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Excision of Giant Cell Tumour of Tendon Sheath

56 citationsUpdated Oct 2026
Illustration: Excision of Giant Cell Tumour of Tendon Sheath

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Overview

Giant cell tumour of tendon sheath (GCTTS) is a common benign neoplasm of the hand that is locally aggressive and possesses the potential for osseous invasion [5, 6]. Although the condition does not metastasize [2], it is characterized by a significant risk of local recurrence following excision [4, 5, 8]. This recurrence risk is the primary clinical concern, as GCTTS is a benign lesion where local aggressiveness defines the post-operative trajectory [4, 6].

Recurrence of giant cell tumors of the tendon sheaths typically occurs within 36 months of excision [4]. While the proliferative activity of localized GCTTS, measured by the MIB-1 staining index, is not related to its high recurrence rate and local aggressiveness [9], the tumour remains a benign synovial neoplasm with the potential for local recurrence, similar to pigmented villonoid synovitis [17].

Reports of GCTTS in the paediatric population are rare [5]. The condition is managed with the understanding that it is a benign entity where recurrence is the principal risk, necessitating surveillance for local regrowth within the first three years post-surgery [4, 5, 8].

Anatomy & Pathophysiology

Tumor Characteristics and Etiology

Giant cell tumor of tendon sheath (GCTTS) is a benign, non-metastatic condition that represents the second most common benign proliferative tumour in the upper extremities after ganglion cysts [2][20]. In the hand, it is the second most common soft tissue tumor after synovial ganglions [15]. The etiology remains unknown, with pathogenetic theories including inflammatory processes, trauma, immune mechanisms, and neoplasia [15]. Inflammation resulting from reactive or regenerative hyperplasia is the generally accepted theory of pathogenesis [20]. However, genetic factors have been observed, and flow cytometry of DNA from specimens reveals a significant number of aneuploid cases, strongly favoring a genetic cause for neoplastic transformation [39][20]. Current evidence supports a neoplastic rather than inflammatory process [39]. GCTTS is considered a localized form of pigmented villonodular synovitis [15].

Clinically, GCTTS usually presents as a solitary, firm, slow-growing nodular lesion that is typically asymptomatic [15][20]. As the tumor grows, patients may present with swelling, pain, and limitation of movement [20]. The common mode of presentation is a firm, non-tender slowly growing mass fixed to deeper structures [39]. Tumor location is usually on the flexor aspect, although attachment to the extensor apparatus is well documented [39]. A definite history of trauma was recorded in 5% of lesions [19]. The male-to-female ratio is 1:1.47, with a mean age ranging from 32 to 51 years [19]. GCTTS are most commonly found in the fingers and among women in their fourth and fifth decades [20]. The index finger is the most frequent location, accounting for 29.7% of cases [19]. Pain was reported in 15.7% of cases, and sensory disturbances in 4.57% [19].

Regarding classification, Type I tumours (single lesions) were more frequently detected (78.7%) than Type II tumours (two or more distinct tumours not joined together) (21.3%) [19]. Type 1 GCTTS includes a nodular or multinodular lesion surrounded by a capsule, while Type 2 describes tumours with no connective tissue membrane and satellite, diffuse, or multicentric nodules [20]. Multifocal lesions are rarely described and commonly involve the same finger or the volar aspect of different fingers [15]. Local infiltration is a relatively common feature, but frank metastasis has not been reported [39].

Anatomical Context and Surgical Considerations

The fundamental consideration in managing hand tumours is reconciling adequate tumour clearance with the maintenance of function and appearance [30]. Marginal excision is the treatment of choice for GCTTS, but it is often difficult due to the tumor's location and strict adherence to the tendon or neurovascular bundles [27]. The surgeon must ensure complete excision of the tumor and removal of any residual satellite nodules to address factors predisposing to recurrence [27]. A magnifying loupe is used to help a careful research of satellite lesions and to respect surrounding structures during excision [27].

Diagnostic imaging plays a critical role in planning. MRI is the most useful examination for diagnosis and treatment planning [20]. Radiography can be helpful in evaluating cortical destruction but is not helpful in the definitive diagnosis [20]. The diagnosis is usually made from clinical examination [20]. A history of minor trauma resulting in ligament rupture of the thumb’s MCP joint should lead to a suspicion of an underlying pathology such as tenosynovial giant cell tumour [16]. Pigmented villonodular synovitis may arise from bursae or tendon sheaths, and both forms may invade bone [38]. Bone invasion may lead to a false diagnosis of malignant tumor [38]. Angiography in patients with pigmented villonodular synovitis usually shows highly vascular lesions with early filling of draining veins, which is also regarded as a sign of malignant tumor [38]. Patients with GCTTS and bone erosion showed significantly higher rates of local recurrence (P = 0.0001) [39]. A definite association was observed between clinical outcome and the number of nodules as well as the presence of bone erosion [39].

The extrinsic flexors of the finger consist of the flexor digitorum profundus and the flexor digitorum superficialis [67]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [67]. Within this tunnel, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [67]. The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx and consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [67]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [67].

The gliding mechanism for tendons in narrow crowded areas is assured by the synovial sheath, which allows a considerable amplitude of movement [68]. Synovial sheaths at specific sites are surrounded by fibrous sheaths that keep the tendon close to the skeleton, particularly when pulling tendons cross the sinus of an articular angle [68]. The fibrous sheath assumes the role of a pulley when the tendon changes direction [68]. The gliding mechanism represented by the synovial sheaths is much more developed on the palmar aspect [68]. There are three digitopalmar synovial sheaths for the flexor tendons of the index finger, long finger, and ring finger [68]. The superficial and deep flexor tendons of the digits also glide over each other [68]. Each synovial sheath has a visceral and parietal component separated by a potential synovial cavity containing a very thin layer of synovial fluid, which constitutes the basic gliding and nutritional mechanism [68]. Any alteration of these gliding mechanisms has important functional repercussions [68].

The dorsal integument must be supple, elastic, and malleable to allow metacarpophalangeal joint flexion [68]. Interphalangeal flexion is accomplished by means of a special arrangement of skin folds on the dorsum of each articulation [68]. The vessels and nerves in the hand adapt themselves to differences in length and are surrounded by loose fibroadipose connective tissue [68]. The extrinsic muscles continue into the tendons, which must glide in relation to the other elements of the hand to perform their function [68]. In unrestricted areas where the tendon has a straight trajectory, it is surrounded by the paratenon and areolar connective tissue arranged in layers [68]. The pattern of paratenon and areolar connective tissue applies to most extensor tendons except on the dorsal aspect of the wrist [68]. The extensor synovial tendon sheaths are present only at the level of the wrist, which is the only joint in the hand capable of active dorsal flexion [68].

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [44]. The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [44]. The base of each metacarpal articulates with the distal row of the carpus [44]. The carpus articulates with the skeleton of the forearm through its proximal row [44]. The radioulno-carpal articulation has two axes of movement to which is added a third—pronation and supination from the forearm [44]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [44]. The radial ray or first ray is the shortest and is made up of only three bones—a metacarpal and two phalanges [44]. The first ray continues the external column of the carpus formed by the scaphoid and trapezium [44]. The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [44]. This position, along with the shape of the metacarpotrapezial joint, explains the gap between the first ray and the palm, and allows the thumb metacarpal to oppose the other four digital rays [44].

The other four digital rays are of unequal length and are formed by four skeletal segments—a metacarpal and three phalanges [44]. The lengths of the metacarpals vary, with the thumb metacarpal being the shortest and the index finger the longest [44]. The proximal and particularly the middle phalanges of the middle and ring fingers are longer than those of the index finger so that the long finger, and usually the ring finger, are longer than the index finger [44]. The relative lengths of skeletal segments vary with the movements of opening and closing the fist [44]. The digital extremes of each ray converge in flexion either toward the pulp of the thumb for thumb pinch or toward the base of the thenar eminence for power grip [44]. This convergence away from the median axis means that the more ulnar the digit, the more obliquely it must deviate as it approaches the palm [44]. The two ulnar metacarpals, especially the fifth, have slightly more mobility in flexion–rotation, compensating for their lack of length [44]. The convergence of the palmar digits toward the scaphoid tubercle results from the orientation of their distal segments in flexion [44]. These deviations are produced essentially at the level of the metacarpophalangeal and the proximal interphalangeal articulations [44].

The skeleton of the hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [44]. When the thumb spreads to grasp an object, the cup becomes a gutter whose major oblique axis follows the thumb crease [44]. It is essential for the prehensile role of the hand that these curvatures be respected in both their longitudinal and transverse axes [44]. The transverse axis of the palm, which corresponds to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis, represented by the median ray [44]. This transverse axis is oblique, more distal at the metacarpophalangeal joint of the index finger and more proximal at the fifth metacarpophalangeal joint [44]. The transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [44]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [44].

The hand is both an organ designed to obtain information and an organ of execution [58]. The hand functions efficiently only if the proximal joints of the limb are stable and yet mobile [58]. The hand moves within a large volume of space, the shoulder being the apex [58]. The shoulder is the most mobile joint in the body and it allows orientation of the upper limb as required [58]. The movements of the clavicle amplify those of the shoulder [58]. The arm assures projection of the limb from the trunk [58]. The elbow, through flexion–extension movements, brings the hand closer to or moves it away from the body [58]. Distal to the elbow, there is in effect only one physiological unit [58]. The combined movements of the wrist and forearm place the hand in a position for grasping [58]. For gripping, the wrist is usually in flexion when close to the trunk and in extension when placed at a distance [58]. Forearm rotation (pronation–supination) plays an important role, particularly for bringing food to the mouth [58]. The hand’s blood and nerve supplies are continuous with those of the rest of the limb [58]. Some of the hand's muscles, the extrinsic muscles, arise in the arm and forearm [58].

The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [58]. The proximal “carpometacarpal” half of the hand is flattened, presenting two faces, each with a unique anatomical and functional significance [58]. The back of the hand (the dorsum) is the surface that is usually visible and is therefore aesthetically important [58]. The palmar surface, which is usually hidden, is the functional surface [58]. The posterior or dorsal aspect is convex, and the anterior, palmar or volar aspect is concave [58]. The distal half of the hand is separated into five digits, which flex toward the palm [58]. The digits converge in closing—that is, they flex and adduct—and diverge in opening—that is, they extend and abduct [58]. The digits are divided into the thumb and four fingers [58]. The thumb has a more proximal and lateral position, allowing movement inward and outward from the palm [58]. The four fingers are the distal extension of the carpometacarpal part of the hand [58]. The digits can be flexed from a distal position to a proximal position on the palm [58]. The hinges of these movements are not at the bases of the digits, but at the thenar crease and at the transverse distal palmar crease [58]. The digits are of different lengths [58]. When the digits are fully extended and touching each other, the tips almost describe a regular curve, the peripheral digits being the shortest [58]. When the fingers are separated, they diverge irregularly, the web space of the thumb being the largest and deepest [58]. When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [58]. The hand is remarkably mobile and malleable [58]. The hand is capable of conforming to the shape of objects to be grasped or studied, and of emphasizing an idea being expressed [58]. These possibilities and varieties of function are realized through the unique structure of this organ, which consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [58]. There are about the same number of tendons activated by the forearm muscles as there are muscles situated entirely within the hand [58].

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [43]. Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus [43]. Intrinsic muscles have both origin and insertion within the hand [43]. Extrinsic muscles are either flexors or extensors [43]. Intrinsic muscles contribute to both digital flexion and extension [43]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [43]. The first (most radial) compartment contains the abductor pollicis longus and the extensor pollicis brevis [43]. The abductor pollicis longus has multiple slips that insert at the base of the thumb metacarpal and radially abducts the thumb [43]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint of the thumb [43]. The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [43]. The extensor carpi radialis longus, inserting on the index metacarpal, dorsiflexes and radially deviates the wrist [43]. The extensor carpi radialis brevis, inserting into the base of the middle metacarpal, provides balanced wrist dorsiflexion [43]. The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm through the third compartment and turns abruptly radialward about Lister tubercle [43]. Lister tubercle is

Classification

Pseudocapsule-based Classification: Giant cell tumour of tendon sheath (GCTTS) is classified into two main types based on whether the entire tumour is surrounded by one pseudocapsule [26]. Type I consists of a nodular or multinodular lesion surrounded by a capsule [20]. Type II describes tumours with no connective tissue membrane and satellite, diffuse, or multicentric nodules [20]. Both Type I and Type II tumours are sub-classified according to the thickness of the capsule, lobulation of the tumour, the presence of satellite lesions, and the diffuse or multicenteric nature of the tumour [26].

Recurrence Patterns: In a prospective study of 43 consecutive cases, none of the 30 Type I tumours recurred [26]. Recurrence occurred in five out of 13 Type II tumours [26]. Second recurrences were observed with Type II B and C tumours but not with Type II A tumours [26].

Other Considerations: Giant cell tumors of the tendon sheath correspond to a localized form of pigmented villonodular synovitis [15]. The World Health Organization classifies diffuse pigmented villonodular synovitis as 'diffuse-type giant cell tumour' with ICD-O code 9251/0 [46]. Giant-cell tumours of tendon sheaths are considered the extra-articular equivalent of localised pigmented villonodular synovitis [46].

Clinical Presentation

Giant cell tumor of tendon sheath (GCTTS) is the second most common soft tissue tumor in the hand, following synovial ganglions [15, 20, 39]. The lesion typically presents as a solitary, firm, slow-growing nodular mass [15]. It is most frequently located on the volar aspect of the hand [15], with the index finger accounting for 29.7% of cases [19]. Although the tumor usually occurs on the flexor aspect, attachment to the extensor apparatus is well documented [39]. GCTTS is most commonly found in the fingers and among women in their fourth and fifth decades [20]. The male-to-female ratio is 1:1.47 [19], and the mean age of patients ranges from 32 to 51 years [19].

On inspection and palpation, the common mode of presentation is a firm, non-tender, slowly growing mass fixed to deeper structures [39]. The tumor is usually slow-growing, painless, benign, and consists of soft tissue [20]. While usually asymptomatic, patients may present with swelling, pain, and limitation of movement as the tumor grows [20]. Pain or sensory disturbances were reported in 15.7% and 4.57% of cases, respectively [19]. A definite history of trauma was recorded in 5% of lesions [19].

Regarding tumor multiplicity, Type I tumors (single lesions) are more frequently detected (78.7%) than Type II tumors (two or more distinct tumors) (21.3%) [19]. Multifocal lesions are rarely described and commonly involve the same finger or the volar aspect of different fingers [15].

Clinicians should maintain a high index of suspicion for underlying pathology in specific scenarios. A history of minor trauma resulting in ligament rupture of the thumb’s MCP joint should lead to a suspicion of an underlying pathology [16]. Furthermore, prolonged and atypical swelling of soft tissue, even with a previous traumatic lesion, may indicate underlying malignancy, necessitating proper imaging before surgery [33]. Giant cell tumour of the distal biceps tendon sheath is a potential cause of anterior elbow symptoms [21].

Investigations

MRI: Magnetic resonance imaging is essential for diagnosing localized pigmented villonodular synovitis and defining its localization and treatment strategy [105]. Pre-operative MRI evaluation makes an important contribution to the diagnosis of localized pigmented villonodular synovitis [115]. While MRI provides valuable clues for diagnosis, definitive diagnosis relies on histopathological confirmation [114]. Although MRI findings and location might help in the diagnosis of tenosynovial giant cell tumors, careful assessment is mandatory, especially in unusual locations [113]. The absence of disease on MRI should not be used as the sole criterion in determining whether a repeat resection should be performed [32].

Biopsy: Closed biopsy of the musculoskeletal system compares favorably with other techniques and can be done with a low complication rate [18].

Other Considerations: Giant cell tumors of the tendon sheath typically present as a solitary and firm slow-growing nodular lesion, which affects the volar aspect of the hand [15]. These tumors represent the second most common type of soft tissue tumors in the hand after synovial ganglions [15]. GCTTS must be included in the differential diagnosis of a soft tissue lesion around the ankle [41]. Giant cell tumor of tendon sheath (GCTTS) is locally aggressive and has the possibility of osseous invasion [6]. GCTTS may undergo malignant change even though it is rare [41]. Tumor cells may be implanted in a surgical wound, as indicated by reports of soft-tissue recurrence within a surgical scar [12].

Treatment

Non-Operative

The provided evidence base does not support specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections for tenosynovial giant cell tumors. Surgical intervention is the primary focus of the available data.

Operative

Indications: Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors [7]. Marginal excision is the standard treatment for giant cell tumor of tendon sheath [27], and local excision appears to be a satisfactory method of treatment [25]. Surgical excision is the most commonly accepted treatment for these lesions [20]. For diffuse-type giant cell tumor with bony erosions, open synovectomy combined with bone grafting is a safe and effective operation for the salvage of the ankle joint [99]. In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function [3].

Surgical Approach / Technique: Tenosynovial GCTs should be excised as extensively as possible, ideally with R0 margins [13]. Surgeons must ensure complete excision of the tumor and removal of any residual satellite nodules to reduce recurrence risk [27]. Preoperative planning aided by a tissue diagnosis with fine needle aspiration cytology, wide surgical exposure, and meticulous dissection with help of magnification are imperative for a successful outcome in GCTTS [40]. A magnifying loupe is used to help a careful research of satellite lesions and to respect surrounding structures during excision [27]. Arthroscopic excision is effective for localized type of GCTTS for all four joints [96]. It is the treatment of choice and is currently thought to be curative for localized pigmented villonodular synovitis arising from the quadriceps tendon sheath [55]. Arthroscopic excision is the preferred treatment for localized pigmented villonodular synovitis due to its effectiveness and minimal morbidity [101]. Open synovectomy is the standard method of management for pigmented villonodular synovitis [116], and the ideal treatment is complete operative excision [117]. Complete resection of the mass and nerve decompression can lead to complete resolution of symptoms even with a long delay in diagnosis for pigmented villonodular synovitis of the elbow [22].

Adjuncts: Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision [11]. The authors recommend intralesional surgery with polymethylmethacrylate for the majority of primary GCTs [100]. Treatment is directed at controlling the lesion locally, with curettage and adjuvant therapy being the primary goal for most lesions to preserve the articular surface [23]. Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss [14]. Both curettage and resection/amputation are acceptable treatment options for giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease [10]. Giant-cell tumor of bone was effectively treated with megavoltage radiation in patients in whom operative resection would have been difficult or was not feasible, with a ten-year lack of progression rate of 85 percent [35].

Other Considerations: Surgical treatment for localized-type tenosynovial giant cell tumors led to good functional results, with pain resolving in 71% and swelling resolving in 85% of patients at final follow-up [76]. Surgical treatment for pigmented villonodular synovitis led to good functional results with an average Enneking score of 92% of normal limb function [36]. Vigilance for malignancy is encouraged, and aggressive treatment such as wide excision or amputation may be necessary for certain lesions like giant cell tumors to prevent recurrence [1]. Reconstruction should be considered if an acceptable margin can be obtained without compromising vital structures in limb salvage surgery of the upper extremity [79].

Complications

Recurrence: Recurrence is the primary risk for giant cell tumors of the tendon sheaths in the hand [4, 8]. The overall recurrence rate for giant cell tumour of tendon sheath of the digits is 14.8% [19], with rates after surgical excision varying widely from 4% to 44% [28]. Incomplete excision is a primary cause of recurrence [28]. In a study of 64 cases, the recurrence rate was 3 cases (4.7%) [27]. In a prospective study of 43 consecutive cases, none of the type I giant cell tumours of tendon sheath recurred [26]. Recurrence occurred in five out of 13 type II giant cell tumours of tendon sheath [26]. Second recurrences were seen with type II B and C giant cell tumours of tendon sheath, but not type II A tumours [26]. Although most recurrences of giant-cell tumor of bone can be expected within the first two years, some patients remain at risk for a much longer period, with recurrences occurring nineteen to thirty years after initial treatment [34]. Two cases of soft-tissue recurrence of giant-cell tumor within a surgical scar have been reported, indicating that tumor cells may be implanted in a surgical wound [12].

Malignancy and Metastasis: Vigilance for malignancy is encouraged for giant cell tumors to prevent recurrence [1]. Aggressive treatment such as wide excision or amputation may be necessary for certain lesions like giant cell tumors to prevent recurrence [1]. Tenosynovial GCTs should be excised as extensively as possible, ideally with R0 margins, and regular follow-up evaluations are mandatory [13].

Local Aggressiveness and Infiltration: Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, though diffuse disease presents challenges due to high recurrence rates [7].

Nerve palsy: Posterior interosseous nerve palsy can occur secondary to pigmented villonodular synovitis of the elbow [22]. Complete resection of the mass and nerve decompression can lead to complete resolution of symptoms even with a long delay in diagnosis for posterior interosseous nerve palsy secondary to pigmented villonodular synovitis [22].

Recovery

Other Considerations: Recurrence is the primary risk following excision of giant cell tumors of the tendon sheaths in the hand [4]. These lesions are benign synovial neoplasms with the potential for local recurrence [8, 17]. The reported recurrence rate after surgical excision varies from 4% to 44% [28]. Incomplete excision is a primary cause of this recurrence [28]. Diffuse disease presents challenges due to high recurrence rates [7]. Tenosynovial giant cell tumors should be excised as extensively as possible, ideally with R0 margins [13]. Local excision of the tumour appears to be a satisfactory method of treatment for Nora’s lesion [25]. In cases of infiltrative giant cell tumor of tendon sheath, radiation therapy may provide local tumor control with preservation of hand function [3]. Regular follow-up evaluations are mandatory for tenosynovial giant cell tumors [13].

Key Evidence

  • [L5] Vigilance for malignancy is encouraged, and aggressive treatment such as wide excision or amputation may be necessary for certain lesions like giant cell tumors to prevent recurrence. [1] (10.1016/j.jhsa.2010.08.015)
  • [L5] Giant cell tumor of tendon sheath is a benign condition that does not metastasize. [2] (10.1016/s0749-0712(21)00046-9)
  • [L4] In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function. [3] (10.1016/j.jhsa.2012.01.011)
  • [L4] Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk, typically occurring within 36 months of excision. [4] (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. [5] (10.1177/1753193412455792)
  • [L5] The authors agree that giant cell tumor of tendon sheath (GCTTS) is locally aggressive and made reference to the possibility of osseous invasion. [6] (10.1016/j.jhsa.2013.04.049)
  • [L5] Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, though diffuse disease presents challenges due to high recurrence rates. [7] (10.5435/jaaos-d-24-01255)
  • [L4] Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk. [8] (10.1016/j.jhsa.2013.08.051)
  • [L4] The proliferative activity of localized giant cell tumour of tendon sheath, measured by the MIB-1 staining index, is not related to its high recurrence rate and local aggressiveness. [9] (10.1016/j.jhsb.2004.06.012)
  • [L4] Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control. [10] (10.1177/17531934211007820)
  • [L3] Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision. [11] (10.1007/s004020100317)
  • [L4] Two cases of soft-tissue recurrence of giant-cell tumor within a surgical scar are reported, indicating that tumor cells may be implanted in a surgical wound. [12] (10.2106/00004623-196749020-00016)
  • [Case_report] Tenosynovial GCTs should be excised as extensively as possible, ideally with R0 margins, and regular follow-up evaluations are mandatory. [13] (10.1016/j.otsr.2016.10.018)
  • [L3] Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. [14] (10.1007/s11999-014-4054-3)
  • [L5] [15] (10.1007/s12593-015-0185-3)
  • [L5] We conclude from this case that a history of minor trauma resulting in ligament rupture of the thumb’s MCP joint should lead to a suspicion of an underlying pathology. [16] (10.1177/17531934211004437)
  • [L4] Pigmented villonoid synovitis and giant-cell tumor of tendon sheath are benign synovial neoplasms with the potential for local recurrence. [17] (10.2106/00004623-198466010-00012)
  • [L4] Closed biopsy of the musculoskeletal system compares favorably with other techniques and can be done with a low complication rate. [18] (10.2106/00004623-197961030-00010)
  • [L1] [19] (10.1007/s11552-011-9341-9)
  • [L4] [20] (10.1177/17531934231222401)
  • [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. [21] (10.1177/1758573217701064)
  • [Case_report] Complete resection of the mass and nerve decompression can lead to complete resolution of symptoms even with a long delay in diagnosis. [22] (10.1016/j.otsr.2012.11.015)
  • [L4] Treatment is directed at controlling the lesion locally, with curettage and adjuvant therapy being the primary goal for most lesions to preserve the articular surface. [23] (10.1016/j.hcl.2004.03.016)
  • [L5] Local excision of the tumour appears to be a satisfactory method of treatment. [25] (10.1016/s0266-7681(97)80269-0)
  • [L3] [26] (10.1054/jhsb.2000.0522)
  • [L4] [27] (10.11138/gchir/2013.34.5.149)
  • [L4] Recurrence after surgical excision of GCTTS varies widely from 4% to 44%, with incomplete excision being a primary cause. [28] (10.1016/j.jhsa.2012.11.001)
  • [L5] The fundamental consideration in the management of hand tumours is to reconcile adequate tumour clearance with the maintenance of function and appearance. [30] (10.1016/0266-7681(91)90159-l)
  • [L3] The absence of disease on MRI should not be used as the sole criterion in determining whether a repeat resection should be performed. [32] (10.1016/j.jhsa.2010.05.009)
  • [L5] Prolonged and atypical swelling of soft tissue, even with a previous traumatic lesion, may indicate underlying malignancy, necessitating proper imaging before surgery. [33] (10.1016/j.csm.2013.03.008)
  • [L4] Although most recurrences of giant-cell tumor of bone can be expected within the first two years, some patients remain at risk for a much longer period, with recurrences occurring nineteen to thirty years after initial treatment. [34] (10.2106/00004623-199408000-00013)
  • [L4] Giant-cell tumor of bone was effectively treated with megavoltage radiation in patients in whom operative resection would have been difficult or was not feasible, with a ten-year lack of progression rate of 85 percent. [35] (10.2106/00004623-199911000-00008)
  • [L4] Surgical treatment led to good functional results with an average Enneking score of 92% of normal limb function. [36] (10.1097/01.blo.0000224051.01873.fb)
  • [Case_report] [38] (10.2106/00004623-197860060-00020)
  • [L3] [39] (10.1016/s0266-7681(98)80084-3)
  • [L4] [40] (10.1007/s12593-010-0020-9)
  • [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. [41] (10.1055/s-0039-1679102)
  • [L4] [46] (10.1302/0301-620x.95b3.30192)
  • [L4] Arthroscopic excision is the treatment of choice and is currently thought to be curative. [55] (10.1016/j.arthro.2005.12.035)
  • [L3] [76] (10.2106/jbjs.18.01147)
  • [L5] [79] (10.1016/j.hcl.2004.03.001)
  • [L4] Arthroscopic excision is effective for localized type of GCTTS for all four joints. [96] (10.1016/j.otsr.2017.03.016)
  • [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. [99] (10.1186/s12891-017-1824-6)
  • [L3] The authors recommend intralesional surgery with polymethylmethacrylate for the majority of primary GCTs. [100] (10.1007/s11999-010-1501-7)
  • [L4] Arthroscopic excision is the preferred treatment due to its effectiveness and minimal morbidity. [101] (10.1007/s00167-003-0448-6)
  • [L4] Magnetic resonance imaging is essential to diagnose this pathologic condition and to define accurately its localization and treatment strategy. [105] (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. [113] (10.1186/s12891-016-1050-7)
  • [L4] MRI provides valuable clues, but definitive diagnosis relies on histopathological confirmation. [114] (10.1186/s12891-026-09563-w)
  • [L4] Pre-operative evaluation with MRI made an important contribution to the diagnosis of LPNS. [115] (10.1007/s00167-002-0318-7)
  • [L4] Open synovectomy is the standard method of management. [116] (10.5435/00124635-200606000-00007)
  • [Case_report] The ideal treatment for pigmented villonodular synovitis is complete operative excision. [117] (10.2106/00004623-199072060-00022)

See Also

References

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

[3] 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

[4] 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

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

[6] Malignant Giant Cell Tumor of the Tendon Sheath. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.049

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

[8] 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

[9] The Effect of Cellular Proliferative Activity on Recurrence and Local Tumour Extent of Localized Giant Cell Tumour of Tendon Sheath. Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsb.2004.06.012

[10] Giant cell tumour of hand bones: outcomes of treatment. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211007820

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

[12] Soft-Tissue Recurrence of Giant-Cell Tumor of Bone after Irridiation and Excision. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749020-00016

[13] 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

[14] Is Intralesional Treatment of Giant Cell Tumor of the Distal Radius Comparable to Resection With Respect to Local Control and Functional Outcome?. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-4054-3

[15] 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

[16] Tenosynovial giant cell tumour mimicking ulnar collateral ligament rupture at the thumb metacarpophalangeal joint. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211004437

[17] 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

[18] Closed biopsy of musculoskeletal lesions.. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961030-00010

[19] Giant Cell Tumour of Tendon Sheath of the Digits. A Systematic Review. HAND. 2011. DOI: 10.1007/s11552-011-9341-9

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

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

[22] 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

[23] Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.03.016

[25] Nora’s Lesion. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80269-0

[26] Giant Cell Tumours of Tendon Sheath: Classification and Recurrence Rate. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2000.0522

[27] Giant cell tumor of tendon sheath: study of 64 cases and review of literature. Giornale di Chirurgia - Journal of Surgery. 2013. DOI: 10.11138/gchir/2013.34.5.149

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

[30] Soft Tissue Tumours of the Hand. Journal of Hand Surgery. 1991. DOI: 10.1016/0266-7681(91)90159-l

[32] Predictive Value of Magnetic Resonance Imaging in Determining Presence of Residual Disease After Marginal Excision of Unsuspected Soft Tissue Sarcomas of the Hand. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.05.009

[33] Dilemmas in Distinguishing Between Tumor and the Posttraumatic Lesion with Surgical or Pathologic Correlation. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2013.03.008

[34] Late recurrence of giant-cell tumor of bone. A report of four cases.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199408000-00013

[35] Megavoltage Radiation Therapy for Axial and Inoperable Giant-Cell Tumor of Bone. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199911000-00008

[36] What Affects the Recurrence and Clinical Outcome of Pigmented Villonodular Synovitis?. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000224051.01873.fb

[38] Pigmented villonodular synovitis involving bone. Case report.. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860060-00020

[39] Measurement of Invasive Potential Provides an Accurate Prognostic Marker for Giant Cell Tumour of Tendon Sheath. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80084-3

[40] Giant Cell Tumor of Tendon Sheath: Case Series and Review of Literature. Journal of Hand and Microsurgery. 2010. DOI: 10.1007/s12593-010-0020-9

[41] 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

[43] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[44] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[46] 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

[55] 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

[58] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[67] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

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[76] Surgical Treatment of Localized-Type Tenosynovial Giant Cell Tumors of Large Joints. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.01147

[79] Principles of limb salvage surgery of the upper extremity. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.03.001

[96] 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

[99] 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

[100] Giant Cell Tumor of Bone: Risk Factors for Recurrence. Clinical Orthopaedics & Related Research. 2011. DOI: 10.1007/s11999-010-1501-7

[101] 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

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

[113] 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

[114] 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

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

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

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

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