[Pigmented villonodular synovitis. A rare differential diagnosis of synovial joint swelling]

Tenosynovial Giant Cell Tumor (TSGCT) of the hip: MRI accuracy and results of surgical treatment

Tenosynovial Giant Cell Tumor (TSGCT) or formerly pigmented villonodular synovitis (PVNS) is a rare nonmalignant tumor of the synovia seldom affecting the hip. MRI and surgical resection are the gold standards in its diagnosis and treatment. However, the accuracy of MRI is unknown, and only few reports on its surgical treatment results exist. The goal of the study was to investigate the MRI accuracy, results after surgical treatment, and natural history of untreated MRI-diagnosed hip TSGCT. Twenty-four consecutive patients with suspected TSGCT on hip MRI, between December 2006 and January 2018, were identified from our medical database. Six refused to participate. About 18 patients with a minimal follow-up of 18 months were enrolled. Charts were reviewed for histopathology results, specific treatment and recurrence. At the last follow-up, all patients had a clinical (Harris Hip Score [HHS]) and radiological examination (x-ray and MRI). Out of 18 patients with suspected TSGCT on MRI, with a mean age of 35y (range 17-52), 14 had surgi- cal resection and 4 refused surgery 1 of whom had a CT-guided biopsy. Out of 15 cases with biopsies, in 10 TSGCT was confirmed. Three surgically-treated patients showed recurrence on MRI after 24, 31 and 43 months. Two non-treated patients showed progression after 18 and 116 months. At the last follow-up (65 m; range 18-159), the mean HHS with or without recurrence was 90 and 80pts (ns). Operative vs. non-operative treatment showed HHS of 86 and 90pts (ns). In the conservatively-treated group, HHS with and without progression was 98 and 82pts (ns), respectively. MRI-suspected TSGCT of the hip was confirmed with biopsy in two-thirds of the cases. Surgical treatment showed recurrence in more than one-third of the patients. Two out of four untreated patients showed progression of the TSGCT-suspected lesion.

Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology

BACKGROUND

 Magnetic Resonance Imaging (MRI) is a very innovative, but at the same time complex and technically demanding diagnostic method in radiology. It plays an increasing role in high-quality and efficient patient management. Quality assurance in MRI is of utmost importance to avoid patient risks due to errors before and during the examination and when reporting the results. Therefore, MRI requires higher physician qualification and expertise than any other diagnostic imaging technique in medicine. This holds true for indication, performance of the examination itself, and in particular for image evaluation and writing of the report. In Germany, the radiologist is the only specialist who is systematically educated in all aspects of MRI during medical specialty training and who must document a specified, high number of examinations during this training. However, also non-radiologist physicians are increasingly endeavoring to conduct and bill MRI examinations on their own.

METHOD

 In this position statement, the following aspects of quality assurance for MRI examinations and billing by radiologists and non-radiologist physician specialists are examined scientifically: Requirements for specialist physician training, MRI risks and contraindications, radiation protection in the case of non-ionizing radiation, application of MR contrast agents, requirements regarding image quality, significance of image artifacts and incidental findings, image evaluation and reporting, interdisciplinary communication and multiple-eyes principle, and impact on healthcare system costs.

CONCLUSION

 The German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists are critical with regard to MRI performance by non-radiologists in the interest of quality standards, patient welfare, and healthcare payers. The 24-month additional qualification in MRI as defined by the physician specialization regulations (Weiterbildungsordnung) through the German state medical associations (Landesärztekammern) is the only competence-based and quality-assured training program for board-certified specialist physicians outside radiology. This has to be required as the minimum standard for performance and reporting of MRI exams. Exclusively unstructured MRI training outside the physician specialization regulations has to be strictly rejected for reasons of patient safety. The performance and reporting of MRI examinations must be reserved for adequately trained and continuously educated specialist physicians.

KEY POINTS

· MR imaging plays an increasing role due to its high diagnostic value and serves as the reference standard in many indications.. · MRI is a complex technique that implies patient risks in case of inappropriare application or lack of expertise.. · In Germany, the radiologist is the only specialist physician that has been systematically trained in all aspects of MRI such as indication, performance, and reporting of examinations in specified, high numbers.. · The only competence-based and quality-assured MRI training program for specialist physicians outside radiology is the 24-month additional qualification as defined by the regulations through the German state medical associations.. · In view of quality-assurance and patient safety, a finalized training program following the physician specialization regulations has to be required for the performance and reporting of MRI examinations..

CITATION FORMAT

· Hunold P, Bucher AM, Sandstede J et al. Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology. Fortschr Röntgenstr 2021; 193: 1050 - 1060.

[Imminent fracture of the tibia due to an osteolytic lesion caused by an intraosseous tenosynovial giant cell tumor : An unusual clinico-histopathological constellation]

Der tenosynoviale Riesenzelltumor (TSGCT) ist eine seltene gutartige Erkrankung von Gelenkschleimhäuten, Sehnenscheiden und Schleimbeuteln. Wir berichten über die ungewöhnliche Konstellation einer intraossären Manifestation der proximalen Tibia eines Unterschenkelstumpfes nach Burgess-Amputation infolge eines lokal nicht beherrschbaren tenosynovialen Riesenzelltumors des oberen Sprunggelenkes. Die Kürettage des Lokalbefundes und die operative Stabilisierung durch eine intramedulläre Verbundosteosynthese führten zu einer frühzeitigen Rehabilitation der Exoprothesenversorgung mit Wiedererlangung der Patientenautonomie.

Localized Pigmented Villonodular Synovitis of the Knee Co-existing with Extra-articular Nodular Synovitis of the Popliteus Tendon Sheath: A Case Report

Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder affecting the synovial membranes of joints, bursae, and tendons. The knee joint is one of the most common locations for an intra-articular type of PVNS and this is usually of the diffuse type of PVNS or diffuse pigmented villonodular synovitis (DPVNS). DPVNS tends to be more associated with affectation of contiguous structures. We report a case of a localized form of the disease affecting the knee joint coexisting with an extra-articular lesion of the same nature involving the popliteus tendon sheath of the same knee. The clinical condition was managed with a combined surgical approach of arthroscopic marginal excision for the intra-articular lesion and excision biopsy for the extra-articular lesion.

[Rheumatoid arthritis-mimics : When appearances are deceptive]

Rheumatology represents a discipline full of differential diagnoses. Even for classical diseases, such as rheumatoid arthritis as the most frequent chronic inflammatory joint disease and described so clearly in many textbooks, it is not uncommon that it can be a diagnostic challenge in daily practice. This applies to arthritic joint involvement and also to frequently associated extra-articular manifestations. The patient history and results of the clinical examination are essential; however, laboratory and imaging findings often make a significant contribution to confirming the diagnosis, especially in early phases of the disease. This article, which makes no claims to completeness, focuses on diseases that in the opinion of the authors can imitate rheumatoid arthritis due to similar joint and other organ manifestations. These include metabolic, inflammatory infective and non-infective as well as tumorous diseases. A misinterpretation as rheumatoid arthritis as a rule leads to long-term and severe consequences for affected patients. Thus, the diagnosis of rheumatoid arthritis should be questioned and re-evaluated in cases of unusual accompanying symptoms, atypical course of disease and a lack of response to standard treatment approaches.

Localized Pigmented Villonodular Synovitis of the Posterior Knee Compartment with Popliteal Vessel Compression: A Case Report of Arthroscopic Resection Using Only Anterior Knee Portals

Background

Pigmented villonodular synovitis is a rare pathology causing hyperplasia of the synovium. It mostly affects young populations and most commonly the knee joint. It rarely affects the posterior compartment of the knee as the case presented in this study. Open surgery is usually used to treat this condition; however, in our case it was excised arthroscopically despite the anatomical challenges of the posterior knee compartment.

Case Presentation

This case presents a female patient with a complaint of posterior-region pain of her left knee post direct trauma post fall. This was directly followed by knee joint blockage for 1-week duration before presentation to the hospital. On MRI, she was found to have a multiloculated hemosiderin-containing structure of synovial origin within the femoral notch, extending beyond the joint capsule displacing the popliteal vessels. The patient underwent arthroscopic resection of the lesion, which was found to be pigmented villonodular synovitis on anatomopathological examination. On 6-month follow-up, the patient showed good clinical evolution with the absence of symptoms and back-to-normal daily activities.

Conclusion

This is a rare case of PVNS affecting the posterior knee joint compartment of a middle-aged woman, which was successfully excised arthroscopically, with no residual affected tissue or recurrence on 6-month follow-up.

Diffuse pigmented villonodular synovitis in knee joint: diagnosis and treatment

Pigmented villonodular synovitis is a rare proliferative condition of the synovium. Although the condition can present in any joint, the knee is the most commonly affected site. Despite being a benign condition, pigmented villonodular synovitis is often aggressive, with marked extra-articular extension in some cases. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate. There is no standard method of management of this lesion. Open surgery is a classical and effective method for treatment. Arthroscopic synovectomy, however, has gained popularity, and has several advantages over the open technique particularly in exclusively articular cases. The combined approach is suggested in cases with extra-articular involvement. Synovectomy through any approach may prevent secondary osteoarthritis and subsequent joint arthroplasty. Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy appears to decrease the rate of local recurrence in diffuse cases. The authors observed a great heterogeneity in reporting of functional results, and specific conclusions should not be drawn. Each patient should be managed in accordance with his/her particular condition.