The management of diffuse-type giant cell tumour (pigmented villonodular synovitis) and giant cell tumour of tendon sheath (nodular tenosynovitis)

Radiotherapy for non-cancer diseases: benefits and long-term risks

PURPOSE

The discovery of X-rays was followed by a variety of attempts to treat infectious diseases and various other non-cancer diseases with ionizing radiation, in addition to cancer. There has been a recent resurgence of interest in the use of such radiotherapy for non-cancer diseases. Non-cancer diseases for which use of radiotherapy has currently been proposed include refractory ventricular tachycardia, neurodegenerative diseases (e.g. Alzheimer's disease and dementia), and Coronavirus Disease 2019 (COVID-19) pneumonia, all with ongoing clinical studies that deliver radiation doses of 0.5-25 Gy in a single fraction or in multiple daily fractions. In addition to such non-cancer effects, historical indications predominantly used in some countries (e.g. Germany) include osteoarthritis and degenerative diseases of the bones and joints. This narrative review gives an overview of the biological rationale and ongoing preclinical and clinical studies for radiotherapy proposed for various non-cancer diseases, discusses the plausibility of the proposed biological rationale, and considers the long-term radiation risks of cancer and non-cancer diseases.

CONCLUSIONS

A growing body of evidence has suggested that radiation represents a double-edged sword, not only for cancer, but also for non-cancer diseases. At present, clinical evidence has shown some beneficial effects of radiotherapy for ventricular tachycardia, but there is little or no such evidence of radiotherapy for other newly proposed non-cancer diseases (e.g. Alzheimer's disease, COVID-19 pneumonia). Patients with ventricular tachycardia and COVID-19 pneumonia have thus far been treated with radiotherapy when they are an urgent life threat with no efficient alternative treatment, but some survivors may encounter a paradoxical situation where patients were rescued by radiotherapy but then get harmed by radiotherapy. Further studies are needed to justify the clinical use of radiotherapy for non-cancer diseases, and optimize dose to diseased tissue while minimizing dose to healthy tissue.

Localized pigmented villo-nodular synovitis of trochanteric bursa

This is the first report on a localized pigmented villo-nodular synovitis (PVNS or TSGCT) occurring in the trochanteric bursa. Bursal involvement in PVNS is extremely rare. Most often PVNS occurs either as a localized or diffuse lesion in a major synovial joint, such as the knee, ankle joint or hip joint. In principle, all synovial structures can be involved. The case reported here is remarkable regarding the long period between the occurrence of the first symptoms and the final diagnosis as well as the age of the female patient (75 yrs). Therapeutically a complete resection was performed in order to avoid recurrence. More then three years later the patient did well and there has been no evidence of recurrence yet.

Tenosynovial Giant Cell Tumor Observational Platform Project (TOPP) Registry: A 2-Year Analysis of Patient-Reported Outcomes and Treatment Strategies

BACKGROUND

The Tenosynovial giant cell tumor Observational Platform Project (TOPP) registry is an international prospective study that -previously described the impact of diffuse-type tenosynovial giant cell tumour (D-TGCT) on patient-reported outcomes (PROs) from a baseline snapshot. This analysis describes the impact of D-TGCT at 2-year follow-up based on treatment strategies.

MATERIAL AND METHODS

TOPP was conducted at 12 sites (EU: 10; US: 2). Captured PRO measurements assessed at baseline, 1-year, and 2-year follow-ups were Brief Pain Inventory (BPI), Pain Interference, BPI Pain Severity, Worst Pain, EQ-5D-5L, Worst Stiffness, and -Patient-Reported Outcomes Measurement Information System. Treatment interventions were no current/planned treatment (Off-Treatment) and systemic treatment/surgery (On-Treatment).

RESULTS

A total of 176 patients (mean age: 43.5 years) were included in the full analysis set. For patients without active treatment strategy -(Off-Treatment) at baseline (n = 79), BPI Pain Interference (1.00 vs. 2.86) and BPI Pain Severity scores (1.50 vs. 3.00) were numerically favorable in patients remaining Off-Treatment compared with those who switched to an active treatment strategy at year 1. From 1-year to 2-year -follow-ups, patients who remained Off-Treatment had better BPI Pain Interference (0.57 vs. 2.57) and Worst Pain (2.0 vs. 4.5) scores compared with patients who switched to an alternative treatment strategy. In addition, EQ-5D VAS scores (80.0 vs. 65.0) were higher in patients who remained -Off-Treatment between 1-year and 2-year follow-ups compared with patients who changed treatment strategy. For patients receiving systemic treatment at baseline, numerically favorable scores were seen in patients remaining on systemic therapy at 1-year follow-up: BPI Pain Interference (2.79 vs. 5.93), BPI Pain Severity (3.63 vs. 6.38), Worst Pain (4.5 vs. 7.5), and Worst Stiffness (4.0 vs. 7.5). From 1-year to 2-year follow-up, EQ-5D VAS scores (77.5 vs. 65.0) were higher in patients who changed from systemic treatment to a different treatment strategy.

CONCLUSION

These findings highlight the impact D-TGCT has on patient quality of life, and how treatment strategies may be influenced by these outcome measures. (ClinicalTrials.gov number: NCT02948088).

Multi-Focal Giant Cell Tumor of A Single Tendon Sheath: A Rare Case Report

A giant cell tumor of the tendon sheath (GCTTS) is a rare benign tumor that typically presents as a solitary mass in the hand or wrist. Multifocal presentation of GCTTS is extremely rare and has been reported in only a few cases. Although the origin of multifocal giant cell tumors of the tendon sheath remains incompletely elucidated, it is a rare disorder that distinguishes itself from the diffuse form of GCTTS that typically occurs near major joints. In this case study, we report a patient with a localized multifocal GCTTS affecting the tendon sheath of the flexor pollicis longus (FPL) on the volar surface of the right thumb. The diagnosis was confirmed by both radiological and histological examinations. Additionally, the patient underwent surgical excision of the tumor masses and did not encounter any recurrence during the six-month follow-up period.

Tenosynovial giant cell tumors of digits: MRI differentiation between localized types and diffuse types with pathology correlation

OBJECTIVE

To compare the MRI findings between the localized- and diffuse-type tenosynovial giant cell tumors (TSGCTs) of digits with pathology correlation.

METHODS

Twenty-eight patients with newly diagnosed TSGCTs of digits (22 localized and 6 diffuse types) who underwent preoperative MRI and surgical excision were included from Jan. 2015 to September 2021. MRI findings regarding nodularity, margins, morphology of hypointensity with pathology correlation, and disease extent (bone erosion, articular involvement, muscle involvement, tendon destruction, and neurovascular encasement) were assessed.

RESULTS

Diffuse type was significantly larger (P = 0.006), more multinodular on both MRI and pathology (P = 0.038, both) with significant agreement, and infiltrative on both MRI and pathology (P < 0.001, both) with substantial agreement, and showed central granular on MRI and strong hemosiderin deposition on pathology (P = 0.022 and P = 0.021) with moderate agreement than localized type. Localized type showed significantly more frequent peripheral capsules on both MRI and pathology (P < 0.001, both) with moderate agreement than diffuse type. However, the septum on both MRI and pathology showed no statistically significant difference between the two groups (P = 0.529 and P = 0.372) without significant agreement. The disease extent was more severe in the diffuse type than the localized type regarding articular involvement (P < 0.001), muscle involvement (P < 0.001), and tendon destruction (P = 0.010). No statistically significant differences were found between the two groups regarding bone erosion (P = 0.196) or neurovascular bundle encasement (P = 0.165).

CONCLUSIONS

Diffuse-type TSGCTs of digits presented as locally aggressive lesions with larger, multinodular, infiltrative masses exhibiting stronger hemosiderin deposition and more severe disease extents of articular, muscle, and tendon involvement than the localized type.

A prospective real-world study of the diffuse-type tenosynovial giant cell tumor patient journey: A 2-year observational analysis

BACKGROUND AND OBJECTIVES

Diffuse-tenosynovial giant cell tumor (D-TGCT) is a rare, locally aggressive, typically benign neoplasm affecting mainly large joints, representing a wide clinical spectrum. We provide a picture of the treatment journey of D-TGCT patients as a 2-year observational follow-up.

METHODS

The TGCT Observational Platform Project registry was a multinational, multicenter, prospective observational study at tertiary sarcoma centers spanning seven European countries and two US sites. Histologically confirmed D-TGCT patients were categorized as either those who remained on initial treatment strategy (determined at baseline visit) or those who changed treatment strategy with specific changes documented (e.g., systemic treatment to surgery) at the 1-year and/or 2-year follow-up visits.

RESULTS

A total of 176 patients were assessed, mean diagnosis age was 38.4 (SD ± 14.6) years; most patients had a knee tumor (120/176, 68.2%). For the 2-year observation period, most patients (75.5%) remained on the baseline treatment strategy throughout, 54/79 patients (68.4%) remained no treatment, 30/45 patients (66.7%) remained systemic treatment, 39/39 patients (100%) remained surgery. Those who changed treatment strategy utilized multimodal treatment options.

CONCLUSIONS

This is the first prospectively collected analysis to describe D-TGCT patient treatments over an extended follow-up and demonstrates the need for multidisciplinary teams to determine an optimal treatment strategy.

Localized tenosynovial giant cell tumor: a rare case of snapping hip

We report on a 40-year-old male with a 9-month-long history of snapping of his right hip caused by a previously undescribed etiology of internal extra-articular snapping hip, namely due to a localized tenosynovial giant cell tumor. Both dynamic ultrasound evaluation and MRI proved to be crucial in the diagnosis of this rare entity. Auto-provocation of the snapping showed an anterior hip mass moving posteriorly to the psoas tendon which elucidated the pain and clicking sensation. Subsequent MRI demonstrated a peripheral low-intensity rim due to hemosiderin deposition around the synovial mass which is indicative for pigmented villonodular tenosynovitis. Treatment consisted of arthroscopic shaver burr resection. Immediately postoperatively, the snapping sensation could not be provoked anymore by the patient. The purpose of reporting on this case report is to emphasize several successive learning points. First, dynamic ultrasound aids in diagnosis and differentiation of the types of snapping hip. Second, specific MRI features are suggestive of tenosynovial giant cell tumor, recognizing these traits may prevent delayed diagnosis and subsequent aggravated clinical course. Third, localized pigmented villonodular tenosynovitis around the hip may present as an internal extra-articular snapping hip and is of consideration in the differential diagnosis of recurrent snapping hip.

Surgical management of 144 diffuse-type TGCT patients in a single institution: A 20-year cohort study

BACKGROUND AND OBJECTIVES

Surgery is the mainstay of treatment for tenosynovial giant cell tumors (TGCTs). However, achieving a cure through surgery alone remains challenging, especially for the diffuse-type (D-TGCT).

METHODS

Our goal was to describe the surgical management of patients with D-TGCT related to large joints, treated between 2000 and 2020. We analyzed the effect of (in)complete resections and the presence of postoperative tumor (POT) on magnetic resonance imaging (MRI) on radiological and clinical outcomes.

RESULTS

A total of 144 patients underwent open surgery for D-TGCT, of which 58 (40%) had treatment before. The median follow-up was 65 months. One hundred twenty-five patients underwent isolated open surgeries, in which 25 (20%) patients' D-TGCT was intentionally removed incompletely. POT presence on the first postoperative MRI was observed in 64%. Both incomplete resections and POT presence were associated with higher rates of radiological progression (73% vs. 44%; Kaplan-Meier [KM] analysis p = 0.021) and 59% versus 7%; KM analysis p < 0.001), respectively. Furthermore, patients with POT presence clinically worsened more often than patients without having POT (49% vs. 24%; KM analysis p = 0.003).

CONCLUSIONS

D-TGCT is often resected incompletely and tumor presence is commonly observed on the first postoperative MRI, resulting in worse radiological and clinical outcomes. Therefore, surgeons should try to remove D-TGCT in toto and consider other multimodal therapeutic strategies.

Combined Arthroscopic and Endoscopic Synovectomy for Diffuse Pigmented Villonodular Synovitis (PVNS) of the Ankle

The current treatment of choice for diffuse-type pigmented villonodular synovitis (PVNS) is surgical excision. Complete synovectomy is necessary because of the local aggressiveness of the disease, with a significant recurrence rate and a minor chance of malignant transformation. The recurrence rate is even greater in those cases with extra-articular extension. Arthroscopic and endoscopic synovectomy have the advantage of avoidance of extensive soft-tissue dissection, which is associated with open synovectomy. The purpose of this Technical Note is to describe the details of combined arthroscopic and endoscopic synovectomy as treatment for diffuse PVNS of the ankle. By a combination of different arthroscopic and endoscopic approaches of the ankle region, a complete synovectomy of both intra-articular and extra-articular components of diffuse-type PVNS is feasible.

Randomized placebo-controlled double-blind phase II study of zaltoprofen for patients with diffuse-type and unresectable localized tenosynovial giant cell tumors: The REALIZE study

Background

A tenosynovial giant cell tumor (TGCT) is a locally aggressive benign neoplasm arising from intra- or extra-articular tissue, categorized as localized (L-TGCT, solitary lesion) and diffuse (D-TGCT, multiple lesions) TGCT. Surgical excision is the mainstay of the treatment, and a high local recurrence rate of approximately 50% has been reported. We focused on zaltoprofen, a nonsteroidal anti-inflammatory drug that can activate peroxisome proliferator-activated receptor gamma (PPARγ) and inhibit the proliferation of TGCT stromal cells. Therefore, we conducted a randomized trial to evaluate the safety and effectiveness of zaltoprofen in patients with D-TGCTs or unresectable L-TGCTs.

Methods

This randomized, placebo-controlled, double-blind, multicenter trial evaluated the safety and efficacy of zaltoprofen. In the treatment group, zaltoprofen (480 mg/day) was administered for 48 weeks; the placebo group received similar dosages without zaltoprofen. The primary outcome was progression-free rate (PFR) 48 weeks after treatment administration. Disease progression was defined as the following conditions requiring surgical intervention: 1) repetitive joint swelling due to hemorrhage, 2) joint range of motion limitation, 3) invasion of the adjacent cartilage or bone, 4) severe joint space narrowing, and 5) increased tumor size (target lesion).

Results

Forty-one patients were allocated to the zaltoprofen (n=21) or placebo (n=20) groups. The PFR was not significant between the zaltoprofen group and the placebo group at 48 weeks (84.0% and 90.0%, respectively; p=0.619). The mean Japanese Orthopedic Association knee score significantly improved from baseline to week 48 in the zaltoprofen group (85.38 versus 93.75, p=0.027). There was a significant difference between the values at 48 weeks of placebo and zaltoprofen group (p=0.014). One severe adverse event (grade 3 hypertension) was observed in the zaltoprofen group.

Discussion

This is the first study to evaluate the efficacy and safety of zaltoprofen in patients with TGCT. No significant differences in PFR were observed between the groups at 48 weeks. Physical function significantly improved after zaltoprofen treatment. The safety profile of zaltoprofen was acceptable. This less invasive and safer treatment with zaltoprofen, compared to surgical removal, could be justified as a novel approach to treating TGCT. Further analysis of long-term administration of zaltoprofen should be considered in future studies.

Clinical Trial Registration

University Hospital Medical Information Network Clinical Trials Registry, identifier (UMIN000025901).

Benign Hand Tumors (Part II): Soft Tissue Tumors

Background: Benign soft-tissue tumors of the hand are more common than both their benign bone and malignant soft-tissue counterparts. This study evaluates the characteristics and treatment of benign soft tissue tumors in light of 1 institution's experience. Methods: Histologically confirmed benign soft-tissue tumors of the hand were retrospectively identified using International Classification of Disease codes from 1992 to 2015. A medical chart review was conducted to collect patient demographics, tumor epidemiology, and treatment. Results: A total of 199 soft-tissue tumors were identified. The median patient age at time of treatment was 47.4 ± 14.7 years in age. The majority of tumors were located in the digits (n = 168, 84%) and treated by excision (n = 191, 96%). Localized type tenosynovial giant cell tumors (n = 71, 36%) were the most common and had the highest rates of recurrence (8.5%) in this series. Other frequent histologies included hemangioma, schwannoma, and glomus tumors. Conclusion: Awareness and understanding of tumor characteristics may help physicians with diagnosis and treatment. There is an extensive variety of tumors, but the principles of clinical and imaging diagnosis are common to all of them. Marginal excision for the treatment pain, improvement of function, and cosmetic correction applies to all these tumors independent of the histology.

Tenosynovial giant cell tumors (TGCT): molecular biology, drug targets and non-surgical pharmacological approaches

INTRODUCTION

Tenosynovial giant cell tumor (TGCT) is a mono-articular, benign or locally aggressive and often debilitating neoplasm. Systemic therapies are becoming part of the multimodal armamentarium when surgery alone will not confer improvements. Since TGCT is characterized by colony-stimulating factor-1 (CSF1) rearrangements, the most studied molecular pathway is the CSF1 and CSF1 receptor (CSF1R) axis. Inhibiting CSF1-CSF1R interaction often yields considerable radiological and clinical responses; however, adverse events may cause treatment discontinuation because of an unfavorable risk-benefit ratio in benign disease. Only Pexidartinib is approved by the US FDA; however, the European Medicines Agency has not approved it due to uncertainties on the risk-benefit ratio. Thus, there is a need for safer and effective therapies.

AREAS COVERED

Light is shed on disease mechanisms and potential drug targets. The safety and efficacy of different systemic therapies are evaluated.

EXPERT OPINION

The CSF1-CSF1R axis is the principal drug target; however, the effect of CSF1R inhibition on angiogenesis and the role of macrophages, which are essential in the postoperative course, needs further elucidation. Systemic therapies have a promising role in treating mainly diffuse-type, TGCT patients who are not expected to clinically improve from surgery. Future drug development should focus on targeting neoplastic TGCT cells.

Anterior Capsule Reconstruction in the Setting of PVNS

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a benign proliferative disease affecting tendon sheaths and synovial tissue. Pigmented villonodular synovitis in the foot and ankle has a high rate of recurrence, which can be destructive if incompletely removed. This case series analyzes functional outcomes after PVNS operative resection with an anterior ankle capsular reconstruction, using a novel technique.

METHODS

Three patients with PVNS underwent surgery between 2010 and 2020. The operative technique involved a posterior, midline approach for PVNS resection of the affected ankle joint, followed by a standard anterior approach for capsular excision. Subsequent anterior capsular reconstruction was performed with a regenerative tissue matrix and a bioresorbable anchoring system. Preoperative and postoperative range of motion for the ankle and subtalar joints, visual analog scale (VAS) for pain, and return to daily activities was assessed along with appropriate radiographs and magnetic resonance imaging (MRI) imaging.

RESULTS

All 3 surgeries had a mean follow-up period of 52.3 (range, 4-123) months and resulted in successful recovery as assessed by the VAS and self-reported activity. Preoperative ankle dorsiflexion and plantarflexion along with subtalar inversion and eversion range of motion were all normal. Postoperative ankle motion and subtalar motion were not statistically different. No complications or recurrence of PVNS was observed.

CONCLUSION

Further investigation is warranted to better understand the clinical outcomes of this technique designed to successfully eliminate PVNS recurrence.

LEVEL OF EVIDENCE

IV- Retrospective case series.

Pigmented Villonodular Synovitis of the Flexor Hallucis Longus Tendon Treated by Means of Tendoscopy and Endoscopic Synovectomy

Pigmented villonodular synovitis (PVNS) of the tendon sheath (tenosynovial giant cell tumor) is a rare disorder that is often misdiagnosed because of slow growth and an atypical presentation. Open surgical excision is the treatment of choice, although recurrence is a common complication. In this report, a case of PVNS of the flexor hallucis longus tendon in the ankle and hindfoot is described. The diagnosis was confirmed by endoscopic inspection and biopsy, and complete synovectomy was performed through the endoscope. The patient remained disease free after 24 months of follow up.

Postoperative radiotherapy for pigmented villonodular synovitis (PVNS): case series and literature review

Purpose:

Pigmented villonodular synovitis (PVNS) is a rare benign proliferative disease of the synovium with locally aggressive behaviour. We reviewed our experience using external beam radiotherapy (RT) in the treatment of PVNS.

Method:

We report five cases of PVNS who underwent Arthroscopic Synovectomy followed by postoperative RT in National Oncology centre in Oman. The total dose RT ranges between 30 and 36 Gray (Gy) Three-dimensional radiotherapy technique.

Conclusion:

Postoperative RT is effective in preventing disease recurrence and should be offered following maximal cytoreduction to enhance local control in PVNS.

The diffuse-type tenosynovial giant cell tumor (dt-TGCT) patient journey: a prospective multicenter study

Background

Tenosynovial giant cell tumor (TGCT) is a rare, locally aggressive neoplasm arising from the synovium of joints, bursae, and tendon sheaths affecting small and large joints. It represents a wide spectrum ranging from minimally symptomatic to massively debilitating. Most findings to date are mainly from small, retrospective case series, and thus the morbidity and actual impact of this rare disease remain to be elucidated. This study prospectively explores the management of TGCT in tertiary sarcoma centers.

Methods

The TGCT Observational Platform Project registry was a multinational, multicenter, prospective observational study involving 12 tertiary sarcoma centers in 7 European countries, and 2 US sites. This study enrolled for 2 years all consecutive ≥ 18 years old patients, with histologically diagnosed primary or recurrent cases of diffuse-type TGCT. Patient demographic and clinical characteristics were collected at baseline and every 6 months for 24 months. Quality of life questionnaires (PROMIS-PF and EQ-5D) were also administered at the same time-points. Here we report baseline patient characteristics.

Results

166 patients were enrolled between November 2016 and March 2019. Baseline characteristics were: mean age 44 years (mean age at disease onset: 39 years), 139/166 (83.7%) had prior treatment, 71/166 patients (42.8%) had ≥ 1 recurrence after treatment of their primary tumor, 76/136 (55.9%) visited a medical specialist ≥ 5 times, 66/116 (56.9%) missed work in the 24 months prior to baseline, and 17/166 (11.6%) changed employment status or retired prematurely due to disease burden. Prior treatment consisted of surgery (i.e., arthroscopic, open synovectomy) (128/166; 77.1%) and systemic treatments (52/166; 31.3%) with imatinib (19/52; 36.5%) or pexidartinib (27/52; 51.9%). Treatment strategies at baseline visits consisted mainly of watchful waiting (81/166; 48.8%), surgery (41/166; 24.7%), or targeted systemic therapy (37/166; 22.3%). Patients indicated for treatment reported more impairment compared to patients indicated for watchful waiting: worst stiffness NRS 5.16/3.44, worst pain NRS 6.13/5.03, PROMIS-PF 39.48/43.85, and EQ-5D VAS 66.54/71.85.

Conclusion

This study confirms that diffuse-type TGCT can highly impact quality of life. A prospective observational registry in rare disease is feasible and can be a tool to collect curated-population reflective data in orphan diseases.

Name of registry: Tenosynovial Giant Cell Tumors (TGCT) Observational Platform Project (TOPP).

Trial registration number: NCT02948088.

Date of registration: 10 October 2016.

URL of Trial registry record: https://clinicaltrials.gov/ct2/show/NCT02948088?term=NCT02948088&draw=2.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01820-6.

Patient-Derived Tumor Xenografts Plus Ex Vivo Models Enable Drug Validation for Tenosynovial Giant Cell Tumors

INTRODUCTION

Tenosynovial giant cell tumor (TGCT) is a locally aggressive tumor with colony-stimulating factor 1 receptor (CSF1R) signal expression. However, there is a lack of better in vivo and ex vivo models for TGCT. This study aims to establish a favorable preclinical translational platform, which would enable the validation of efficient and personalized therapeutic candidates for TGCT.

PATIENTS AND METHODS

Histological analyses were performed for the included patients. Fresh TGCT tumors were collected and sliced into 1.0-3.0 mm³ sections using a sterilized razor blade. The tumor grafts were surgically implanted into subrenal capsules of athymic mice to establish patient-derived tumor xenograft (PDTX) mouse models. Histological and response patterns to CSF1R inhibitors evaluations were analyzed. In addition, ex vivo cultures of patient-derived explants (PDEs) with endpoint analysis were used to validate TGCT graft response patterns to CSF1R inhibitors.

RESULTS

The TGCT tumor grafts that were implanted into athymic mice subrenal capsules maintained their original morphological and histological features. The "take" rate of this model was 95% (19/20). Administration of CSF1R inhibitors (PLX3397, and a novel candidate, WXFL11420306) to TGCT-PDTX mice was shown to reduce tumor size while inducing intratumoral apoptosis. In addition, the CSF1R inhibitors suppressed circulating nonspecific monocyte levels and CD163-positive cells within tumors. These response patterns of engrafts to PDTX were validated by ex vivo PDE cultures.

CONCLUSIONS

Subrenal capsule supports the growth of TGCT tumor grafts, maintaining their original morphology and histology. This TGCT-PDTX model plus ex vivo explant cultures is a potential preclinical translational platform for locally aggressive tumors, such as TGCT.

Pediatric Tenosynovial Giant Cell Tumor of the Flexor Hallucis Longus Tendon Sheath: A Case Report

CASE

An otherwise healthy 13-year-old girl presented with a firm nodule on the plantar right forefoot that was tender after cheerleading. Initial workup was unremarkable, but magnetic resonance imaging revealed a multilobulated mass surrounding the flexor hallucis longus tendon. Surgical resection revealed a tenosynovial mass without tendon infiltration. Pathologic examination was consistent with tenosynovial giant cell tumor. The patient resumed cheerleading and remained asymptomatic after 1 year.

CONCLUSION

As far as we know, this is the first report of a tenosynovial giant cell tumor of the flexor hallucis longus in a pediatric patient; it illustrates the importance of considering this lesion when diagnosing a pediatric plantar mass.

Chondroid Tenosynovial Giant Cell Tumor: A Rare Case Involving the Infratemporal Fossa

Tenosynovial giant cell tumor (TGCT) is a benign soft-tissue neoplasm that rarely occurs in the craniofacial region. We report a case of a 27-year-old male who presented to our unit in September 2017 with severe temporomandibular joint (TMJ) pain and progressive limitation opening his mouth. Based on clinical and imaging examinations, a well-defined soft tissue lesion was identified within the right infratemporal fossa, causing pressure on the TMJ and the surrounding structures. The lesion was surgically excised through trans-mandibular and endoscopic approaches. Histopathology diagnosis revealed a rare chondroid subset of TGCT. At 18 months follow-up, the patient showed resolution of the jaw pain, good functional and esthetic outcomes, and no evidence of recurrence.

Tenosynovial Giant Cell Tumor in an Infant

In this report, the authors describe a child presenting at 6 months old with a rapidly expanding extracranial left temporal mass concerning for malignancy. The mass was successfully treated at 16 months with radical surgical excision. The patient was found to have a tenosynovial giant cell tumor, diffuse type, completely encased by the temporalis muscle. To our knowledge, this is the first report of a case of diffuse type tenosynovial giant cell tumor in the temporalis muscle, without articular involvement, presenting in an infant.

Management of Tenosynovial Giant Cell Tumor: A Neoplastic and Inflammatory Disease

Background:

Patients with diffuse tenosynovial giant cell tumor (TGCT) face a high risk of recurrence, progression, and disability. This systematic review assesses the recent evidence of surgical, adjuvant, and systemic treatments for TGCT.

Methods:

We searched PubMed and Ovid with the terms “Giant cell tumor of tendon sheath” OR “pigmented villonodular synovitis” OR “tenosynovial giant cell” AND “treatment” OR “surgery.” Inclusion criteria: published 2013 to present; prospective or retrospective design; English language; > 20 patients with histopathological confirmed diagnosis of TGCT; and ≥ 1 efficacy and/or safety outcome from surgery, systemic drug therapy, or adjuvant ⁹⁰yttrium radiosynoviorthesis.

Results:

Of the 434 studies identified, 25 met the inclusion criteria. Of 11 studies in patients with disease in the knee, nine examined surgical treatment approaches, and two evaluated adjuvant ⁹⁰yttrium radiosynoviorthesis. Of 11 studies in patients with mixed sites of disease, six assessed surgical treatment approaches, and five evaluated systemic drug therapies. Three studies assessed surgery in patients with TGCT in the hand, hip, and ankle or foot.

Discussion:

The high rates of recurrence and risks associated with surgery emphasize the need for novel treatments in patients with symptomatic, advanced TGCT. Systemic therapy may be valuable as part of a multidisciplinary approach.

Recurrence-free management of type 2 variant of giant cell tumour of extensor tendon sheath of thumb

A 30-year-old woman presented with swelling in her right thumb of 3-month duration which was slow-growing in nature without a history of trauma. On examination, firm non-tender swelling with ill-defined border over the dorsomedial aspect of the first metacarpal was noted. The swelling was mobile only in the vertical plane with restricted adduction and abduction. Plain X-ray revealed mild erosion of the first metacarpal head. Diagnostic ultrasound confirmed the lesion to arise from the extensor tendon sheath of diffuse type without any bony involvement. A wide local excision biopsy of the swelling was planned. Intraoperatively, a 3×2 cm greyish-white mass, bony hard in consistency with lobulated surface was found arising from the tendon sheath of the extensor tendon of the thumb; it was completely excised with a wide margin. Histopathological examination revealed polyhedral cells admixed with osteoclastic type giant cells. Biopsy from the first metatarsal was normal. The patient is on follow-up for the last 5 years with no evidence of recurrence.

A rare localized giant cell tumor of the tendon sheath originating from the ligamentum mucosum: A case report

Giant cell tumor of the tendon sheath (GCTTS) occurs most often in the hand and rarely in the feet, and as an extremely uncommon presentation in the knee joint. Case reports involving GCTTS in the knee joint generally describe it originating from the nearby anterior cruciate ligament, posterior cruciate ligament, patellar tendon, and medial plica. To the best of our knowledge, there are no previously reported case reports involving GCTTS originating in the ligamentum mucosum. In this article, we describe a 27-year-old male patient who was admitted to the orthopedic emergency room with a painful locked knee. He had severe pain that was worse with activity and a decreased range of motion. Magnetic resonance imaging (MRI) indicated massive swelling and a well- circumscribed lobulated intraarticular mass at the distal one third of the ligamentum mucosum. The mass was removed successfully with arthroscopic-assisted mini-open excision, and histological analysis subsequently diagnosed it as a localized type of GCSTT. The patient remained asymptomatic and a follow-up MRI two years after surgery did not show any recurrence of the lesion.

Diffuse-type tenosynovial giant cell tumor of the temporomandibular joint with skull base invasion: a report of 22 cases with literature review

OBJECTIVES

The aim of this study was to retrospectively analyze the clinical characteristics, surgical treatment, and prognosis of patients with diffuse-type tenosynovial giant cell tumor (D-TGCT) involving the temporomandibular joint (TMJ) and the skull base.

STUDY DESIGN

A retrospective study was performed in patients with D-TGCT involving the TMJ and the skull base at our institute from April 2009 to August 2018. Data on clinical characteristics, surgical treatment, and prognosis were collected and analyzed. A literature search on D-TGCT involving the TMJ was conducted and the data analyzed.

RESULTS

The study included 22 patients (14 males and 8 females), with an average age of 44 years. The main symptoms were headache and hearing limitation, accompanied by a swelling in the TMJ area. Magnetic resonance imaging (MRI) showed low signals on T1- and T2-weighted images. All lesions were completely removed. Temporal bone flap, titanium mesh, and temporal muscle flap were used for reconstruction. The recurrence rate was 4.5%. In the literature, 115 cases were reported. Surgery alone was performed in 88 cases; postoperative radiotherapy was performed in 19 cases; the tumor recurrence rates were 9.1% and 15.8% for the 2 procedures, respectively. All patients were alive at the end of the follow-up period.

CONCLUSIONS

D-TGCT involving the TMJ and the skull base is a locally aggressive but benign lesion necessitating complete resection and has a good prognosis.

Radiosynoviorthesis after Surgery in the Treatment of Patients with Ankle Pigmented Villonodular Synovitis: A Case Series

Pigmented villonodular synovitis (PVNS) of the ankle is a very rare, locally aggressive, proliferative disorder. Although surgical excision represents the standard curative treatment, the PVNS relapse rate is high. We present our study of five young athletes (range 20–36 years) with a histopathological diagnosis of PVNS of the ankle, who were treated by surgery and adjuvant radiosynoviorthesis (RSO). The operation involved either arthroscopic (four patients) or open (one patient) debridement, followed by intraarticular RSO with the radiopharmaceutical erbium-169 (¹⁶⁹Er). They were evaluated with the Foot Function Index (FFI) and a visual analog scale (VAS) for pain. At a median follow up period of 47 months (range 36–54 months), all five patients reported marked pain relief with improvements in their daily activities. In particular, the median FFI decreased from 77% (range 71.0%–84.5%) pre-treatment, to 0.5% (range 0%–6%) after treatment. The median VAS score decreased from 4 (range 3–7) to 0 (range 0–1), respectively. Throughout the follow-up period, there were no major complications regarding either therapeutic intervention (arthroscopic or open debridement, RSO). Based on these results, it can be concluded that adjuvant RSO with ¹⁶⁹Er following surgical excision is effective and safe in the treatment of PVNS of the ankle.

Results of muscle strength and range of motion after total open knee synovectomy

AIM OF THE STUDY

Scar tissue formation after synovectomy limits range of motion and causes muscle atrophy. The functional results for patients who underwent total open knee synovectomy often included questionnaires, and assessment of muscle strength was lacking in the literature. Therefore, we aimed to identify the strength and range of motion outcomes for patients who underwent total open synovectomy and to compare the results with the contralateral limb and healthy individuals.

METHOD

Knee range of motion and muscle strength were assessed in fourteen patients that underwent total (anterior and posterior) open knee synovectomy and were compared with the contralateral limb and with 14 healthy individuals matched by sex, age, height, and weight.

RESULTS

The range of motion of flexion decreased 8.4% compared with the contralateral limb (95% CI - 18.9 to - 4.7, p = 0.002) and 9.9% compared with the control group (95% CI 3.9-14.9, p < 0.01). Knee extension strength decreased by 35% compared with the contralateral limb (95% CI 11.1-77.2, p = 0.01) and 37% compared with the control group (95% CI - 112.4-12.1, p = 0.01).

CONCLUSION

Despite the aggressiveness of the surgical procedure, the patients achieved satisfactory functional results.

Uncommon tumors of temporomandibular joint: An institutional experience and review

BACKGROUND

The temporomandibular joint (TMJ) harbors a myriad of pathologic alterations including arthritides and benign and malignant neoplasms.

METHODS

Herein, we describe our institutional experience of some uncommon and unusual synovial pathologies of the TMJ along with a review of literature. We searched through the archives of department of pathology and institutional electronic medical record for specimens of TMJ between 1999 and 2019. Hematoxylin and eosin slides were reviewed and data (final diagnosis, age, gender, clinical presentation, tumor size, treatment modality, recurrence, and vital status) were collected.

RESULTS

A total of seven cases were identified including four cases of synovial chrondromatosis; and one case each of tenosynovial giant cell tumor, localized type, tenosynovial giant cell tumor, diffuse type, and synovial sarcoma.

CONCLUSIONS

The article emphasizes on the clinical, radiologic, pathologic, and molecular features of these uncommon entities. The differential diagnosis of each entity is also discussed. Current updates in the management are also reviewed.

Soft tissue tumours of the elbow: current concepts

Soft tissue tumours of the elbow are mostly benign. Malignant tumours in this area, although uncommon, often present unique clinical and histopathological characteristics that are helpful for diagnosis.Management of soft tissue tumours around the elbow may be challenging because of their rarity and the proximity to neurovascular structures. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. A missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences for the patient.This article reviews the most common benign and malignant soft tissue tumours of the elbow and discusses the clinicopathological findings, imaging features and current therapeutic concepts. Cite this article: EFORT Open Rev 2019;4:668-677. DOI: 10.1302/2058-5241.4.190002.

Intra-articular nodular fasciitis: a rare lesion case report and an updated review of the literature

BACKGROUND

Nodular fasciitis is a benign proliferation of myofibroblasts that usually arises in subcutaneous tissues of the trunk, neck, head, and upper extremities of young adults. It is not reported to arise in the joints.

CASE PRESENTATION

In this report, we describe a rare case where nodular fasciitis occurred in an intra-articular location in the right knee of a 20-year-old man. The patient presented with 3-months' duration of knee pain without history of trauma to the extremity. Physical examination revealed pain, joint effusion, and limited range of motion (ROM) of the affected knee. Magnetic resonance imaging (MRI) showed a 2.5 × 2 × 1 cm lesion in front of the posterior cruciate ligament. Arthroscopically, the soft tissue mass was removed and pathologically diagnosed as a rare, benign, intra-articular nodular fasciitis. Symptoms resolved 1 month after the operation and no recurrence was found at the 6 months follow-up.

CONCLUSION

The present paper describes detailed characteristics of intra-articular nodular fasciitis and provides an updated comprehensive summary of 21 prior case reports.

Bone Remodeling and the Role of TRAF3 in Osteoclastic Bone Resorption

Skeletal health is maintained by bone remodeling, a process in which microscopic sites of effete or damaged bone are degraded on bone surfaces by osteoclasts and subsequently replaced by new bone, which is laid down by osteoblasts. This normal process can be disturbed in a variety of pathologic processes, including localized or generalized inflammation, metabolic and endocrine disorders, primary and metastatic cancers, and during aging as a result of low-grade chronic inflammation. Osteoclast formation and activity are promoted by factors, including cytokines, hormones, growth factors, and free radicals, and require expression of macrophage-colony stimulating factor (M-CSF) and receptor activator of NF-κB ligand (RANKL) by accessory cells in the bone marrow, including osteoblastic and immune cells. Expression of TNF receptor-associated factor 6 (TRAF6) is required in osteoclast precursors to mediate RANKL-induced activation of NF-κB, which is also necessary for osteoclast formation and activity. TRAF3, in contrast is not required for osteoclast formation, but it limits RANKL-induced osteoclast formation by promoting proteasomal degradation of NF-κB-inducing kinase in a complex with TRAF2 and cellular inhibitor of apoptosis proteins (cIAP). TRAF3 also limits osteoclast formation induced by TNF, which mediates inflammation and joint destruction in inflammatory diseases, including rheumatoid arthritis. Chloroquine and hydroxychloroquine, anti-inflammatory drugs used to treat rheumatoid arthritis, prevent TRAF3 degradation in osteoclast precursors and inhibit osteoclast formation in vitro. Chloroquine also inhibits bone destruction induced by ovariectomy and parathyroid hormone in mice in vivo. Mice genetically engineered to have TRAF3 deleted in osteoclast precursors and macrophages develop early onset osteoporosis, inflammation in multiple tissues, infections, and tumors, indicating that TRAF3 suppresses inflammation and tumors in myeloid cells. Mice with TRAF3 conditionally deleted in mesenchymal cells also develop early onset osteoporosis due to a combination of increased osteoclast formation and reduced osteoblast formation. TRAF3 protein levels decrease in bone and bone marrow during aging in mice and humans. Development of drugs to prevent TRAF3 degradation in immune and bone cells could be a novel therapeutic approach to prevent or reduce bone loss and the incidence of several common diseases associated with aging.

Inconclusive benefit of adjuvant 90Yttrium hydroxyapatite to radiosynovectomy for diffuse-type tenosynovial giant-cell tumour of the knee

Aims

Intra-articular 90Yttrium (90Y) is an adjunct to surgical treatment by synovectomy for patients with diffuse-type tenosynovial giant-cell tumour (dtTGCT) of the knee, with variable success rates. Clinical information is, however, sparse and its value remains unclear. We investigated the long-term outcome of patients who underwent synovectomy with and without adjuvant treatment with 90Yttrium.

Patients and Methods

All patients with dtTGCT of the knee who underwent synovectomy between 1991 and 2014 were included in the study. Group A patients underwent synovectomy and an intra-articular injection of 90Yttrium between six and eight weeks after surgery. Group B patients underwent surgery alone.

Results

There were 34 patients in group A and 22 in group B. Recurrence of dtTGCT was identified by MRI, which was undertaken in patients with further symptoms. At a mean follow-up of 7.3 years (2.5 to 25.4), there was residual disease in 15 patients in group A and 11 in group B (p < 0.363). The mean Musculoskeletal Tumor Society (MSTS) score at final follow-up was 85% and 83%, respectively (p < 0.91).

Conclusion

There were no significant differences in outcome between patients treated surgically for dtTGCT of the knee with or without an adjuvant intra-articular injection of 90Yttrium. We were unable to provide conclusive evidence of any benefits derived from the adjuvant treatment. Cite this article: Bone Joint J 2018;100-B:984–8.

Surgical treatment for diffused-type giant cell tumor (pigmented villonodular synovitis) about the ankle joint

Background

Diffused-type giant cell tumor(Dt-GCT) is a rare, aggressive disorder of the joint synovium, bursa and tendon sheaths. Osseous erosions and subchondral cysts may develop as the result of synovium infiltration in Dt-GCT. We present a retrospective study of a series of patients who are diagnosed with Dt-GCT about the ankle joint, there clinical outcome is evaluated in this study.

Material and method

Fifteen patients with radiologically and histologically confirmed Dt-GCT about the ankle joint were identified in our foot and ankle department. Patients were managed with open synovectomy for the tumor tissue and bone grafting for bony erosions. X-rays and MRI scans were used for evaluation of the tumor and bony erosions pre- and post-operatively. Pre- and post-operative ankle function was assessed using the American Orthopedic Foot and Ankle Society –Ankle and Hindfoot (AOFAS-AH) score and the Muscularskeletal Tumor Society (MSTS) score.

Results

The mean follow-up duration was 37.4 months (range 25 to 50 months). There were 6 males and 9 females, with a mean age of 35 years old (range 18 to 65 years). All patients had talar erosion with the average size of 10.1*9.1*8.2 mm, distal tibia was affected in 5 patients with the average size of 6.2*5.6*5.8 mm. 7 patients had tendon involvement, 2 patients had recurrence and progression of ankle osteoarthritis. Both of them underwent ankle fusion. At the time of last follow-up, the mean AOFAS-AH score increased from 49 to 80 points (p < 0.05), the MSTS score increased from 12 to 22 points (p < 0.05).

Conclusion

For Dt-GCT with bony erosions, open synovectomy combined with bone grafting seems to be a safe and effective operation for the salvage of ankle joint. Fusion is recommended for failed and severe cartilage destruction of the ankle joint.

Scaphoid instability caused by a giant cell tumour of the tendon sheath: A case report

Giant-cell tumour of the tendon sheath (GCTTS) is a soft tissue tumour that may invade bone, causing an intrinsic osseous lesion or instability on radiographs. A case with scaphoid instability caused by a histologically-confirmed neighbouring GCTTS has rarely been described in the literature. No definite and radical method is available for the treatment of GCTTS. This report describes an unusual case of a 22-year-old woman who previously experienced a GCTTS in her right elbow, which was removed 10 years earlier. Currently, she presented with an enlarged painless right wrist mass with focal swelling. The mass has been present for 5 years. During the previous 6 months, she felt something pop and experienced pain with limited motion in her right wrist. Magnetic resonance imaging demonstrated a well-circumscribed soft tissue mass. Under general anaesthesia, complete surgical resection of the mass was undertaken. Histopathological examination revealed that the mass was a GCTTS. Less invasive leverage reduction with external fixator support and iliac crest bone autologous graft for treatment of carpal instability were performed. Radical resection combined with external fixator support and bone grafting can provide a new option for the treatment of carpal instability.

Giant cell tumor of soft tissues: A case report of extra-articular diffuse-type giant cell tumor of the quadriceps

INTRODUCTION

Giant cell tumors of soft tissue (GCTs) are a relatively rare entity. It is a distinct but uncommon group of neoplasms morphologically identical to osseous giant cell tumor. The diffuse type of extra-articular GCT arising within muscle is a rare benign soft tissue tumor with a wide spectrum of clinical presentation.

PRESENTATION OF CASE

This article reports a rare case of a 44-year-old woman with a mass arising from her right thigh. MRI showed only a few areas of low T2 signal in a mass that was hyper intense to muscle. Histopathology of this lesion located within the right quadriceps muscle revealed admixture of multinucleated giant cell with mononuclear cells. This patient was treated by surgical resection and followed up for recurrence.

DISCUSSION

Diffuse-type GCTs are commonly located in the periarticular soft tissues, but on rare occasions these lesions can be purely intramuscular or subcutaneous and can be challenging to diagnose. Characteristic findings include gradient echo secondary to hemosiderin deposition, and the low signal on T2.

CONCLUSION

Because extra-articular diffuse-type GCTs are rare, the differential diagnosis is challenging. The clinical outcomes of diffuse-type GCTs are unclear because of their rarity. Benign clinical course is expected if the lesion is excised adequately.

Extra-articular diffuse-type tenosynovial giant cell tumor with benign histological features resulting in fatal pulmonary metastases

Diffuse-type tenosynovial giant cell tumor (TS-GCT) is categorized as a locally aggressive but non-metastasizing neoplasm according to the WHO classification. Herein, we report an extremely rare case of a 41-year-old woman who developed multiple metastases from diffuse TS-GCT with benign histological features. The patient complained of a painful buttock mass and imaging studies revealed a soft tissue tumor of the buttock and multiple pulmonary nodules. The buttock tumor was excised and the final diagnosis was extra-articular diffuse-type TS-GCT. By video-assisted thoracic surgery, pulmonary nodules were pathologically identical to the primary tumor. Residual pulmonary nodules progressively grew, and she developed a muscle metastasis and a subcutis metastasis. She died of respiratory dysfunction due to multiple pulmonary metastases 1 year after primary surgery. Very few reports on histologically benign metastases from TS-GCT have been published, and the natural course of this rare condition remains unclarified. This rare case could provide important information for further clinical evaluation of this tumor.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues, and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location means that developing evidence-based guidelines is complicated by the limitations of the data available. However, this makes it more important that STS are managed by teams, expert in such cases, to ensure consistent and optimal treatment, as well as recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous version published in 2010 (Grimer et al. in Sarcoma 2010:506182, 2010). The original guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This current version has been updated and amended with reference to other European and US guidance. There are specific recommendations for the management of selected subtypes of disease including retroperitoneal and uterine sarcomas, as well as aggressive fibromatosis (desmoid tumours) and other borderline tumours commonly managed by sarcoma services. An important aim in sarcoma management is early diagnosis and prompt referral. In the UK, any patient with a suspected soft tissue sarcoma should be referred to one of the specialist regional soft tissues sarcoma services, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging, plus a biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon. In tumours at higher risk of recurrence or metastasis pre- or post-operative radiotherapy should be considered. Systemic anti-cancer therapy (SACT) may be utilized in some cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late-effects of treatment. For local recurrence, and more rarely in selected cases of metastatic disease, surgical resection would be considered. Treatment for metastases may include radiotherapy, or systemic therapy guided by the sarcoma subtype. In some cases, symptom control and palliative care support alone will be appropriate.

Multifocal pigmented villonodular synovitis in a child: A case report

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disorder of the synovial membrane that typically presents in adults and affects a single joint. Multifocal PVNS is very rare, particularly in childhood. We reported a rare case of multifocal PVNS affecting over 20 joints in a child.

CLINICAL PROCEDURE

A 7-year-old female patient had a 6-month history of multifocal joints swelling with mild pain. She was diagnosed as polyarticular juvenile idiopathic arthritis at a local hospital. Naproxen, methotrexate, infliximab, and pavlin were used to treat the patient for 2 months. However, the treatment had no effect, the joints swelling remained. The patient was then transferred to our hospital. Physical examination revealed multiple joints swelling, especially in the shoulders joints. Puncture fluid from a shoulder joint was bloody. Magnetic resonance imaging (MRI) revealed synovial thickening and hemosiderin deposition. Biopsy of joint synovium found villous nodules, the invasion of foam cells, and hemosiderin deposition. By collecting all of the evidence, the diagnosis of PVNS was confirmed.

CONCLUSIONS

PVNS was easily misdiagnosed as rheumatoid arthritis and the formal treatment was usually delayed. This case described here is the first case of PVNS involving such a large numbers of joints that has been reported in the literature.

Pigmented villonodular synovitis: a crowdsourcing study of two hundred and seventy two patients

PURPOSE

We aimed to ascertain the feasibility of crowdsourcing via Facebook for medical research purposes; by investigating surgical, oncological and functional outcome and quality-of-life (QOL) in patients with pigmented villonodular synovitis (PVNS) enrolled in a Facebook community (1112 members).

METHODS

Patients completed online open surveys on demographics, surgery and clinical outcomes (group 1); and patient-reported outcome measures (PROMs) including knee-injury osteoarthritis outcome score (KOOS), hip-disability osteoarthritis outcome score (HOOS), Toronto extremity salvage score (TESS) and SF-36 (group 2). Mean follow-up was 70 months (12-374). Consistency checks were performed with Cohen's kappa statistic for intra-rater agreement.

RESULTS

The first survey was completed by 272 patients (group 1) and 72 patients completed the second (group 2). In group 1, recurrence-rate was 58 % (69/118) after arthroscopic, 36 % (35/97) after open and 50 % (5/10) after combined synovectomy (p = 0.003). In group 2, recurrence-rate was 67 % (26/39) after arthroscopic and 51 % (17/33) after open synovectomy (p = 0.19). Recurrence-risk was increased for diffuse disease (OR = 16; 95%CI = 3.2-85; p < 0.001). Mean function and QOL did not differ after arthroscopic or open synovectomy: KOOS 49 vs. 58 (p = 0.24), HOOS 62 vs. 53 (p = 0.56), TESS 78 vs. 82 (p = 0.86), SF-36 61 vs. 66 (p = 0.41). Cohen's kappa statistic for intra-rater agreement was good to outstanding (κ = 0.68-0.95; p < 0.001).

CONCLUSION

Local recurrence-risk was higher for diffuse-type disease and arthroscopic synovectomy. Functional outcome and QOL were comparable for both types of surgery. Gathering data via crowdsourcing seems a promising and innovative way of evaluating rare diseases including PVNS.

Arthroscopic Synovectomy and Postoperative Assisted Radiotherapy for Treating Diffuse Pigmented Villonodular Synovitis of the Knee: An observational retrospective study

OBJECTIVE

This retrospective observational study aims to explore the treatment procedure and outcomes of arthroscopically assisted radiotherapy for diffuse pigmented villonodular synovitis (PVNS) of the knee joint.

METHODS

From September 2006 to August 2011, 28 diffuse PVNS patients were diagnosed and treated under arthroscopy. Twenty six underwent post-operative radiotherapy. All patients were followed up, and the average follow-up period was 54 months (range: 24 to 72 months).

RESULTS

All 26 patients who received external radiotherapy showed no recurrence at post-operative follow-up; The Lysholm knee joint function score increased from 54.3±9.0 at pre-operation to 71.2±6.7 at post-operation (paired t-test, t = -13.35, P< 0.01).

CONCLUSIONS

Arthroscopic synovectomy is an ideal treatment for PVNS of the knee. Adjuvant post-operative external radiotherapy prevents the recurrence of diffuse PVNS.

Diffuse-type giant cell tumor of the tendon sheath in the temporal region incidentally diagnosed due to a temporal tumor: A report of two cases and review of the literature

Diffuse-type tenosynovial giant cell tumor (D-GCTS) is a rare benign lesion that not only frequently occurs in the fingers, but also along the tendon sheaths of the foot and ankle. The present study reports the cases of two middle-aged patients that were diagnosed with D-GCTS. The presentation of the D-GCTS lesions was extremely rare, as the tumors were located in the temporal fossa and threatened the skull base and external auditory canal. There were similarities and differences between the two patients in their clinical symptoms, disease progressions and invading sites. The patients' disease course occurred unnoticed with the absence of pain, was protracted and became infiltrative. However, the female patient was admitted to the hospital due to the occurrence of pain in the left temporal region, and the male patient presented at the doctor due to a painless left temporal mass and external auditory canal bleeding. Therefore, the operation area of the two patients was not the same. This type of illness should be considered in the differential diagnosis for masses occurring in the temporal region. Total tumor removal is the best treatment for D-GCTS, and the careful monitoring of recurrence can achieve a good clinical outcome subsequent to the surgical resection.

Refractory knee giant cell tumor of the synovial membrane treated with intra-articular injection of Infliximab: a case series and review of the literature

Giant cell tumor (GCT) of the synovial membrane, also known as pigmented villonodular synovitis, causes a progressive, relapsing and destructive arthropathy affecting one or more synovial joints. Systemic therapy can be combined to intra-articular treatments, including surgical synoviectomy, especially when monoarticular. Despite that, the synovial membrane commonly grows again with clinical relapse. Here, we report three case of patients diagnosed with GCT of the knee who had an early relapse of the disease even after surgical synoviectomy. All of them underwent intra-articular therapy with infliximab and subsequent synoviectomy to eradicate residual tissue. A complete remission of CGT was achieved without relapse occurring during the follow-up. These preliminary data need to be confirmed by further clinical trials; however, intra-articular therapy with infliximab might be deemed a potential option to treat CGT of a single joint.

Tenosynovial, diffuse type giant cell tumor of the temporomandibular joint, diagnosis and management of a rare tumor

The purpose of this paper was to describe a rare unusual case of primary mandibular condylar tenosynovial giant cell tumor of diffuse type with predominantly intraosseous growth and its management by resection and functional reconstruction with a vascularized costochondral graft. Clinical presentation was swelling in the right condylar area and limited mouth opening with radiological evidence of central bone destruction and magnetic resonance imaging showed central hemosiderin deposition. Fine needle aspiration did not lead to a diagnosis and an open biopsy had to be performed. Management consisted of tumor resection and reconstruction with a free vascularized costochondral graft. Tenosynovial diffuse type giant cell tumor of the temporomandibular joint is very rare. Complete resection leads to a low recurrence rate and reconstruction with a costochondral free vascularized flap leads to an excellent functional outcome.