U tế bào khổng lồ bao gân (khối u ở ngón tay hoặc ngón cái) Thông tin In-depth

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Giant cell tumors of the tendon sheaths in the hand are benign lesions [2].
• Recurrence is the primary risk for giant cell tumors of the tendon sheaths in the hand [2].
• Recurrence for giant cell tumors of the tendon sheaths typically occurs within 36 months of excision [2].
• Giant cell tumors of the synovial sheaths in the hand are benign lesions [3].
• Recurrence is the primary risk for giant cell tumors of the synovial sheaths in the hand [3].
• Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors [7].
• Diffuse tenosynovial giant cell tumor disease presents challenges due to high recurrence rates [7].
• In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function [1].

Anatomy & Pathophysiology

Epidemiology & Demographics

• Giant cell tumours of tendon sheath (GCTTS) are the second most common benign proliferative tumours in the upper extremities after ganglion cysts [65].
• GCTTS are usually slow-growing, painless, benign, and consist of soft tissue [65].
• GCTTS are most commonly found in the fingers and among women in their fourth and fifth decades [65].
• In a systematic review of 605 patients, the male-to-female ratio for GCTTS of the digits was 1:1.47 [11].
• In a study of 64 cases, the male-to-female ratio for GCTTS was 1:1.66 [25].
• In a series of 12 patients, the mean age for GCTTS was 29.5 years, ranging from 10 to 53 years [23].
• In a study of 64 cases, the age of patients ranged from 15 to 77 years with a mean age of 45 years [25].

Clinical Presentation & Location

• GCTTS are usually asymptomatic, but as the tumour grows, patients may present with swelling, pain, and limitation of movement [65].
• In a systematic review of 605 patients, pain was reported in 15.7% of cases and sensory disturbances in 4.57% [11].
• In a systematic review of 605 patients, a definite history of trauma was recorded in 5% of lesions [11].
• In a systematic review of 605 patients, the most frequent tumour location was the index finger (29.7%) [11].
• In a study of 64 cases, the most frequent location of the tumor was the long finger in 23.5% of patients [25].
• In a study of 64 cases, lesions were found over the thumb in 20.3% of patients [25].
• In a study of 64 cases, lesions were found over the index finger in 20.3% of patients [25].
• In a study of 64 cases, lesions were found over the hand in 20.3% of patients [25].
• In a series of 12 patients, the most common presentation was with a mass over the hand, with a predilection to the thumb (n=7) [23].

Morphology & Histology

• Type I GCTTS are defined as nodular or multinodular lesions surrounded by a capsule [65].
• Type II GCTTS are defined as tumours with no connective tissue membrane and satellite, diffuse, or multicentric nodules [65].
• In a systematic review of 605 patients, Type I tumours (single lesions) were detected in 78.7% of cases [11].
• In a systematic review of 605 patients, Type II tumours (two or more distinct tumours that were not joined together) were detected in 21.3% of cases [11].
• Microscopically, all GCTTS tumors contained multinucleated giant cells, histiocytes, and haemosiderin deposits [25].
• Macroscopically, the average size of GCTTS tumors was 1.35 cm, with a range of 0.3 cm to 5 cm [25].

Pathogenesis & Etiology

• GCTTS originate from the synovial membrane, tendon sheath, or synovial bursa [65].
• The pathogenesis of GCTTS remains unclear [65].
• Inflammation resulting from reactive or regenerative hyperplasia is the generally accepted theory of pathogenesis for GCTTS [65].
• Genetic factors have been observed in previous studies regarding GCTTS pathogenesis [65].

Imaging & Local Invasion

• Radiography can be helpful in evaluating cortical destruction but is not helpful in the definitive diagnosis of GCTTS [65].
• Magnetic resonance imaging (MRI) is the most useful examination for the diagnosis and treatment planning of GCTTS [65].
• In a series of 12 patients, radiological changes in the form of bony indentation were seen in only 2 cases [23].
• In a study of 64 cases, bone erosion was found in 3 patients (4.7%) [25].
• In a study of 64 cases, tendon involvement occurred in 7 cases (10.9%), with a flexor-to-extensor ratio of 4:3 [25].
• In a study of 64 cases, involvement of the neurovascular bundle was presented in 7 patients (10.9%) [25].

Classification

• Giant cell tumour of tendon sheath (GCTTS) is classified into two main types based on whether the entire tumour is surrounded by one pseudocapsule [56].
• Type I GCTTS consists of single lesions [11].
• Type II GCTTS consists of two or more distinct tumours that are not joined together [11].
• Type I tumours were detected in 78.7% of patients in a systematic review of 605 patients [11].
• Type II tumours were detected in 21.3% of patients in a systematic review of 605 patients [11].
• In a prospective study of 43 cases, none of the 30 Type I tumours recurred [56].
• In a prospective study of 43 cases, recurrence occurred in five out of 13 Type II tumours [56].
• Second recurrences were observed with Type II B and C tumours but not with Type II A tumours [56].
• Type II tumours are associated with a higher risk of recurrence compared to Type I tumours [11].
• The Al-Qattan classification is used to classify GCTTS lesions based on capsule thickness, lobulation, satellite lesions, and diffuse or multicentric nature [23].

Clinical Presentation

• Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk [2].
• Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk [3].
• Pigmented villonodular synovitis and giant-cell tumor of tendon sheath are benign synovial neoplasms with the potential for local recurrence [38].
• Patients with giant cell tumor of tendon sheath may present with a discrete mass or with joint swelling, pain, or locking or catching [26].
• The most frequent tumour location for giant cell tumour of tendon sheath of the digits is the index finger, accounting for 29.7% of cases [11].
• In a series of 91 finger tumors, 31 occurred at the distal joints, with 18 on the dorsal aspect and 13 distributed about evenly on the radial, ulnar, and volar aspects [22].
• The tumors were usually firm, lobulated, and non-tender [22].
• The masses were somewhat fixed [22].
• Pain was reported in 15.7% of cases of giant cell tumour of tendon sheath of the digits [11].
• Sensory disturbances were reported in 4.57% of cases of giant cell tumour of tendon sheath of the digits [11].
• A definite history of trauma was recorded in 5% of lesions [11].
• The male-to-female ratio for giant cell tumour of tendon sheath of the digits was 1:1.47 [11].
• The mean age for giant cell tumour of tendon sheath of the digits ranged from 32 to 51 years [11].
• Type I tumours (single lesions) were more frequently detected (78.7%) than type II tumours (two or more distinct tumours that were not joined together) (21.3%) [11].
• Type II tumours were associated with higher recurrence rates [11].
• The overall recurrence rate for giant cell tumour of tendon sheath of the digits was 14.8% [11].
• The duration of symptoms for finger tumors ranged from two weeks to fifteen years, with an average duration of thirty-eight months [22].
• In a series of 12 patients, the mean age was 29.5 years, ranging from 10 to 53 years [23].
• Radiological changes in the form of bony indentation were seen in only 2 cases out of 12 [23].
• Direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence [21].

Investigations

• MRI findings and location might help in the diagnosis of tenosynovial giant cell tumors, but careful assessment is mandatory, especially in unusual locations [84].
• Radiologists should be familiar with the imaging characteristic of giant cell tumors of the mobile spine with invasion of adjacent vertebrae [87].

Treatment

Surgical Excision

• Complete surgical resection is the treatment of choice for most patients with tenosynovial giant cell tumors [7].
• Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years [8].
• En bloc resection and matched nonvascularized toe phalangeal transfer resulted in a functional tumor-free digit with a low complication rate and no recurrences for Campanacci Grade 2 or 3 giant cell tumors of the phalanges [17].
• Repeated curettage with adjuvants eventually resulted in the cure for all patients and is a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet [68].
• Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision [63].
• Intralesional excision with cautery and methylmethacrylate provides a reliable method of treatment of giant cell tumors with good long-term functional results [37].
• Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss [6].
• Intralesional excision appears to be more appropriate for the treatment of local lesions (eg, Grades 1 and 2) than Grade 3 GCTs of the distal radius [27].
• Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control [4].
• The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome [24].
• Reconstruction after wide excision by nonvascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications [73].
• The use of a massive biocompatible bipolar unconstrained prosthesis is a viable treatment option for distal radius reconstruction after en-bloc resection of a giant cell tumour, offering rapid functional improvement without donor-site morbidity [62].
• This is a simple and effective modality of reconstruction after resection of distal radial tumors [13].
• Aggressive and malignant bone tumors of the second through fifth metacarpals generally require en bloc bone excision [18].
• It is essential that an adequate, safe margin of normal tissue first be excised en bloc with the tumor for aggressive and malignant bone tumors of the second through fifth metacarpals [18].
• Wide en bloc excision of soft tissue sarcomas with negative margins is required to achieve local control of the lesion [18].
• At a minimum, aggressive soft tissue tumors, such as bone tumors, require ray resection or removal of multiple rays [18].
• Central palmar lesions more likely require sacrifice of three rays; those on the border are more likely than those in the center to be salvageable by removing just two rays [18].
• In the presence of proximal, broader, and larger lesions, all four digits or the entire hand may have to be sacrificed to save the patient [18].
• If a malignant tumor has broken into the midpalm and extends across the metacarpals, removal of all digital rays may be needed to gain an adequate soft tissue margin [18].
• If a tumor extends proximally from the metacarpal level, a more proximal level of hand, wrist, or forearm amputation is required for safe tumor management [18].
• Malignant soft tissue tumors in the palm or carpal tunnel often require at least partial hand amputation [18].
• Below-elbow amputation is necessary to treat larger tumors [18].
• This case offers a practical strategy for the surgical management of this rare hand tumor [5].

Recurrence and Risk Factors

• Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk, typically occurring within 36 months of excision [2].
• In total, 14.8% of patients had tumour recurrence in a systematic review of giant cell tumour of tendon sheath of the digits [11].
• Type II tumours (two or more distinct tumours that were not joined together) were associated with higher recurrence rates than Type I tumours (single lesions) [11].
• Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence [12].
• Diffuse disease presents challenges due to high recurrence rates for tenosynovial giant cell tumors [7].
• Our recurrence rate was 4,7% (n=3) in a study of 64 cases of giant cell tumor of tendon sheath [25].
• In 3 patients (4,7%) bone erosion was found, and in 7 cases (10,9%) tendon involvement was found in a study of 64 cases of giant cell tumor of tendon sheath [25].
• In the three recurrence cases, surgical excision was difficult [25].
• We recommend selective use of curettage and cementing in Grade III lesions, particularly with extensive soft tissue involvement [35].

Complications

• The pooled recurrence rate for giant cell tumour of tendon sheath of the digits after surgical excision is 14.8% [11].
• Type II tumours (two or more distinct tumours that were not joined together) are associated with higher recurrence rates than Type I tumours [11].
• Direct involvement of the extensor tendons, flexor tendons, or joint capsule places patients in a high-risk category for recurrence [21].
• Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years for fibroma of tendon sheath [8].
• En bloc resection and matched nonvascularized toe phalangeal transfer for Campanacci Grade 2 or 3 giant cell tumor of the phalanges resulted in no recurrences [17].
• Patients with giant cell tumor of bone who are at higher risk of recurrence should be clinically followed more closely [15].
• Metachronous multicentric giant cell tumor can recur with a disease-free interval of up to 24 years [43].

Recovery

• Recurrence for giant cell tumors of the tendon sheaths in the hand typically occurs within 36 months of excision [2].
• Surgical treatment for pigmented villonodular synovitis led to good functional results with an average Enneking score of 92% of normal limb function [10].
• Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence in giant cell tumor of tendon sheath [12].
• Patients with pigmented villonodular synovitis of the hip managed with arthroscopic synovectomy reported good functional outcomes without evidence of recurrence in a 19 patient cohort with an average follow-up of almost 7 years [76].

Key Evidence

• [L4] In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function. [1] (10.1016/j.jhsa.2012.01.011)
• [L4] Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk, typically occurring within 36 months of excision. [2] (10.1016/j.otsr.2013.03.008)
• [L4] Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk. [3] (10.1016/j.jhsa.2013.08.051)
• [L4] Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control. [4] (10.1177/17531934211007820)
• [Paper] This case offers a practical strategy for the surgical management of this rare hand tumor. [5] (10.1177/15589447261480384)
• [L3] Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. [6] (10.1007/s11999-014-4054-3)
• [L5] Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, though diffuse disease presents challenges due to high recurrence rates. [7] (10.5435/jaaos-d-24-01255)
• [L4] Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years. [8] (10.1177/1753193412469146)
• [L4] Surgical treatment led to good functional results with an average Enneking score of 92% of normal limb function. [10] (10.1097/01.blo.0000224051.01873.fb)
• [L1] [11] (10.1007/s11552-011-9341-9)
• [L3] Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence. [12] (10.1186/s12891-019-2866-8)
• [L4] This is a simple and effective modality of reconstruction after resection of distal radial tumors. [13] (10.1016/j.jhsa.2022.05.011)
• [L4] Our observations suggest there are subsets of patients with giant cell tumor of bone who are at higher risk of recurrence and should be clinically followed more closely. [15] (10.1007/s11999-011-2172-8)
• [L4] En bloc resection and matched nonvascularized toe phalangeal transfer resulted in a functional tumor-free digit with a low complication rate and no recurrences. [17] (10.1016/j.jhsa.2024.06.013)
• [L3] Direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence. [21] (10.1016/j.jhsa.2009.12.004)
• [L4] [22] (10.2106/00004623-196951010-00005)
• [L4] [23] (10.1007/s12593-010-0020-9)
• [L3] The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome. [24] (10.1177/1558944717743598)
• [L4] [25] (10.11138/gchir/2013.34.5.149)
• [Case_report] [26] (10.1016/j.jhsa.2014.11.010)
• [L3] Based on data obtained from the number of studies available, intralesional excision appears to be more appropriate for the treatment of local lesions (eg, Grades 1 and 2) than Grade 3 GCTs of the distal radius. [27] (10.1007/s11999-012-2464-7)
• [L4] We recommend selective use of this procedure in Grade III lesions, particularly with extensive soft tissue involvement. [35] (10.4103/0019-5413.77138)
• [L4] Intralesional excision with cautery and methylmethacrylate provides a reliable method of treatment of giant cell tumors with good long-term functional results. [37] (10.1097/01.blo.0000128280.59965.e3)
• [L4] Pigmented villonoid synovitis and giant-cell tumor of tendon sheath are benign synovial neoplasms with the potential for local recurrence. [38] (10.2106/00004623-198466010-00012)
• [L4] This patient has the longest disease-free interval of a metachronous multicentric giant cell tumor reported to date, with 24 years passing between the initial presentation and the multicentric recurrence. [43] (10.1097/01.blo.0000068770.86536.e1)
• [L3] [56] (10.1054/jhsb.2000.0522)
• [Case_report] The use of a massive biocompatible bipolar unconstrained prosthesis is a viable treatment option for distal radius reconstruction after en-bloc resection of a giant cell tumour, offering rapid functional improvement without donor-site morbidity. [62] (10.1016/j.otsr.2013.04.001)
• [L3] Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision. [63] (10.1007/s004020100317)
• [L4] [65] (10.1177/17531934231222401)
• [L3] Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet. [68] (10.1302/0301-620x.95b6.30876)
• [L4] Reconstruction after wide excision by nonvascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications. [73] (10.1007/s00402-010-1059-6)
• [L4] Patients reported good functional outcomes without evidence of recurrence in a 19 patient cohort with an average follow-up of almost 7 years. [76] (10.1177/2325967119s00413)
• [L4] Although MRI findings and location might help in the diagnosis of a T-GCT, careful assessment is mandatory, especially in unusual locations. [84] (10.1186/s12891-016-1050-7)
• [L4] Radiologists should be familiar with this imaging characteristic. [87] (10.1186/s12891-021-04610-0)

References

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[35] Local recurrences after curettage and cementing in long bone giant cell tumor. Indian Journal of Orthopaedics. 2011. DOI: 10.4103/0019-5413.77138

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[43] Metachronous Multicentric Giant Cell Tumor: A Case Report and Literature Review. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000068770.86536.e1

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[62] Massive wrist prosthesis for giant cell tumour of the distal radius: A case report with a 3-year follow-up. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.04.001

[63] Oncologic and functional results after treatment of giant cell tumors of bone. Archives of Orthopaedic and Trauma Surgery. 2001. DOI: 10.1007/s004020100317

[65] The effect of surgical factors on recurrence of tendon sheath giant cell tumours. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231222401

[68] Giant cell tumours of the small bones of the hands and feet. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b6.30876

[73] Autogenous non-vascularized fibula for treatment of giant cell tumor of distal end radius. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1059-6

[76] Pigmented Villonodular Synovitis of the Hip Managed with Arthroscopic Synovectomy: An Analysis of 19 Cases with up to 10-year Follow-up. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00413

[84] Tenosynovial giant cell tumors in unusual locations detected by positron emission tomography imaging confused with malignant tumors: report of two cases. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1050-7

[87] Giant cell tumors of the mobile spine with invasion of adjacent vertebrae: an unusual imaging finding. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04610-0