Clinical Challenge: Growth on the Left Index Finger

Second to ganglion cyst, giant cell tumor of tendon sheath is the most common tumor affecting the hand.1 These tumors slowly expand and are asymptomatic at onset. Lesions may become large enough to interfere with joint mobility and cause sensory abnormalities....

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Second to ganglion cyst, giant cell tumor of tendon sheath is the most common tumor affecting the hand.¹ These tumors slowly expand and are asymptomatic at onset. Lesions may become large enough to interfere with joint mobility and cause sensory abnormalities. The growths most commonly arise in patients aged 40 to 60 years.¹ The volar aspect of the index finger is most commonly involved, followed by the long finger.² Dorsal digits, palm, wrist, foot, knee, ankle, elbow, and hip involvement are rare but have been reported.³ Histologically, giant cells are composed of 4 main cell types: synovial cell, multinucleated giant cell, foam cell, and histiocyte-like cell.1Osteoclast-like giant cells and lymphocytes are classically seen throughout the tumor.⁴

Giant cell tumor of tendon sheath presents as a firm nodule in a digit. The tumor is a well-circumscribed, nontender, nonpulsatile mass that does not transilluminate upon examination.¹ Women are more likely than men to be affected.⁵ Patients will typically present for examination 6 months to 2.5 years after initial onset of the tumor. Diagnosis is largely made by clinical examination.¹ Radiographic evaluation will show silhouette of soft-tissue mass. Erosion of bone may occur if the mass juxtaposes on the bone. Magnetic resonance imaging is the most definitive imaging study; however, due to the cost-effectiveness of ultrasound and radiography, it is not frequently obtained.¹ Although the origin and pathogenesis of giant cell tumor of tendon sheath are unclear, reactive or regenerative hyperplasia associated with an inflammatory process is thought to be involved.⁵

Excision of the tumor using open surgery or arthroscopic synovectomy is the preferred treatment for these benign yet highly recurrent tumors. Upon surgical resection, the tumor appears multilobulated within a brown-yellow, encapsulated mass with a small tail involving the articular space. Surrounding tissues should be examined for satellite lesions. Adjuvant radiation therapy may be recommended after a second surgery to avoid further recurrence.¹

References

1. 1. Adams EL, Yoder EM, Kasdan ML. Giant cell tumor of the tendon sheath: experience with 65 cases. Eplasty. 2012;12(50):423-430.
2. 2. Briët JP, Becker SJE, Oosterhoff TCH, Ring D. Giant cell tumor of tendon sheath. Arch Bone Jt Surg. 2015;3(1):19-21.
3. 3. Ushijima M, Hashimoto H, Tsuneyoshi M, Enjoji M. Giant cell tumor of the tendon sheath (nodular tenosynovitis). A study of 207 cases to compare the large joint group with the common digit group. Cancer. 1986;57(4):875-884.
4. 4. Farah RS, Holahan HM, Swick BL. Giant cell tumor of the tendon sheath. Cutis. 2014;93(4):174, 181-182.
5. 5. 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(3):244-249.