Eur. Radiol. 5,467-470 (1995) © Springer-Verlag 1995

European Radiology

Musculoskeletal radiology

MRI of giant cell tumor of tendon sheath of the hand: a report of three cases

S. Khan ~' 2, C .H . N e u m a n n 1' 3,4, L. S. Ste inbach ~, 3, K. D. Harr ington 5

1 San Francisco Magnetic Resonance Center, 3333 Califor~fia Street, San Francisco, CA 94118, USA 2 Department of Radiology, Kings College Hospital, SE 5 9RS, GB-London, U. K. 3 Department Radiology, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA 4 Department of Radiology, Desert Hospital, 1150 N. Indian Canyon Drive, Palm Springs, CA 92262, USA 5 Department of Orthopedic Surgery, Childrens Hospital, 3700 California Street, San Francisco, CA 94118, USA

Received 12 February 1993; Revision received 18 July 1994; Accepted 24 August 1994

Introduct ion

Giant cell tumor of tendon sheath (GCTTS), also known as fibroxanthoma, benign synovioma, benign fi- brous histiocytoma, and localized pigmented villonodu- lar synovitis (PVNS), is the second most common soft tissue tumor of the hand, following ganglion [1]. The presurgical diagnosis of GCTTS is commonly done clin- ically. Assessment of the extent of the lesion is at times difficult. Incomplete surgical excision may lead to high recurrence rates ranging from 10 to 20 % in some series and up to 50 % in others [2]. We present three cases of histologically proven GCTTS in which MRI was per- formed to assess the tumor prior to surgery and for eva- luation of suspected recurrence. The appearance on spin-echo (SE) sequences and enhancing characteris- tics after IV administration of gadopentate di- meglumine are described.

Patients and methods

Case 1

An 18-year-old male presented with a 3-month history of an enlarging, painless mass on the volar surface of the interphalangeal joint of the left thumb. A soft tissue mass was seen on plain film with associated smooth ero- sion of the distal phalanx. An MR examination was per- formed on a 1.5 T imager (GE Signa Milwaukee, Wis.) using a small-parts transmit-receive volume coil (Med- ical Advances, Milwaukee, Wis.). Tl-weighted sagittal as well as proton-density-weighted and T2-weighted axial images were obtained prior to Tl-weighted sagit- tal images with fat saturation and after IV administra- tion of 10 ccm gadopentetate dimeglumine (Berlex Lab- oratories, Wayne, N J).

The Tl-weighted sagittal images revealed a low-to- intermediate signal intensity (SI) mass in close relation to and partially surrounding the flexor pollicis longus tendon (Fig. 1), well demarcated from the adjacent soft tissue. There was also evidence of osseous erosion at the base of the distal phalanx and violation of the joint capsule (Fig. l a). The T2-weighted sagittal and axial images showed homogeneous low SI within the lesion less well demarcated against osseous cortex and ten- dons. The Tl-weighted sagittal images with fat-satura- tion and IV gadolinium-DTPA showed mild-to-moder- ate diffuse enhancement of the mass (Fig. 1 b).

At surgery a well-defined tumor was exposed and completely excised (Fig. 1 c). The lesion was well cir- cumscribed, but not encapsulated. The histologic speci- men had free margins and showed proliferation of his- tiocytes coalescing to form multinucleate giant cells characteristic of a GCTTS.

Correspondence to: C. H. Neumann

468 S. Khan et al.: MRI of giant cell tumor

Fig. 1 a-c. a Sagittal Tl-weighted im- age (TR/TE 549/17; slice thickness 3 mm; FOV 8; 256 x 128 matrix; 4 NEX) of the thumb using a 1.5 T imager (GE Signa, Milwaukee, Wis.) and a small-parts transmit-receive vo- lume surface coil (Medical Advances, Milwaukee, Wis.). It shows an inter- mediate signal intensity (SI), well-de- fined mass on the volar surface of the interphalangeal joint with violation of the joint capsule (curved long white ar- rows), and erosion of bone (black ar- row). b Sagittal Tl-weighted image with fat saturation after IV administration of 10 ccm gadopentetate dimeglumine (Berlex Laboratories, Wayne, NJ) (TR/TE 500/17; 3 mm thickness; FOV 8; 256 x 128 matrix; 4 NEX), demonstrating mild uniform enhance- ment of the lesion and its close prox- imity to the flexor pollicis longus ten- don (black arrow). Oil capsules used as tumor marker on skin surface (curved short white arrows), c Intraoperative view of the giant cell tumo~ of tendon sheath (GCTTS) at surgery

During surgery the extensive spread of this recurrent tumor along the flexor tendons and its synovial com- partment was confirmed. The tumor was surgically ex- cised. Microscopic sections revealed hemosiderin-laden foamy macrophages with rare and scattered multi- nucleated giant cells and lymphoid aggregates, focal areas of hyalinization, and synovial tufts and sheets of synovial-like cells, confirming the diagnosis of recur- rent GCTTS.

Case 2

This patient was a 28-year-old healthy, right-handed male with a previous history of a GCTTS in his left lit- tle finger, which was resected 3 years prior to admis- sion. The patient presented with a recurrent swelling of the fifth finger in the same location as the prior tumor with extension of the tumor into the palm and volar as- pect of the distal forearm.

An MRI examination performed was for assessment of tumor extent using a 0.35 T imager (Diasonics Inc., South San Francisco, Calif.). On sagittal Tl-weighted SE images an intermediate SI mass was seen volarly along the fifth digit surrounding the flexor digitorum profundus tendon (Fig. 2). There was no evidence of oss- eous involvement.

Case 3

This 22-year-old female had a history of excision of a GCTTS on the volar surface of the left little finger. She presented with a 6-month history of recurrent swelling in the region of the previous surgery. The conventional radiograph demonstrated smooth erosion of the volar aspect of the middle phalanx. An MRI examination was performed on a 1.5 T GE Signa scanner using a standard 3-inch (7.5 cm) receive surface coil. SE T1- weighted as well as proton-density- and T2-weighted images were obtained without IV contrast. The sagittal proton-density- and T2-weighted scans showed a small mass between the middle and distal phalanges and the flexor digitorum profundus tendon of the little finger (Fig. 3). The mass was well defined and of uniform inter- mediate and low SI. There was smooth erosion of the middle phalanx. Based on the MR appearance a diagno- sis of recurrent GCTTS was made preoperatively, which was confirmed at surgery.

S.Khan et al.: MRI of giant cell tumor 469

Fig.2. This sagittal Tl-weighted MR image of the little finger (TR/ TE 750/24; slice thickness 5 mm; FOV 16 cm; 256 x 256 matrix; 2 NEX) obtained on a 0.35 T MR imager (Diasonics Inc., South San Francisco, Calif.) demonstrates a lobulated intermediate SI mass surrounding the flexor digitorum tendons representing biop- sy-proven GCTTS

Discussion

Fig.3. Sagittal proton-density-weighted and T2-weighted MR images (TR/TE 1600/30/80; 3mm slice thickness; FOV10; 256 x 192 matrix; 2 NEX) of the little finger were obtained on a 1.5 T imager (GE Signa, Milwaukee, Wis.) using a standard 3-inch (7.5 cm) receive surface coil. They demonstrate a subtle intermedi- ate-to-low SI mass (white arrows) between the flexor digitorum profundus tendon (black arrows) and the distal phalanx. A recur- rence of GCTTS was confirmed by surgery

The GCTTS is a common soft tissue tumor of the hand. It may present at any time from adolescence to old age. One series had an age range of 20 to 86 years with a mean age of 48 years [2]. The female-to-male ra- tio is 3 : 2. The tumor is nearly always benign, although malignant GCTTS has been reported [6, 7]. Most pa- tients present with a painless, slowly growing palpable mass or nodule not attached to the skin. Upon physi- cal examination the tumor is firm and often fixed in position. Surgery is the treatment of choice. There is, however, a high recurrence rate of 10-20 % in most series and up to 50 % in others [2]. The GCTTS is most of the time not difficult to diagnose clinically prior to surgery. The differential diagnosis of a pain- less soft tissue mass in the hand is small. As such one needs to consider ganglion, lipoma, vascular, or neuro- genic tumors.

Radiographic findings usually reveal a soft tissue mass. If large, there may be an adjacent area of bony erosion caused by pressure from th mass [3]. Other fea- tures are rare and include periosteal reaction (8 %), soft tissue calcification (5 %), and intraosseous invasion (13 %) [4]. There is also a high incidence of degenera- tive arthritis involving the joints near the tumor [5].

In the three cases presented GCTTS had similar MRI characteristics. On Tl-weighted images these tu- mors showed almost homogeneous intermediate SI sim-

ilar to muscle with only few areas of low SI (Figs. I a, 2, and 3). The masses were clearly demarcated against ad- jacent connective tissue structures including subcuta- neous fat, cortical bone, and normal tendon. On T2- weighted images uniform decrease in SI was observed in these tumors, making them less clearly demarcated against adjacent tendon and cortical bone. The inter- mediate-to-low SI on Tl-weighted, proton-density- and T2-weighted sequences is characteristic for hemosider- in-laden histiocytes found in the tumor [10]. Susceptibil- ity effects due to hemosiderin or calcium deposits may be seen on T2-weighted or gradient-recalled images [11-13]. The GCTTS mildly enhances after IV adminis- tration of gadopentetate dimeglumine as demonstrated in case 1 (Fig. lb) . As shown in these cases MRI was helpful in defining the presence of new or recurrent GCTTS, and defining the exact anatomical location, margins and extent, including invasion of adjacent bone, joint capsule, and neurovascular bundle. The rela- tionship of the tumor to the tendon is well demonstrated [9]. The MR examinations can also exclude other le- sions, because of typical differences in signal character- istics. Lipomas have high signal on Tl-weighted images and moderate signal decrease on T2-weighted images, and usually do not show enhancement. Ganglions ex- hibit intermediate SI on Tl-weighted images and high SI on T2-weighted images, due to their mucinous con-

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tent. E n h a n c e m e n t is usually only seen in the wall of a ganglion. Vascular and neural lesions display variable or h o m o g e n e o u s l y increased SI on T2-weigh ted images and show c o m m o n l y s t rong e n h a n c e m e n t after IV con- trast application.

As shown in these examples M R I can be used to evaluate diagnostical ly difficult cases of GCTTS. It is also helpful in p reopera t ive p lanning and for the detec- t i o n of recurrences.

References

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4. Karasick D, Karasick S (1992) Giant cell tumor of tendon sheath: spectrum of radiologic findings. Skeletal Radiol 21(1): 21%224

S. Khan et al.: MRI of giant cell tumor

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