received September 12, 2002;
accepted after revision October 24, 2002.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or representing the views of
the Department of the Army or the Department of the Air Force.
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Giant cell tumor of the tendon sheath comprises approximately 1.6% of all soft-tissue tumors and is characteristically a benign peritendinous fibrous mass [1, 2]. There is debate as to whether the tumor is a true neoplasm or a pseudoneoplastic inflammatory response to soft-tissue trauma [1]. This hypervascular lesion arises from the synovium of the tendon sheath or synovial lining of joints or bursa and is characterized microscopically by synovial cells, histiocytes, multinucleated giant cells, inflammatory cells, macrophages, xanthoma cells, and collagen [1, 2, 3, 4]. Both a localized and a diffuse form have been described. The localized form can arise in or extrinsic to a joint, and the diffuse form predominantly originates outside the joint. Grossly, giant cell tumor of the tendon sheath appears as a rubbery, multinodular, well-encapsulated, grayish tan, brown, orange, or yellow mass; the color depends on the proportion of foam cells and degree of hemosiderin deposition. A collagenous capsule surrounds the lesion [1, 4].
Clinically, the lesion is a slow-growing soft-tissue mass that develops over months to years and can cause varying degrees of pain or be asymptomatic [1, 3, 4]. It develops predominantly in the hand but can also be found around the foot, ankle, knee, or hip. [1, 2, 4]. To the best of our knowledge, this is the first reported case of a giant cell tumor of the tendon sheath arising from the peroneus tendon sheath. It can occur at any age, with peak incidence between the third and fifth decades; there may be a female predominance [1, 4]. Patients may report a history of trauma to the affected area [1, 4]. The tumor commonly encircles a nearby tendon or more rarely the neurovascular bundles [4].
Radiography may reveal a soft-tissue mass, or findings may be entirely normal. Pressure erosions of underlying bone can infrequently be seen (10-20%) [1, 2, 4]. Periosteal reaction, osteopenia, calcification, degenerative or cystic changes, and intraosseous invasion are other rare radiographic manifestations [1, 4]. Characteristic MR imaging findings include the presence of fibrosis, which is manifested as areas of low signal intensity on all pulse sequences, and hemosiderin deposition, which results in blooming artifact on gradient echo images. The extent of the mass may be obscured by signal intensity similar to muscle on T1-weighted images [3]. However, fibrosis and inflammatory cell infiltrate can result in varying degrees of enhancement, which aids in defining the extent of the tumor [2, 3]. The differential diagnosis includes any soft-tissue mass with low signal intensity on both T1-weighted and T2-weighted images, such as a desmoid tumor (particularly if deep) or pigmented villonodular synovitis, which more commonly involves the larger joints. Aside from possessing similar signal characteristics, giant cell tumor of the tendon sheath also histologically resembles pigmented villonodular synovitis. Other differential considerations include desmoid tumor, fibroma, cavernous hemangioma, ganglion cyst, granuloma, fibrosarcoma, malignant fibrous histiocytoma, synovial cell sarcoma, chondroma, granuloma, and tophaceous gout. None of these entities typically contain hemosiderin, however.
The treatment of choice for giant cell tumor of the tendon sheath is local excision with clear margins to minimize the risk of recurrence. Radiation therapy has been advocated, but data showing that it decreases recurrence are scarce [2].
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  C. C. Roberts, P. T. Liu, and F. S. Chew Imaging Evaluation of Tendon Sheath Disease: Self-Assessment Module Am. J. Roentgenol., March 1, 2007; 188(3_Supplement): S10 - S12. [Abstract] [Full Text] [PDF]
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