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\begin{document}

\title{Giant cell tumor of tendon sheath of distal phalanx of thumb.}



\author[1]{Puja Chaurasia}%
\affil[1]{Narayani Central Hospital}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\selectlanguage{english}
\begin{abstract}
We report a rare case of giant cell tumor tendon sheath in 26 year old
man as a benign soft tissue tumor of thumb; managed by complete
excision. Histopathological examination revealed spindle shaped cells
with numerous multi-nucleated giant cells. Keywords: soft tissue tumor,
tendon sheath, distal phalanx, thumb%
\end{abstract}%



\sloppy


\textbf{Giant cell tumor of tendon sheath of distal phalanx of thumb.}

Dr. Puja Chaurasia, MS General Surgery

E-mail ID: daffodilpuja@gmail.com

Key clinical message: Giant cell tumor of the phalanges is a rare
entity; therefore delayed or missed diagnosis of giant cell tumor
especially of the thumb distal phalanx can be extremely debilitating.

Abstract

We report a rare case of giant cell tumor tendon sheath in 26 year old
man as a benign soft tissue tumor of thumb; managed by complete
excision. Histopathological examination revealed spindle shaped cells
with numerous multi-nucleated giant cells.

Keywords: soft tissue tumor, tendon sheath, distal phalanx, thumb

Introduction

Giant cell tumor of tendon sheath (GCTTS) is a rare, benign, slow
growing, locally aggressive soft tissue tumor of the hand region with an
overall incidence of 1 in 50,000 individuals {[}1{]}. Etiology of the
entity includes trauma, inflammation, metabolic disease and neoplasia
{[}2,3{]}. It occurs at any age with female predominance in third to
fifth decade of life {[}4{]}. Histopathological examination of the tumor
with clinical examination and various radiological armamentariums aid in
the diagnosis{[}5{]}. Complete surgical excision is the therapeutic goal
though the risk of recurrence is 30-45\%~{[}6{]}. Long-term follow-up is
advised in order to detect early recurrence {[}7{]}.

Case presentation

A 26 year old male presented with complaints of painless lump in the
distal phalanx of his right thumb. The lump was gradually progressive in
size since he first noticed it 3 months back. He denied any history of
trauma or prior occurrence of the lesion, fever, bruising, numbness,
tingling and purulent discharge. Clinical examination revealed a 3x2 cm
firm, mobile, solitary mass attached to a tendon on the volar bulb of
right thumb. The lump didn't extend into the subungual region and
adjacent skin was normal. There were no signs of inflammation or
discharge. The full range of motion of the distal interphalangeal joint
could be obtained. There were no signs of neurosensory indifference. We
thereafter made a differential diagnosis of either giant cell tumor or
ganglionic cyst.

Investigation

A plain radiograph was obtained which showed a soft tissue swelling with
normal bones; no fracture, dislocation, or destructive lesion (Figure 1)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1: Posteroanterior X-ray of the right hand

An ultrasound examination revealed a hypoechoic complex solid looking
cystic lesion measuring about 21 x 16 mm at the ventral aspect of the
right thumb with floating low level echoes. No intralesional vascularity
is observed. Adjacent vessels are normal (Figure 2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2: Ultrasound examination of the tumor

Intra-operatively, a volar oblique incision was made on the right thumb
under local anesthesia. The dissection was then carried into the
subcutaneous tissue. A large mass measuring 3x2x0.5 cm grey brown in
colour was completely removed (Figure 3).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 3: Tumor after complete resection

The histopathological examination demonstrated features of giant cell
tumor tendon sheath. Cut section examination revealed greyish white mass
with cystic spaces. It showed tissue exhibiting proliferation of cells.
The cells were having round to oval and spindle nuclei. The cells were
arranged in fascicles and storiform pattern focally. Numerous
multinucleated giant cells were seen dispersed in the stroma. Areas of
edema were also seen (Figure 4 and Figure 5).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
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Figure 4: Hematoxylin and eosin staining of resected specimen on 10x
magnification.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

Figure 5: Hematoxylin and eosin staining of the resected specimen
showing numerous multinucleated giant cells and mononuclear cells on 20x
magnification.

The patient was then evaluated 10 days later in the out patient
department. The patient had an uneventful post-operative course and
continues to do well at 1 month post surgery with no complaints and no
signs of recurrence (Figure 6).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure 6: Post-operative image of the thumb at 1 month of GCTTS
excision.

Discussion

This case was intended to report a rare case of giant cell tumor tendon
sheath of distal phalanx. Giant cell tumors most commonly affect the
first three fingers, with the index finger being the most frequently
involved and in this patient, thumb was the site of lesion {[}5,7,8{]}.
These tumors are most commonly found in the region of the distal
interphalangeal (DIP) joint, followed by the proximal phalanx similar to
this study {[}9,10{]}.

GCTTS manifests clinically as a firm, painless, gradually growing focal
mass likely to impair the function of the involved tendon and joint
{[}3,4{]}. A plain radiograph commonly detects any soft tissue swelling
and also determine whether a fracture, dislocation, or destructive
lesion exists {[}5{]}. In this case, there was no joint restriction,
fracture, dislocation or bony destruction which may be due to early
presentation to the hospital. Sonography can be used to distinguish
between solid and cystic lesions, its relationship with the surrounding
structures and to detect satellite lesions {[}5,11{]}. MRI is the
preferred imaging modality, particularly for evaluating extra-articular
manifestations {[}5,12{]}. In this specific case, a hypoechoic complex
solid looking cystic lesion was detected on ultrasonography, however MRI
was not performed due to unaffordability of the patient.

In this patient, GCTTS and ganglion cyst were the differential diagnoses
we came up with based on the history, clinical and radiological
examination. An ultrasound revealed that a ganglion cyst was more likely
than a giant cell tumor. Complete surgical excision is the primary
treatment for GCTTS~{[}5{]}. In this case, the mass was excised in toto.
Because of the presence of a pseudocapsule, the tumor is frequently
removed as a whole~{[}5{]}. However, after surgical excision, the
tumor's characteristics were more suggestive of a giant cell tumor,
indicating histopathological confirmation. A histopathological
examination of the excised tissue was performed, which confirmed the
diagnosis of GCTTS. Hence, histopathological examination is a must to
confirm the diagnosis {[}6,13{]}.

Recurrence is a major risk factor. Given the reported high recurrence
rate of up to 45\%, long-term follow-up after excision is
advised~{[}6,7{]}. The recurrence was significantly higher at the thumb
interphalangeal (IP) and distal digital interphalangeal (DIP)
joints~{[}1{]}. The reason may be the difficult excision of the tumor
distally~at the proximal interphalangeal (PIP) joint or the thumb IP and
DIP joint due to the proximity of neurovascular structures to tumor
margins~{[}14{]}.

The patient was then evaluated 10 days later in the out patient
department. The patient had an uneventful post-operative course and
continues to do well at 1 month post surgery with no complaints and no
signs of recurrence which was in line with a similar study by Boeisa and
Khalaf {[}7{]}.

Conclusions

This study presents a rare case of giant cell tumor tendon sheath of
distal phalanx thumb and its diagnosis and treatment in a resource
constraint country. This study also emphasizes on the significance of
histopathological examination for the confirmation of diagnosis.

Conflict of interest: None

Source of funding: No source of funding

Acknowledgement: I would like to show my gratitude to Dr Anand
Chaurasia, Department of Pathology, for providing the diagnostic
histopathological findings.

Ethical clearance: Not applicable.

Consent: Written informed consent was obtained from the patient for
publication of this case report and any accompanying images.

Data availability statement: Data available on request from the authors.

References

\begin{enumerate}
\tightlist
\item
  Al-Qattan M. Giant cell tumors of tendon sheath: classification and
  recurrence rate.~\emph{J Hand Surg.~}
  2001;26B:72--75.~{[}\emph{PubMed}{]}~{[}\emph{Google Scholar}{]}
\item
  Lowyck H, Smet L. Recurrence rate of giant cell tumors of the tendon
  sheath.~\emph{Eur J Plast Surg.~} 2006;28:385--388.
  doi:~10.1007/s00238-005-0791-6.~{[}\emph{CrossRef} {]}~{[}\emph{Google
  Scholar}{]}
\item
  Suresh SS, Zaki H:~\emph{Giant cell tumor of tendon sheath: case
  series and review of literature}. J Hand Microsurg. 2010,
  2:67-71.~\emph{10.1007/s12593-010-0020-9}
\item
  Fletcher CDM, Unni K, Mertens F:~\emph{World Health Organization
  Classification of Tumours. Pathology and Genetics of Tumours of Soft
  Tissue and Bone}. IARC Press, Lyon, France; 2002.
\item
  Adams EL, Yoder EM, Kasdan ML:~\emph{Giant cell tumor of the tendon
  sheath: experience with 65 cases}. Eplasty. 2012, 12:e50.
\item
  Collen J, Mount G, Pollock P, Shrout J, Malafronte P, Vangeertruyden
  P, Oglesby R:~\emph{Giant cell tumor of the tendon sheath}. J Clin
  Rheumatol. 2009, 15:85-7.~\emph{10.1097/RHU.0b013e31818aa87a}
\item
  Boeisa A N, Al Khalaf A A (September 22, 2022) Giant Cell Tumor of
  Tendon Sheath of the Distal Phalanx. Cureus 14(9): e29461.
  doi:10.7759/cureus.29461
\item
  Arslan G, Karaali K, \selectlanguage{ngerman}Çubuk M, Gelen T, Lüleci E:~\emph{Giant cell
  tumor of the fourth metacarpal bone}. Clin Imaging. 2000,
  24:139-42.~\emph{10.1016/S0899-7071(00)00185-6}
\item
  Darwish FM, Haddad WH:~\emph{Giant cell tumour of tendon sheath:
  experience with 52 cases}. Singapore Med J. 2008, 49:879-82.
\item
  Hwang JS, Fitzhugh VA, Gibson PD, Didesch J, Ahmed I:~\emph{Multiple
  giant cell tumors of tendon sheath found within a single digit of a
  9-year-old}. Case Rep Orthop. 2016,
  2016:1834740.~\emph{10.1155/2016/1834740}
\item
  Lautenbach M, Kim S, Millrose M, Eisenschenk A:~\emph{Nodular giant
  cell tumour of the tendon sheath of the hand: analysis of eighty-four
  cases: diagnostic decisions and outcome}. Int Orthop. 2013,
  37:2211-5.~\emph{10.1007/s00264-013-1994-2}
\item
  Peh WC, Wong Y, Shek TW, Ip WY:~\emph{Giant cell tumour of the tendon
  sheath of the hand: a pictorial essay}. Australas Radiol. 2001,
  45:274-80.~\emph{10.1046/j.1440-1673.2001.00920.x}
\item
  Monaghan H, Salter DM, Al-Nafussi A:~\emph{Giant cell tumour of tendon
  sheath (localised nodular tenosynovitis): clinicopathological features
  of 71 cases}. J Clin Pathol. 2001,
  54:404-7.~\emph{10.1136/jcp.54.5.404}
\item
  Kotwal PP, Gupta V, Malhotra R:~\emph{Giant-cell tumour of the tendon
  sheath. Is radiotherapy indicated to prevent recurrence after
  surgery?}. J Bone Joint Surg Br. 2000,
  82:571-3.~\emph{10.1302/0301-620x.82b4.10328}
\end{enumerate}

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