Perturbations of humoral and cellular immunity in a patient with pigmented villonodular synovitis

Pigmented villonodular synovitis of the thoracic spine

Pigmented villonodular synovitis (PVNS) is a proliferative lesion of the synovial membranes. Knees, hips, and other large weight-bearing joints are most commonly affected. PVNS rarely presents in the spine, in particular the thoracic segments. We present a patient with PVNS in the thoracic spine and describe its clinical presentation, radiographic findings, pathologic features, and treatment as well as providing the first comprehensive meta-analysis and review of the literature on this topic, to our knowledge. A total of 28 publications reporting 56 patients were found. The lumbar and cervical spine were most frequently involved (40% and 36% of patients, respectively) with infrequent involvement of the thoracic spine (24% of patients). PVNS affects a wide range of ages, but has a particular predilection for the thoracic spine in younger patients. The mean age in the thoracic group was 22.8 years and was significantly lower than the cervical and lumbar groups (42.4 and 48.6 years, respectively; p=0.0001). PVNS should be included in the differential diagnosis of osteodestructive lesions of the spine, especially because of its potential for local recurrence. The goal of treatment should be complete surgical excision. Although the pathogenesis is not clear, mechanical strain may play an important role, especially in cervical and lumbar PVNS. The association of thoracic lesions and younger age suggests that other factors, such as neoplasia, derangement of lipid metabolism, perturbations of humoral and cellular immunity, and other undefined patient factors, play a role in the development of thoracic PVNS.

Outcome following radiation treatment for high-risk pigmented villonodular synovitis

PURPOSE

Pigmented villonodular synovitis (PVNS) is a rare proliferative process involving synovial membranes. It has a variable course, and while usually benign, may be destructive, resulting in major symptoms and loss of function leading to amputation. Optimum treatment is not always clear, and little information exists with respect to the role of radiotherapy. The purpose was to review our experience with radiotherapy in cases at high risk for recurrence with functional loss including instances where amputation was the sole alternative for symptomatic disease.

METHODS AND MATERIALS

The records of all patients registered between 1972 and 1992 with a diagnosis of PVNS were identified (21 cases). The records of 14 cases who received radiotherapy after referral were reviewed retrospectively for demographic information, radiotherapy treatment parameters, and tumor outcome.

RESULTS

All cases had confirmation of pathologic diagnosis. Six patients had primary and eight had recurrent disease (with a mean of 2.5 prior surgical procedures). All cases had both intra- and extraarticular disease and, without exception, the poorer prognosis diffuse subtype of the disease. The majority had one or more additional risk factors including skin, bone, tendon, neurovascular, or muscle group extension. With a mean follow-up time of 69 months (range 13-250 months), only one patient has shown persistence of disease. With the exception of that single case, all those with measurable disease had obvious disease until at least 12 months and, subsequently, manifested complete responses. The single case was lost from the clinic after 8 months from the initiation of radiotherapy to a dose of 30 Gy in 15 fractions and had a palpable mass at the time. He subsequently was noted to have a persisting mass and an excisional biopsy 9 years later showed PVNS. He remains well 21 years after treatment with good function. Eleven patients enjoyed excellent or good function from the affected limb and three had fair function. All patients had greater use of limb than at the time of treatment. No patient required amputation, and none had evidence of serious radiotherapy complications.

CONCLUSIONS

These results demonstrate that moderate dose radiotherapy is an effective modality in the treatment of a subset of cases with this rare condition. Its use has permitted avoidance of amputation in very advanced cases with acceptable function preservation. When treatment is indicated we currently recommend gross total removal of PVNS. This is followed by moderate dose radiotherapy (35 Gy in 15 fractions) for residual disease where salvage of subsequent recurrence may compromise function.

Pigmented villonodular synovitis of the hip: review of radiographic features in 58 patients

Clinical and radiographic findings were retrospectively reviewed in a multicentric survey of 58 patients with histologically proven pigmented villonodular synovitis (PVNS) of the hip. The most common clinical features were mechanical pain (47 cases) and limitation of joint motion (47 cases). On plain films, a classic form with large and multiple lucencies was found in 36 cases, followed by an osteoarthritis-like form (9 cases), an arthritis-like form (8 cases), normal radiographic appearance (3 cases), osteonecrosis of the femoral head (one case) and joint destruction with acetabular protrusion (one case). Bilateral involvement of the hips was probable in two patients. In contrast to the knee, the hip showed a high prevalence of bony lesions and joint space narrowing. Although an uncommon disease, PVNS of the hip has to be considered when arthritis is associated with uncharacteristic clinical or radiographic findings.

Diffuse and localized tenosynovial giant cell tumor and pigmented villonodular synovitis: a clinicopathologic and flow cytometric DNA analysis

The DNA content and proliferative indexes of seven cases of tenosynovial giant cell tumor of tendon sheath, diffuse type (TGCT-D); 11 cases of tenosynovial giant cell tumor of tendon sheath, localized type (TGCT-L); and seven cases of pigmented villonodular synovitis (PVNS) were analyzed by flow cytometry in an attempt to assess objectively their biologic differences. Three cases of TGCT-D manifested an aneuploid DNA content and four had a diploid DNA pattern. All cases of TGCT-L and PVNS showed a diploid DNA content. The proliferative indexes for TGCT-D were significantly higher than those found in the other two groups. There was no histopathologic feature that correlated with the aneuploid DNA pattern found in two of the three cases of TGCT-D. Only one of the three aneuploid DNA content TGCT-D cases displayed marked cellular pleomorphism with dense fibrous stroma; in that case there was recurrence 4 years after initial excision. Our data further support that TGCT-D, TGCT-L, and PVNS are histopathologically similar but clinically distinct lesions. The high proliferative indexes of TGCT-D may reflect a rapid, uncontrolled growth that may explain its aggressive biologic behavior. The presence of an aneuploid DNA pattern in some cases of TGCT-D in this study, coupled with the reported chromosomal abnormalities and occurrence of malignant transformation in these lesions, clearly supports their neoplastic nature.

Treatment of pigmented villonodular synovitis with yttrium-90: changes in immunologic features, Tc-99m uptake measurements, and MR imaging of one case

Pigmented villonodular synovitis (PVNS) is an uncommon proliferative disease of synovium. We report a 35-year-old male with diffuse form of PVNS of left knee, treated with intraarticular injection of 5 mCi of yttrium-90 (Y-90) silicate colloid consisting of two doses with a 3-month interval between them. During follow-up, the affected knee showed clinical improvement and was accompanied by a decrease of the levels of soluble interleukin-2 receptor in sera and synovial fluids (SF). When compared to osteoarthritis subjects, SF lymphocyte subsets of this case before Y-90 therapy showed a lower CD4:CD8 cell ratio and absence of suppressor inducer cells (CD4+ 2H4+). The Tc-99m pertechnetate knee uptake indexes correlated well with clinical improvement. Serial magnetic resonance imaging revealed significant change one year after Y-90 therapy. The findings of immunological assessment suggested that immunoregulatory dysfunction may be related to the pathogenesis of PVNS.

Cytogenetic evidence of clonality in a case of pigmented villonodular synovitis

Pigmented villonodular synovitis is an uncommon benign lesion that is characterized by diffuse synovial proliferation. Based on animal models, this lesion has been conjectured previously to be reactive in nature. In this report, the authors present the histologic and cytogenetic findings for a pigmented villonodular synovitis that was excised from the right knee of a 47-year-old man. Trisomy 7 was observed in 24 of 75 (35%) metaphases obtained from short-term culture of cells from this tumor. These findings suggest that some cases of pigmented villonodular synovitis represent clonal, neoplastic proliferations.

Diagnostic arthroscopy of the hip joint in pigmented villonodular synovitis

A case of pigmented villonodular synovitis of the hip is presented. The delay between the onset of symptoms and the histopathologic confirmation of this condition generally accounts for the massive local bone invasion, frequently necessitating a total hip arthroplasty. Earlier diagnosis through arthroscopy and subsequent chemical synoviorthesis might reduce the need for more aggressive surgery and improve the prognosis of this rare condition.

Localized nodular tenosynovitis: experience with 115 cases

One hundred fifteen cases of localized nodular synovitis (giant cell tumor of the tendon sheath) were reviewed. The optimal treatment for these lesions is unknown, and a high recurrence rate exists. Growths arose from most of the synovial sites of the hand, including joints, capsular ligaments, and tendon sheaths. Deformation of the bone surface was commonly seen; however, bone invasion was uncommon. The histologic features may vary, but the lesions are always benign and do not metastasize. Treatment consisted of thorough local excision and adjacent joint exploration when appropriate. Recurrence occurred in 10 cases (9%) with one to five additional surgical procedures needed to eradicate the lesion.

Localized nodular synovitis of the knee: a case report

A 25-year-old man with chronic swelling of the right knee had a mass that was eventually palpated in the suprapatellar pouch. Arthrotomy and biopsy revealed localized nodular synovitis. Since surgical excision of the mass the patient has been asymptomatic. While localized nodular synovitis generally appears as an internal derangement of the joint, this patient had signs and symptoms of chronic monoarthritis.