OBJECTIVE To evaluate the results of the treatment of 31 giant-cell tumors of the
tendon sheath of the hand cared for between 2006 and 2015.
METHODS A group of patients for the present retrospective evaluation was defined, covering the period between February 2006 and November 2015, in which 31 records of patients who underwent surgery due to cell tumor of the tendon sheath of the fingers were studied and evaluated. The recommended treatment was complete excision of the tumor with preservation of the adjacent structures. The diagnosis was confirmed by pathological examination. The progress of the treatment after surgery was evaluated, especially regarding the rate of tumor recurrence.
RESULTS Taking all 31 patients into consideration, there was a predominance of the female gender and white ethnicity. Most of these patients were aged between 30 and 50 years. The most affected side was the left one, and most tumors were in the flexor face. There was a predominance of the radial fingers, along with their distal end. A total of 27 patients are being followed up at regular intervals at an outpatient clinic, and three cases of tumor recurrence have been identified.
CONCLUSION An appropriate surgical technique is essential in order to prevent GCTTS recurrences. The results obtained in this research are in agreement with the literature.
Keywords: neoplasms; hands; giant-cell tumors.
OBJETIVO Avaliar os resultados do tratamento de 31 tumores de células gigantes da
bainha do tendão da mão encontrados entre 2006 e 2015.
MÉTODOS Entre fevereiro de 2006 e novembro de 2015, um grupo de pacientes foi selecionado para avaliação retrospectiva, na qual foram estudados e avaliados 31 prontuários de pacientes submetidos a procedimento cirúrgico devido a tumor de células gigantes da bainha do tendão dos dedos da mão. O tratamento preconizado foi a excisão completa do tumor com a preservação das estruturas adjacentes. A confirmação diagnóstica foi feita pelo exame anatomopatológico. Foi avaliada a evolução do tratamento após a cirurgia, principalmente no tocante ao índice de recidivas dos tumores.
RESULTADOS Dos 31 pacientes da amostra, houve predomínio do sexo feminino e da etnia branca. O tumor acometeu principalmente indivíduos entre 30 e 50 anos. O lado mais acometido foi o esquerdo, e amaioria dos tumores estava na face flexora. Houve predominância dos dedos radiais, juntamente com sua extremidade distal. Esses pacientes têm sido acompanhados em intervalos regulares em ambulatório. Dos 27 pacientes reavaliados, foram identificados 3 casos de recidiva tumoral.
CONCLUSÃO Uma técnica cirúrgica adequada é essencial para a prevenção de recidivas do TCGBT. Os resultados obtidos na pesquisa estão em concordância com a literatura atual.
Palavras-chave: neoplasias; mãos; tumores de células gigantes.
|Citation: Galbiatti JA, Milhomens GRS, Silva LFHFe, Santiago DS, Silva Neto JC, Belluci SOB. Retrospective Study of the Results of Surgical Treatment of 31 Giant Cell Tumors of the Tendon Sheath in the Hand*. 54(1):26. doi:10.1016/j.rbo.2017.11.005|
Work developed at the Department of Orthopedics and Traumatology, Irmandade
da Santa Casa de Misericórdia de Marília, Marília, SP, Brazil.
Gabriel Rodrigues dos Santos Milhomens's ORCID is https://orcid.org/0000-0001-6805-5460
|Received: Setembro 16 2017; Accepted: Novembro 23 2017|
Giant-cell tumor of the tendon sheath (GCTTS), which is generically called giant-cell tumor of soft parts (GCTSP), is a benign neoplasm originating at the tendinous, peritendinous or articular synovial tissue. It is also called ﬁbrous histiocytoma of the tendon sheath, xanthogranuloma, ﬁbroxanthoma, tendinous sheath myeloma, pigmented villonodular tenosynovitis, benign synovioma, giant-cell ﬁbrous hemangioma, hemosiderotic sarcoma, xanthomatous histiocytic granuloma, sclerosing hemangioma, myeloxanthoma and villous arthritis. It was ﬁrst described by Chassaignac,1 who considered it a malignant neoplasm of the digital tendon sheath.2-8 Moser9 described the ﬁrst example, the diffuse type, and, in 1912, Dowd (apud Weiss et al)2 questioned if these lesions were truly malignant. Jaffe et al10 introduced the term pigmented villonodular tenosynovitis, which was considered a synonym of GCTTS for some time due to the histological similarities; currently, however, they are recognized as distinctive diseases: the former is characterized as diffuse, and the latter is nodular or localized.2,8,11,12
Giant-cell tumor of the tendon sheath is considered the most frequent hand tumor, and it results from a benign proliferation of histiocytes from the joints and peritendinous synovial tissues developing around the tendon sheaths, joint ligaments and joint synovium.4,12-16 Although there is still some divergence among the researchers, the most accepted etiology is reactive or regenerative hyperplasia associated with inﬂammation.5,17
Giant-cell tumor of the tendon sheath is more common between the ages of 30 and 50 years, with a female predominance in a ratio of approximately 3:2.2,3,8,13,14,17,18 It mostly occurs as tumor growths in the hands, mainly in the radial ﬁngers, frequently close to the distal interphalangeal joint.3,7,8,14,18,19 The tumor favors the ﬂexor aspect of the hand, although the extensor aspect can also be affected. Occasionally, the tumor can be lateral or circunferential.18,20 Other sites may be affected with less intensity, such as the foot, the ankle, the knee and the hip.2,3,14,16
These tumors develop for a long time and often maintain the same size for many years. The affected patients present normal cholesterol levels.2 Percutaneous transillumination can help the differential diagnosis with a ganglion (synovial cyst).
Ultrasound can help deﬁne the dimensions of the tumor, identify satellite lesions, and differentiate ganglions or lipomas, the most common neoplasms of the hand.8 Other diagnostic hypothesis of soft-part tumors must be considered, and only an anatomopathological examination can conﬁrm them.7
Magnetic resonance imaging (MRI) is the most accurate test to deﬁne the lesion and the diagnostic suspicion.3
Giant-cell tumor of the tendon sheath can present itself as a slow-growing, well-circumscribed, ﬁrm, and lobulated mass partially or totally covered by a ﬁbrous capsule and with no alterations in the overlying skin; it generally measures between
0.5 and 4.0 cm in diameter.2,3,7,18,20 Lesions located in the foot are bigger and more irregular than those in the hand.2 On the cross-sectional sections, the lesion is grayish-pink in color, with yellow or brown speckles, depending on the content of lipids, collagen, hemosiderin and histiocytes.2,3,12,19
Diagnosis conﬁrmation is solely based on the anatomopathological examination of the specimen, which often varies histologically according to the proportion of mononuclear cells, giant cells, xanthomatous cells and the degree of collagenization. The tumor is mostly composed of polygonal cells mixed with mildly-elongated hypocellular collagenated zones. Fused spaces are occasionally present, mainly next to the joints. Xanthomatous cells are frequently found in such tumors, and they can contain hemosiderin granules (►Fig. 1). 18 Bone and cartilaginous metaplasia are rarely observed.2,5,20,21
The differential diagnosis includes granulomatous lesions, tendinous xanthomas, tendinous ﬁbromas and epithelioid sarcomas. This tumor is reportedly associated with rheumatoid arthritis, Paget disease of the bone, and degenerative osteoarthritis.2,5,12
The treatment of choice is total excision of the tumor, also known as excisional biopsy. This procedure attempts to spare the joint, tendinous, arterial and neural structures.3,6,12,15 Its recurrence ranges from 5 to 50%, and it is related mainly to tumor resection failure and highly mitotic lesions.20 Amalignant GCTTS variant is rare and difﬁcult to diagnose.7 There are no reports of spontaneous regression.15
The goal of the present work is to evaluate the surgical outcomes of 31 giant-cell tumors of the tendon sheath of the hand treated over a period of 10 years (2006-2015) at the Orthopedics and Traumatology Department of Irmandade da Santa Casa de Misericórdia, in the city of Marília, Brazil. In addition, the study intends to relate the ﬁndings with the information found in the literature, and to highlight the importance of an adequate surgical technique to prevent recurrences.
MATERIAL AND METHODS
A group of patients treated between February 2006 and November 2015 was selected for a retrospective evaluation; from this group, 31 medical records of patients submitted to a surgical procedure due to a GCTTS in the ﬁngers were studied and analyzed. The patients were treated by two orthopedists specialized in hand surgery. From the total sample of 31 patients, 4 were not located for reevaluation. The study was approved by the Ethics in Research Committee of our institution under CAAE number 57226916.6.0000.5413.
The inclusion criteria consisted of hand tumor surgeries performed at the Orthopedics Service of our institution during the predeﬁned period, presenting diagnostic conﬁrmation of GCTTS by anatomopathological gross and microscopic examinations (►Fig. 1).
A serial number was chronologically assigned to each patient based on the date of the surgical treatment by the orthopedists of the Residence Service.
Regarding gender, 7 (22.59%) patients were male, and 24 (77.41%) were female.
The age of the patients ranged from 6 to 74 years, with an average of 43.64 years. Among the female patients, the age ranged from 15 to 74 years (average: 47.64 years), while among male patients, the age ranged from 6 to 56 years (average: 27 years).
A total of 25 (80.64%) patients were Caucasian, and only 6 (19.36%) were not.
►Table 1 shows data regarding serial numbers, initials, gender, age and surgery date of the patients.
|Serial number||Initials||Gender||Age||Surgery date|
The surgical treatment consisted of complete tumor excision along with a detailed review of all subjacent areas to look for small residual nodules, the main cause of recurrence. All patients received locoregional anesthesia, which enabled the installation of a pneumatic tourniquet on the upper limb after active exsanguination with an Esmarche bandage. This technique provides an optimal site with no bleeding for the procedure and improves the surgical technique.
Information regarding recurrences was collected.
In the surgical descriptions, we highlight the access route planning, and took into consideration the anatomical region containing the tumor. The lateral route was used in the digit when the tumor affected the volar and dorsal regions (►Figs. 2-4); a zigzag approach was performed for anterior lesions (►Figs. 5-8); oblique, straight incisions were performed for small tumors (►Figs. 9 and 10); and long, archlike incisions were performed for dorsal tumors.
During the performance of the surgical technique, the tumor was dissected and removed, sparing its pseudocapsule; then, the open area and the tumoral bed were systematically searched for possible tumor fragments; if present, suspicious tissues must be removed to prevent recurrences.
During the postoperative period, a gutter cast was kept for seven days. The stitches were removed between 7 to 14 days postoperatively.
Then, home rehabilitation began with active and passive movements after the removal of the gutter cast.
The postoperative follow-up evaluations and reevaluations occurred in intervals ranging from 5 to 122 months.
The left side of the hand was affected in 17 (54.83%) cases, and the right side, in 14 (45.17%).
Regarding the ﬁngers affected by the tumor, 4 (12.9%) lesions were located in the thumb, 12 (38.7%) in the second digit, 7 (22.5%) in the third digit, 4 (12.9%) in the fourth digit, and 4 (12.9%) in the ﬁfth digit.
Considering the affected phalanx, distal phalanx lesions were found in 16 (51.6%) patients, followed by medial phalanx lesions in 9 (29.0%) patients, and proximal phalanx lesions in 6 (19.4%) patients.
Regarding the anatomical region predominantly affected by the tumor, the volar aspect was compromised in 19 (61.3%) occasions, and the dorsal aspect, in 12 (38.7%).
The arithmetic mean of the 3 dimensions of the tumor was calculated based on the macroscopic analysis, yielding a value of 1.50 x 1.06 x 0.79 cm.
►Table 2 shows data referring to the serial numbers and affected hand, digit and phalanx of the patients, in addition to the anatomical region predominantly occupied by the tumor and its dimensions.
|Serial number||Hand||Digit||Phalanx||Anatomical region||Dimensions (in centimeters)|
|1||Left||1st||Distal||Volar||1.1 × 0.7 × 0.4|
|2||Left||2nd||Distal||Volar||2.0 × 1.1 × 0.7|
|3||Left||2nd||Proximal||Volar||1.9 × 0.8 × 0.8|
|4||Right||3rd||Distal||Volar||1.9 × 1.4 × 0.9|
|5||Right||3rd||Medial||Dorsal||1.4 × 1.0 × 0.6|
|6||Right||4th||Proximal||Volar||1.2 × 0.5 × 0.5|
|7||Right||2nd||Distal||Dorsal||1.5 × 1.3 × 0.7|
|8||Right||2nd||Distal||Dorsal||0.6 × 0.4 × 0.3|
|9||Right||3rd||Distal||Dorsal||0.7 × 0.5 × 0.4|
|10||Left||2nd||Medial||Volar||0.6 × 0.4 × 0.3|
|11||Left||3rd||Medial||Dorsal||1.6 × 1.2 × 0.8|
|12||Right||4th||Proximal||Volar||2.5 × 1.4 × 1.2|
|13||Right||2nd||Distal||Dorsal||1.2 × 1.0 × 0.8|
|14||Left||1st||Proximal||Dorsal||1.5 × 1.3 × 0.7|
|15||Left||5th||Medial||Volar||2.0 × 2.0 × 2.1|
|16||Right||2nd||Distal||Volar||3.2 × 2.5 × 2.8|
|17||Left||2nd||Medial||Volar||1.1 × 0.8 × 0.7|
|18||Left||5th||Distal||Dorsal||1.7 × 1.5 × 1.0|
|19||Right||5th||Medial||Dorsal||1.4 × 1.0 × 0.7|
|20||Left||3rd||Distal||Volar||0.7 × 0.7 × 0.5|
|21||Left||5th||Proximal||Dorsal||0.9 × 0.7 × 0.4|
|22||Right||1st||Distal||Volar||1.5 × 0.8 × 0.5|
|23||Right||2nd||Medial||Dorsal||2.5 × 2.0 × 1.5|
|24||Left||4th||Distal||Volar||1.2 × 0.8 × 0.6|
|25||Left||4th||Proximal||Volar||1.8 × 1.0 × 1.0|
|26||Left||3rd||Distal||Volar||3.2 × 1.5 × 1.5|
|27||Left||1st||Medial||Volar||2.0 × 2.0 × 0.1|
|28||Right||2nd||Distal||Dorsal||1.4 × 0.9 × 0.6|
|29||Left||3rd||Distal||Volar||1.8 × 1.0 × 0.8|
|30||Right||2nd||Medial||Volar||0.3 × 0.3 × 0.3|
|31||Left||2nd||Distal||Volar||0.6 × 0.5 × 0.3|
Considering the 31 patients from the sample, there was a predominance of Caucasian females. The mean age of the patients was 43.64 years. The most affected side was the left one; most tumors were in the ﬂexor aspect and involved mainly the radial ﬁngers, along with their distal extremity.
In all patients, the diagnostic conﬁrmation was based on the anatomopathological examination performed at the Pathology Service. The microscopy of GCTTS is exempliﬁed in ►Fig. 1.
No skin necrosis or infection was observed in any of the cases.
Out of the 31 patients, 27 were reevaluated, and they have been followed up at regular intervals at the clinic. A total of four patients were lost during the reevaluation period. Until now, 3 cases of tumoral recurrence were veriﬁed, in patients identiﬁed by the serial numbers 12, 21 and 28.
When treating any soft-part tumor, it is important to evaluate benign and malign characteristics. After this evaluation, a biopsy or complete excision of the tumor must be proposed. Fortunately, malignant hand tumors are relatively rare and, in general, if not too big, it is possible to excise them at the ﬁrst surgical time.
Giant-cell tumor of the tendon sheath, which is also called giant-cell tumor of soft parts, is found mainly in the hand and, in a lower proportion, it can also involve the foot, the ankle, the knee and the hip.
This tumor type rarely causes pain, and the most frequent clinical presentation is swelling.8,17-19 Due to the slow growing nature of the tumor, the symptoms take six months to two and a half years to appear.3
The recommended treatment is complete tumoral excision sparing adjacent structures.
Retrospective studies always have some drawbacks, since the lack of well-deﬁned criteria to ﬁll out the records can hinder the collection of the required data from all patients. The present work tried to develop a protocol that could be used in all cases and could make the information more homogenous.
The present study required a reevaluation of the patients, and the higher the retroactive time, the higher the chance of losing the patient during follow-up; as such, four patients were lost. This is an acceptable ﬁgure, which represents nearly 13% of the sample. The authors believe that this number is small because the patients belong to a relatively stable community regarding migrations; in addition, medical records always have more than one contact address for the patients.
Concerning age epidemiology, the sample was consistent with the data reported by most studies, between the third and the ﬁfth decades of life, although the tumor can affect children and elderly patients; the mean age of our sample was 43.64 years, ranging from 6 to 74 years.12-14,17,18
Considering the anatomical region predominantly affected by the tumor, the ﬁndings of the present work are similar to those of the literature: it is more frequent in the volar region, which was affected in 19 (61.3%) digits in our sample compared to the dorsal region, which was affected in 12 (38.7%) digits.22 The lesion was volar in almost 70% of the cases. 19,20
The index and medium ﬁngers at the distal interphalangeal joint are the preferred sites for GCTTS. Some literature data refer to a non-signiﬁcant predominance in the radial ﬁngers.3,7,8,14,18,19 The present work yielded data consistent with the literature, since the GCTTS affected the thumb in 4 (12.9%) cases, followed by the second digit in 12 (38.7%) cases, and the third digit in 7 (22.5%) cases, totaling 23 (74.2%) cases.
Loréa et al23 reviewed circumferential tumors and discussed the technical difﬁculty and the two distinct tumor types deﬁned in the immunohistochemistry. Other authors discussed the cellularity and mitotic activity of this tumor type, which still has not been fully clariﬁed in the literature, but it is possibly related to recurrences.24
The literature data is quite diverse regarding tumor recurrence. The recurrence index ranges from 5 to 50%, showing a major discrepancy, frequently related to procedures performed by general surgeons, dermatologists and other physicians, sometimes in outpatient facilities and without a tourniquet or adequate anesthesia.20
Age, gender and tumoral size appear not to inﬂuence the recurrence rate.5 Although there is no literary consensus, some authors believe that the bone erosion, localization,
cellularity and mitotic activity of the neoplasm represent a higher risk of recurrence. Reilly et al5 observed that GCTTS recurrence is higher in the thumb interphalangeal joint and in the distal interphalangeal joints due to the inherent difﬁculty of performing complete tumor excision because of the proximity of neurovascular structures. However, recurrence is mainly related to the surgical procedures during tumor removal.3,14,19
In general, the data obtained in the study and follow-up of these 31 patients are in line with the current literature. Out of the 27 reassessed patients, there were 3 (11.1%) recurrences.