Skip to content

Clinicians › Hand

Excision of Giant Cell Tumour of Tendon Sheath

33 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Giant cell tumour of tendon sheath (GCTTS) is a common benign neoplasm of the hand and synovial sheaths that does not metastasize [1, 3, 5]. While typically localized, it can present in atypical locations such as the distal biceps tendon sheath causing anterior elbow symptoms [10] or the wrist causing snapping [11]. Reports in the paediatric population are rare [3]. The condition is characterized by its potential for local recurrence, which remains the primary risk following intervention [2, 5, 6]. Recurrence typically occurs within 36 months of excision [2].

Complete surgical resection is the treatment of choice for most patients with tenosynovial giant cell tumors [4]. Tenosynovial GCTs should be excised as extensively as possible, ideally achieving R0 margins [7]. For localized pigmented villonodular synovitis, arthroscopic excision is the treatment of choice and is currently considered curative [19]. However, diffuse tenosynovial giant cell tumor disease presents challenges due to high recurrence rates [4]. In cases of infiltrative GCTTS, radiation therapy may provide local tumor control while preserving hand function [9].

Regular follow-up evaluations are mandatory for tenosynovial GCTs to monitor for recurrence [7].

Anatomy & Pathophysiology

Giant cell tumors may present as separate concomitant lesions on both the volar and dorsal aspects of the same hand [8]. The occurrence of these separate concomitant tumors in the same hand suggests a potential micro-traumatic origin due to repeated back-hand blows [8].

Classification

Tenosynovial GCT: This category encompasses tenosynovial giant cell tumors and pigmented villonodular synovitis [4]. Pigmented villonodular synovitis is also known as giant-cell tumor of the tendon sheath and synovial membrane [6]. Giant cell tumors of the tendon sheaths in the hand are benign lesions in which recurrence is the primary risk [5]. Giant cell tumour of tendon sheath is a common benign tumour of the hand that can be locally recurrent after excision, and reports in the paediatric population are rare [3].

Other Considerations: Tenosynovial GCTs should be excised as extensively as possible, ideally with R0 margins, and regular follow-up evaluations are mandatory [7]. There is a case report of lung metastases of diffuse giant cell tumour of the fibular tendon sheath at the ankle [7]. GCTTS may undergo malignant change even though it is rare [14]. There is a case report of multifocal, recurrent, bilateral giant cell tumor of the tendon sheath and pigmented villonodular synovitis involving both upper and lower extremities in an adult [12]. There is a case report of separate concomitant giant cell tumors occurring on both aspects of the same hand [8]. There is a case report of giant cell tumour of the distal biceps tendon sheath in the English language literature [10].

Clinical Presentation

Giant cell tumour of tendon sheath (GCTTS) is a common benign tumour of the hand [3]. Although typically presenting in adults, rare paediatric cases exist, including the youngest reported case in a 4-year-old boy [3]. Unusual anatomical presentations include the first documented instance of GCTTS in the distal biceps tendon sheath, which serves as an unusual cause of anterior elbow symptoms [10].

Concomitant or multifocal disease patterns provide insight into potential aetiologies and systemic associations. Separate concomitant GCTTS on both the volar and dorsal aspects of the same hand has been reported, suggesting a potential micro-traumatic origin due to repeated back-hand blows [8]. Rare instances of multifocal, recurrent, bilateral GCTTS and pigmented villonodular synovitis involving both upper and lower extremities in an adult have also been described [12].

GCTTS must be included in the differential diagnosis of soft tissue lesions around the ankle [14]. Clinical presentation can vary from simple masses to complex functional impairments. A snapping wrist may result from a synovial giant cell tumour combined with an anomalous lumbrical muscle [11]. Additionally, posterior interosseous nerve palsy can be secondary to pigmented villonodular synovitis of the elbow [13].

Rare presentations involve extensive involvement of the flexor-tendon sheath of a finger with associated reactive periostitis of the phalanges [22].

Investigations

MRI: Magnetic resonance imaging is essential for diagnosing tenosynovial giant cell tumors, accurately defining their localization, and establishing the treatment strategy [30]. It provides valuable diagnostic clues, although definitive diagnosis relies on histopathological confirmation [34]. Pre-operative evaluation with magnetic resonance imaging contributes significantly to the diagnosis of localized pigmented villonous synovitis [35]. In cases of peroneal neuropathy secondary to pigmented villonous synovitis, early diagnosis via magnetic resonance imaging and electromyography is critical for prognosis [36]. Although magnetic resonance imaging findings and location may aid in diagnosis, careful assessment is mandatory, particularly in unusual locations [33].

Treatment

Non-Operative

Asymptomatic patients with diffuse pigmented villonodysplasia can be successfully managed nonoperatively [26]. For infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function [9].

Operative

Indications: Complete surgical resection is the treatment of choice for most patients with tenosynovial giant cell tumors [4]. Complete operative excision is the ideal treatment for pigmented villonodular synovitis [29].

Surgical Approach / Technique: Open synovectomy is the standard method of management for pigmented villonodular synovitis [37]. Arthroscopic excision is effective for the localized type of GCTTS in all four joints [24]. Arthroscopic excision is the preferred treatment for localized pigmented villonodular synovitis due to its effectiveness and minimal morbidity [28]. For diffuse-type GCT with bony erosions, open synovectomy combined with bone grafting is a safe and effective operation for the salvage of the ankle joint [27]. Complete resection of the mass and nerve decompression can lead to complete resolution of symptoms in cases of pigmented villonodular synovitis causing nerve palsy [13].

Complications

Recurrence: Recurrence is the primary risk for giant cell tumors of the tendon sheaths in the hand [2, 5]. Giant cell tumor of tendon sheath can be locally recurrent after excision [3]. Recurrence after surgical excision of GCTTS varies widely from 4% to 44%, with incomplete excision being a primary cause [16]. Recurrence typically occurs within 36 months of excision [2]. Diffuse disease presents challenges due to high recurrence rates [4].

Other Considerations: Rare presentations include separate concomitant giant cell tumors occurring on both aspects of the same hand [8]. Multifocal, recurrent, bilateral giant cell tumor of the tendon sheath and pigmented villonodular synovitis involving both upper and lower extremities in an adult has been reported [12].

Recovery

Light activity (weeks): Specific timelines for light activity are not detailed in the available evidence.

Full activity (months): Specific timelines for full activity are not detailed in the available evidence.

Complete recovery / outcome plateau (months): Recurrence is the primary risk for giant cell tumors of the tendon sheaths in the hand, typically occurring within 36 months of excision [2]. Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, although diffuse disease presents challenges due to high recurrence rates [4].

Rehabilitation protocol: Specific rehabilitation protocols are not detailed in the available evidence.

Functional milestones: At 2 years after surgery for a synovial giant cell tumour causing snapping wrist, grip strength was equal to the contralateral side with no recurrence of the tumour [11]. Complete resection of the mass and nerve decompression for posterior interosseous nerve palsy secondary to pigmented villonodular synovitis can lead to complete resolution of symptoms even with a long delay in diagnosis [13]. Patients with pigmented villonodular synovitis of the hip managed with arthroscopic synovectomy reported good functional outcomes without evidence of recurrence in a cohort with an average follow-up of almost 7 years [18]. The prognosis after excision of localized pigmented villonodular synovitis of the knee is excellent, with no recurrences observed in one series [39]. Arthroscopic synovectomy following a timely diagnosis of PVNS produces good outcomes in nodular cases, with no evidence of symptomatic or radiographic disease persistence among patients [47].

Other Considerations: The pathogenesis and optimum treatment of pigmented villonodular synovitis remain unclear, with uncertainties persisting due to the rarity of cases, varying reporting details, and lack of long-term follow-up in most series [15].

Key Evidence

  • [L5] Giant cell tumor of tendon sheath is a benign condition that does not metastasize. [1] (10.1016/s0749-0712(21)00046-9)
  • [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 tumour of tendon sheath is a common benign tumour of the hand that can be locally recurrent after excision, and reports in the paediatric population are rare, with this case believed to be the youngest reported. [3] (10.1177/1753193412455792)
  • [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. [4] (10.5435/jaaos-d-24-01255)
  • [L4] Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk. [5] (10.1016/j.jhsa.2013.08.051)
  • [L4] Pigmented villonoid synovitis and giant-cell tumor of tendon sheath are benign synovial neoplasms with the potential for local recurrence. [6] (10.2106/00004623-198466010-00012)
  • [Case_report] Tenosynovial GCTs should be excised as extensively as possible, ideally with R0 margins, and regular follow-up evaluations are mandatory. [7] (10.1016/j.otsr.2016.10.018)
  • [L5] This case describes the first report of separate concomitant giant cell tumors occurring on both aspects of the same hand, suggesting a potential micro-traumatic origin due to repeated back-hand blows over more than 20 years. [8] (10.1007/s12593-015-0185-3)
  • [L4] In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function. [9] (10.1016/j.jhsa.2012.01.011)
  • [L4] The authors report the first case of giant cell tumour of the distal biceps tendon sheath in the English language literature, highlighting the importance of considering this condition as a potential cause of anterior elbow symptoms. [10] (10.1177/1758573217701064)
  • [Case_report] At 2 years after surgery, the grip strength is equal to the other side and there has been no recurrence of the tumour. [11] (10.1177/1753193409361441)
  • [Case_report] This case report describes a rare instance of multifocal, recurrent, bilateral giant cell tumor of the tendon sheath and pigmented villonodular synovitis involving both upper and lower extremities in an adult. [12] (10.1016/j.jhsa.2014.11.010)
  • [Case_report] Complete resection of the mass and nerve decompression can lead to complete resolution of symptoms even with a long delay in diagnosis. [13] (10.1016/j.otsr.2012.11.015)
  • [L5] GCTTS must be included in the differential diagnosis of a soft tissue lesion around the ankle and may undergo malignant change even though it is rare. [14] (10.1055/s-0039-1679102)
  • [L4] The pathogenesis and optimum treatment of pigmented villonodular synovitis remain unclear, with uncertainties persisting due to the rarity of cases, varying reporting details, and lack of long-term follow-up in most series. [15] (10.2106/00004623-198769060-00026)
  • [L4] Recurrence after surgical excision of GCTTS varies widely from 4% to 44%, with incomplete excision being a primary cause. [16] (10.1016/j.jhsa.2012.11.001)
  • [L4] Patients reported good functional outcomes without evidence of recurrence in a 19 patient cohort with an average follow-up of almost 7 years. [18] (10.1177/2325967119s00413)
  • [L4] Arthroscopic excision is the treatment of choice and is currently thought to be curative. [19] (10.1016/j.arthro.2005.12.035)
  • [L4] This case describes an unusual presentation of pigmented villonodular tenosynovitis involving the entire flexor-tendon sheath of a finger with associated reactive periostitis of the phalanges, a bone change not previously described in association with this lesion. [22] (10.2106/00004623-197759040-00032)
  • [L4] Arthroscopic excision is effective for localized type of GCTTS for all four joints. [24] (10.1016/j.otsr.2017.03.016)
  • [L4] Asymptomatic patients can be successfully managed nonoperatively. [26] (10.1302/0301-620x.95b3.30192)
  • [L4] 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. [27] (10.1186/s12891-017-1824-6)
  • [L4] Arthroscopic excision is the preferred treatment due to its effectiveness and minimal morbidity. [28] (10.1007/s00167-003-0448-6)
  • [Case_report] The ideal treatment for pigmented villonodular synovitis is complete operative excision. [29] (10.2106/00004623-199072060-00022)
  • [L4] Magnetic resonance imaging is essential to diagnose this pathologic condition and to define accurately its localization and treatment strategy. [30] (10.1007/s00167-011-1747-y)
  • [L4] Although MRI findings and location might help in the diagnosis of a T-GCT, careful assessment is mandatory, especially in unusual locations. [33] (10.1186/s12891-016-1050-7)
  • [L4] MRI provides valuable clues, but definitive diagnosis relies on histopathological confirmation. [34] (10.1186/s12891-026-09563-w)
  • [L4] Pre-operative evaluation with MRI made an important contribution to the diagnosis of LPNS. [35] (10.1007/s00167-002-0318-7)
  • [Case_report] Early diagnosis via MRI and EMG is very important for prognosis, and early surgical resection of all pathologic tissues is necessary. [36] (10.1007/s00167-009-0720-5)
  • [L4] Open synovectomy is the standard method of management. [37] (10.5435/00124635-200606000-00007)
  • [L4] The prognosis after excision is excellent, with no recurrences observed in this series. [39] (10.2106/00004623-196749010-00010)
  • [L4] Intraoperative dynamic ultrasound application has the potential to be used in repair of the tendon in minimum invasive surgery. [40] (10.1177/1753193415601288)
  • [L4] Arthroscopic synovectomy following a timely diagnosis of PVNS produces good outcomes in nodular cases, with no evidence of symptomatic or radiographic disease persistence among these patients. [47] (10.1177/2325967118763118)

See Also

References

[1] GIANT CELL TUMORS OF TENDON SHEATH. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00046-9

[2] Giant cell tumors of the tendon sheaths in the hand: Review of 96 patients with an average follow-up of 12 years. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.03.008

[3] Giant cell tumour of tendon sheath in a 4-year-old boy. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412455792

[4] Tenosynovial Giant Cell Tumor and Pigmented Villonodular Synovitis. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01255

[5] Giant Cell Tumors of the Tendon Sheaths in the Hand: Review of 96 Patients With an Average Follow-Up of 12 Years. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.051

[6] Pigmented villonodular synovitis (giant-cell tumor of the tendon sheath and synovial membrane). A review of eighty-one cases.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466010-00012

[7] Lung metastases of diffuse giant cell tumour of the fibular tendon sheath at the ankle: A case report. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.10.018

[8] Multiple Giant Cell Tumors of the Tendon Sheath : Separate Volar and Dorsal Lesions Involving Three Digits of the Same Hand Following Repetitive Trauma. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-015-0185-3

[9] Radiation Therapy for Infiltrative Giant Cell Tumor of the Tendon Sheath. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.011

[10] Trauma or tumour: giant cell tumour of distal biceps tendon sheath, an unusual cause of elbow pain. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217701064

[11] Snapping wrist caused by synovial giant cell tumour and anomalous lumbrical muscle: a case report. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409361441

[12] Recurrent Pigmented Villonodular Synovitis and Multifocal Giant Cell Tumor of the Tendon Sheath: Case Report. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.11.010

[13] Posterior interosseous nerve palsy secondary to pigmented villonodular synovitis of the elbow: Case report and review of literature. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2012.11.015

[14] Giant Cell Tumor of Tendon Sheath Developed over Chimeric-Free Latissimus Dorsi and Serratus Anterior Muscle Flaps. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1679102

[15] Pigmented villonodular synovitis.. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769060-00026

[16] Giant Cell Tumor of the Tendon Sheath. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.11.001

[18] 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

[19] Localized Pigmented Villonodular Synovitis: Arthroscopic Treatment of a Lesion Arising From the Quadriceps Tendon Sheath. Arthroscopy. 2006. DOI: 10.1016/j.arthro.2005.12.035

[22] Pigmented Villonodular Tenosynovitis. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759040-00032

[24] Giant cell tumor of tendon sheath: Open surgery or arthroscopic synovectomy? A systematic review of the literature. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.03.016

[26] Diffuse pigmented villonodular synovitis (diffuse-type giant cell tumour) of the foot and ankle. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b3.30192

[27] Surgical treatment for diffused-type giant cell tumor (pigmented villonodular synovitis) about the ankle joint. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1824-6

[28] Localized pigmented villonodular synovitis in the anteromedial compartment of the knee associated with cartilage lesions of the medial femoral condyle: report of a case and review of the literature. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-003-0448-6

[29] Pigmented villonodular synovitis in a vertebra. A case report.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072060-00022

[30] Arthroscopic treatment of localized pigmented villonodular synovitis of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1747-y

[33] 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

[34] Two rare intra-articsular knee disorders with overlapping symptoms: separate case reports of tenosynovial giant cell tumour and lipoma arborescens and literature review. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09563-w

[35] Two contrasting presentations of localised pigmented villonodular synovitis of the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2002. DOI: 10.1007/s00167-002-0318-7

[36] An unusual presentation of peroneal neuropathy secondary to pigmented villonodular synovitis: a case report. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0720-5

[37] Pigmented Villonodular Synovitis. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200606000-00007

[39] Localized Pigmented Villonodular Synovitis of the Knee. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749010-00010

[40] Hidradenocarcinoma of the finger: a rare tumor, mimicking a giant cell tumor of the tendon sheath. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415601288

[47] Arthroscopic Management of Pigmented Villonodular Synovitis of the Hip in Children and Adolescents. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118763118

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.