Case report 590: Diffuse pigmented villonodular synovitis with a cartilaginous component

Retrospective study of synovial chondromatosis of the temporomandibular joint: clinical and histopathologic analysis and the early-stage imaging features

OBJECTIVE

Herein, we aimed to study the clinical, radiographical, and histopathologic features of synovial chondromatosis in the temporomandibular joint (SC in TMJ) and provide references for early diagnosis and treatment prognosis.

STUDY DESIGN

The medical records and imaging examinations of patients with SC in TMJ, diagnosed using postoperative histopathologic examination, were reviewed and analyzed. Among them, 18 cases who lacked calcified loose bodies on spiral computed tomography or cone beam computed tomography (SCT/CBCT) were selected for further study. Descriptive statistical methods were used to analyze the clinical characteristics of patients.

RESULTS

The study included 100 patients with SC in TMJ, who were predominantly female (male to female: 1:3), and were aged from 21 to 77 years (median, 47). Radiopaque calcified lesions on SCT/CBCT were missing in 18 cases, but cartilaginous nodules were observed during surgery. The cases lacking calcification had a relatively shorter disease course, suggesting they were in the early stages of SC.

CONCLUSION

In the early stage of SC, although calcified loose bodies cannot be detected on SCT/CBCT, attention should be paid to the widening of the posterior superior joint space and sclerosis or slight erosion of the joint fossa. Magnetic resonance imaging would be helpful to detect the early-stage SC in TMJ.

Tenosynovial Giant Cell Tumor, Localized Type With Extensive Chondroid Metaplasia: A Case Report With Immunohistochemical and Molecular Genetic Analysis

Tenosynovial giant cell tumor (TSGCT) of localized type is a common disease occurring mostly in the hands. Diagnosis of this tumor is relatively easy to render with hematoxylin-eosin-stained sections as compared with that of TSGCT of diffuse type. However, very rare cases with chondroid metaplasia that have recently been reported mainly in diffuse type can make pathological differentiation from soft tissue cartilaginous tumors extremely difficult. In this article, the authors present the second reported case of TSGCT of localized type showing extensive chondroid metaplasia. Pathological interpretation was difficult without utilizing immunohistochemistry and fluorescence in situ hybridization. One must be careful not to misdiagnose this lesion as cartilaginous tumors of soft tissue, and we suspect at least some chondroblastoma-like chondroma could be reclassified as TSGCT of localized type with extensive chondroid metaplasia. Morphological, immunohistochemical, and molecular genetic characteristics are presented and discussed.

Potential utility of anti-TNF drugs in synovial chondromatosis associated with ankylosing spondylitis

We describe a previously unreported association of ankylosing spondylitis with synovial chondromatosis, and briefly review previously reported cases and treatment of synovial chondromatosis in patients with other immune-mediated inflammatory arthritides. A 20-year-old man with ankylosing spondylitis whose axial disease was in remission with nonsteroidal anti-inflammatory drugs and oral disease-modifying anti-rheumatic drugs developed recurrent right knee pain and swelling. Magnetic resonance imaging of his right knee revealed calcified loose bodies, suggestive of synovial chondromatosis. While waiting for the surgical intervention and other invasive therapy previously reported in patients with synovial chondromatosis, a trial of etanercept eliminated the pain and swelling of the knee; however, the loose bodies have persisted during the 2-year follow-up. Thus, synovial chondromatosis should be considered in the differential diagnoses of a refractory monoarticular pain and swelling in patients with otherwise controlled inflammatory arthritis. Our report advocates a trial of anti-tumor necrosis factor drugs, which might delay the need for invasive therapy in patients with synovial chondromatosis.

The surgical outcome and recurrence rate of tenosynovial giant cell tumor in the elbow: a literature review

BACKGROUND

Tenosynovial giant cell tumor (TSGCT) is a rare proliferative disorder of the synovium. Because of its aggressive nature and recurrence potential, treatment of TSGCT involves surgical resection with or without synovectomy. There is currently a paucity of literature describing the surgical management of TSGCT at the elbow. The aim of this study was to evaluate clinical outcomes and recurrence rates following open and arthroscopic excision of TSGCT in the elbow.

METHODS

Electronic databases were searched for relevant articles relating to surgical management of TSGCT of the elbow. We included all patients who received surgical treatment for TSGCT, with no age limitations. We excluded any nonsurgical treatment studies. Seventy-seven articles were identified for screening, and a total of 27 patients from 24 studies were included for the review.

RESULTS

The patients' mean (standard deviation [SD]) age was 40.3 (21.7) years, and the most common presenting symptoms included pain (18/27, 66.7%), swelling (19/27, 70.4%), and decreased range of motion of the elbow (9/27, 33.3%). The majority of patients underwent open excision with or without synovectomy (23/27, 85.1%). Of those undergoing open procedures, 16 (16/23,69.6%) had diffuse TSGCT and 14 (14/23, 60.9%) remained symptom free for a mean (SD) follow-up of 38.9 (25.4) months. Four patients (4/27, 14.8%) were treated arthroscopically, all of whom had diffuse disease.

CONCLUSIONS

Our review found that open synovectomy appears to be an effective treatment for both localized and diffuse TSGCT in the elbow, and arthroscopic synovectomy is emerging as a method of surgical management for diffuse TSGCT. However, because of the limited number of patients undergoing surgery for TSGCT, further studies are needed to make a definite conclusion.

Chondroid Tenosynovial Giant Cell Tumor of the Temporomandibular Joint: A Rare Case Report

Tenosynovial giant cell tumor of diffuse type (TGCT-d) or pigmented villonodular synovitis (PVNS) is a locally aggressive lesion that mostly affects the joints of long bones. Chondroid tenosynovial giant cell tumor (CTGCT) or PVNS with chondroid metaplasia is a rare distinct subset of synovial tumors that has a predilection for the TMJ. We report a rare case of CTGCT in the TMJ, initially misdiagnosed as temporomandibular disorder (TMD). A 51-year-old woman was referred to the surgeon with the chief complaint of TMJ pain for 5 years and a past history of an unsuccessful TMD treatment. Extraoral examination revealed discrete preauricular swelling and restricted mandibular range of motion. Panoramic radiograph and computerized tomography showed destruction of the mandibular fossa and condyle. Histologically, the tumor was composed by large mononuclear cells with prominent eosinophilic cytoplasm and grooved nuclei, small histiocytoid cells, osteoclast-like multinucleated cells, brown pigmentation and areas of chondroid metaplasia. Morphological and immunohistochemical characteristics lead to the final diagnosis of CTGCT. The rarity of CTGCT could be attributed to the lack of recognition of this lesion, with cases diagnosed as chondroblastomas, synovial chodromatosis and chondrosarcoma. The patient received immediate reconstruction and recurrence was found 22 months after initial intervention. TGCT-d and CTGCT of the TMJ can present similar symptoms to TMD, but clinicians must distinguish both lesions by complete examination, imaging and, when necessary, histopathologic evaluation.

Fine Needle Aspiration Cytology of Chondroid Tenosynovial Giant Cell Tumor of the Hand

Giant cell tumor (GCT) of tendon sheath is a localized form of tenosynovial GCT, which preferentially affects the joints of hands and feet. Chondroid metaplasia is a rare phenomenon in tenosynovial GCT either in localized or diffuse types. The current case investigates the cytological and histopathological features of chondroid GCT of tendon sheath in a 22-year-old female presenting with wrist swelling.

Magnetic resonance imaging and thallium-201 scintigraphy for the diagnosis of localized pigmented villonodular synovitis arising from the elbow: A case report and review of the literature

Pigmented villonodular synovitis (PVNS) arising from the elbow joint is extremely rare; only 24 cases have been reported. It is extremely difficult to differentiate PVNS from other soft tissue tumors on the basis of imaging findings alone. Therefore, a biopsy is required for definitive diagnosis. A 20-year-old female reported a mass on her right elbow. Physical examination revealed a tumor measuring 3.0x3.0 cm. Magnetic resonance imaging (MRI) revealed that the signal intensity of the tumor was isointense to muscle on T1-weighted images; however, it was hyper- or isointense to muscle on T2-weighted images. In images obtained by gadolinium-enhanced MRI, the margin of the tumor was well-contrasted. Thallium (Tl)-201 scintigrams revealed an abnormal accumulation in the area of the mass in the early and delayed phases. On the basis of clinical findings, imaging characteristics and incision biopsy results, localized PVNS was diagnosed and marginal excision was performed. We thus identified an extremely rare case of PVNS arising from the elbow joint. When interpreting Tl-201 images for the assessment of bone and soft tissue lesions, it is important to recognize PVNS as a condition that simulates malignant tumors. Furthermore, PVNS should be considered in the differential diagnosis when increased Tl-201 activity is closely related to the joint. MRI aids in the differentiation by demonstrating features of hemosiderin degradation products. These findings are likely to be extremely helpful in the differential diagnosis of bone and soft tissue tumors.

Malignant pigmented villonodular synovitis of the temporomandibular joint with lung metastasis: a case report and review of the literature

Malignant pigmented villonodular synovitis (PVNS) is an extremely rare lesion. Approximately 30 cases of malignant PVNS have been reported to date and of these, only 1 case involved the temporomandibular joint. Owing to the rarity of well-documented cases and the heterogeneous histologic features of this group of tumors, there has been some confusion regarding its diagnosis. The heterogeneous features of the sarcomatous areas contain fibrosarcomatous, myxosarcomatous, malignant fibrous histiocytomalike or giant cell tumorlike patterns. However, despite the absence of frank sarcomatous change in the histopathogy of PVNS, there have been 3 reported cases of metastatic lesions in the lung or lymph nodes. Here we present an additional case of clinically malignant PVNS with pulmonary metastasis after recurrence. A 29-year-old man presented in our hospital with a recurrent swelling and pain in the right preauricular area, where benign tumor had been previously resected. MRI demonstrated a large mass with a low signal intensity that seemed to demonstrate a ferromagnetic effect. Surgical resection of the lesion was performed and the diagnosis of PVNS with focal atypical cells was made. Unfortunately, at 30 months post surgery, a thoracic CT found a metastatic nodule in the left lower lobe of the lung.

Chondroid tenosynovial giant cell tumor: a clinicopathological and immunohistochemical analysis of 5 new cases

Tenosynovial giant cell tumor (TGCT) arises from the synovium of joints or tendon sheaths. Chondroid metaplasia in TGCT is rare with only 4 well-documented cases reported in the literature. The authors describe the morphological features and immunophenotype of 5 new cases of chondroid TGCT emphasizing a broader range of matrix patterns in these tumors and an expanded immunophenotype, specifically, staining for clusterin and podoplanin which have recently been found to be expressed in conventional TGCTs. Chondroid metaplasia was extensive in 3 cases. Matrix patterns included chondromyxoid, chondro-osseous, hyaline-like, and lace-like calcification similar to that seen in chondroblastoma. The authors conclude that chondroid TGCT is a rare, distinct synovial tumor with a predilection for the temporomandibular joint that has a similar immunophenotype as conventional TGCT. Chondroid metaplasia may be extensive and have a variety of matrix patterns. Chondroid TGCT needs to be distinguished from other chondroid lesions, including chondroblastoma and chondrosarcoma.

Pigmented villonodular synovitis of the elbow treated with the Tsuge wide joint exposure technique

Pigmented villonodular synovitis (PVNS) is a benign, locally aggressive disease of the synovium; its cause remains unclear. The most frequently involved joint is the knee, followed by the hip, ankle, wrist, and shoulder. Pigmented villonodular synovitis of the elbow joint is rare. Synovectomy is currently believed to be the best treatment for PVNS. Open or arthroscopic synovectomy is usually selected. During synovectomy for PVNS, the possibility of local recurrence after surgery must be considered. The recurrence rate after synovectomy of any joint for PVNS is approximately 40%. Therefore, surgical treatment for PVNS of the elbow requires sufficient removal of the lesion. For good functional results, prevention of postoperative joint stiffness is also necessary. This article describes a case of a 29-year-old woman with PVNS of the right elbow who was treated by total synovectomy using the Tsuge technique. Tsuge reported a new surgical technique for debridement arthroplasty using a posterolateral approach to the elbow in 1987. He has also reported using this procedure during arthroplasty for posttraumatic stiff elbow and for synovectomy in rheumatoid arthritis. This approach permits easy dislocation of the elbow and provides a good view of the whole joint. Although the recurrence rate of PVNS of the elbow is high, our patient has retained good elbow function with no evidence of local recurrence at 30 months postoperatively.

Pigmented villonodular synovitis of the elbow

We present a 16 year old student with right elbow pigmentary villonodular synovitis. Clinical diagnosis, radiological features, MRI findings, biopsy results, management and follow up are discussed. MRI is the diagnostic modality of choice and assists the surgeon for a proper incision. Correlation of all the clinical aspects and the histologic features is usually required for definitive diagnosis. A complete surgical synovectomy provides the best chance for cure, but the goal of eradication of this benign process must be balanced against the morbidity of more aggressive surgery. The patient made a full recovery at the end of 4 years and leads a normal life. Pigmented villonodular synovitis should be included in the differential diagnosis of elbow monoarticular joint swelling in young and middle-aged adults.

Pigmented villonodular synovitis of the elbow with a fenestrated fossa: a case report

We report a case of pigmented villonodular synovitis of the elbow in a 55-year-old woman. Its radiological feature, the fenestrated fossa, may be characteristic of the advanced stage of this disorder.

Pigmented villonodular synovitis with chondroid metaplasia, resembling chondroblastoma of the bone: a report of three cases

We herein describe three cases of pigmented villonodular synovitis with chondroid metaplasia. Two cases involved the temporomandibular joint, whereas the remaining one case occurred in the hip joint. Histologically, the tumors showed a villous pattern and were mainly composed of histiocyte-like cells and scattered osteoclast-like multinucleated giant cells, accompanied by chondroid areas with occasional lace-like calcification. These features resembled those of chondroblastoma of the bone, with the exception of the villous pattern. The histiocyte-like cells showed positive immunoreactivity for CD68, whereas they were negative for S-100 protein. Some of the previously reported cases of chondroblastoma in the temporal bone may have actually been cases of pigmented villonodular synovitis with chondroid metaplasia. When histologically chondroblastoma-like lesions involve the temporal bone or temporomandibular joint, the possibility of pigmented villonodular synovitis with chondroid metaplasia should also be considered, in addition to chondroblastoma of the bone. The correlation between this lesion and synovial chondromatosis remains uncertain.

Pigmented villonodular synovitis of the elbow in a 6-year-old girl: a case report

Pigmented villonodular synovitis of the elbow is rare and even rarer in children. We report a case of pigmented villonodular synovitis of the elbow in a 6-year-old girl who underwent total synovectomy after the diagnosis was confirmed by biopsy. The osteochondral defect at the olecranon was filled with calcium phosphate bone paste. Two years after surgery, neither recurrence nor joint degeneration was found.

Pigmented villonodular synovitis of the elbow: a case report and literature review

Pigmented villonodular synovitis is a well-described, benign proliferative disorder of the synovium that rarely affects the elbow joint. Only 12 cases have been reported in this site. A case is presented of elbow involvement by pigmented villonodular synovitis that was documented by magnetic resonance imaging before surgery and monitored until recurrence.

Pigmented villonodular synovitis of the elbow

Pigmented villonodular synovitis (PVNS) is a monoarticular condition with a variable prognosis. The first account of it was given by Chassaignac in 1852. The condition was given its name by Jaffe in 1941. In separate studies Miller in 1982 and Flandry et al. in 1994 determined the overall incidence of PVNS varied between 1 and 3 per 1,000,000. The joint most commonly involved is the knee, and according to Dorwart et al. the elbow is rarely affected. Seventeen other cases of PVNS of the elbow have been reported, and very scant information exists about optimal treatment or outcome.

Giant cell tumor of tendon sheath: spectrum of radiologic findings

Giant cell tumor of tendon sheath is the second most common tumor of the hand. It can also occur in larger joints. Radiologic features include a soft-tissue mass with or without osseous erosion. Less commonly, it can cause periostitis or permeative osseous invasion; it may rarely calcify. The entire imaging spectrum of this lesion is presented, with emphasis on atypical appearances which can mimic other lesions.