Treatments of tenosynovial giant cell tumours of the temperomandibular joint: a report of three cases and a review of literature

Clinical retrospective analysis with a predictive model for diffused-tenosynovial giant cell tumors of the temporomandibular joint

BACKGROUND

This study aimed to find out the characteristics in relation to tumor recurrence in diffused-tenosynovial giant cell tumor of temporomandibular joint and to develop and validate the prognostic model for personalized prediction.

METHODS

From April 2009 to January 2021, patients with diffused-tenosynovial giant cell tumor of temporomandibular joint at a single center were included in this study. The clinical features and local recurrence-free survival were assessed through the expression of the Ki-67 index and colony-stimulating factor 1 receptor expression. Both univariate and multivariate analyses were performed on the prognostic factors for local recurrence-free survival. An independent predictor nomogram and pertinent tumor characteristics were included.

RESULTS

The retrospective study enrolling seventy eligible patients at the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine. During the follow-up time, eleven patients suffered tumor recurrence. Age was an independent risk factor for local recurrence-free survival (P = 0.032). The Ki-67 index varied significantly in different sites (P = 0.034) and tumor volume (P = 0.017). Multivariate logistic regression was used to develop the prediction model using both statistical significance and prognostic indicators. The C-index of the nomogram based on age, site, Ki-67, and colony-stimulating factor 1 receptor was 0.833. These variates provided good predicted accuracy for a nomogram on local recurrence-free survival. Diffused-tenosynovial giant cell tumor from the temporomandibular joint is extremely uncommon, and certain clinical traits are linked to the tumor proliferation index.

CONCLUSIONS

We identified the risk indicators and developed a nomogram in this study to forecast the likelihood of local recurrence-free survival in patients with diffused-tenosynovial giant cell tumor from temporomandibular joint.

A severe headache due to pigmented villonodular synovitis in a rare location: facial nerve on temporomandibular joint. A case report

BACKGROUND

Pigmented villonodular synovitis (PVNS) is an infrequent benign tumor-like proliferative lesion developing from the synovial membranes of the joint, tendon sheath, and bursa.

CLINICAL PRESENTATION

A 44-year-old woman with numbness on the right side of her face, severe headaches, and swelling in temporomandibular region is presented. On head and neck magnetic resonance imaging, an encapsulated mass approximately 2 cm was detected. The fine-needle aspiration biopsy resulted as suspicion of mesenchymal tumor. A complete resection with the capsule was performed over the temporal branch by monitoring of the facial nerve. The final histopathologic examination resulted as a giant cell tendon sheath tumor.

CONCLUSION

Headache is not the main symptom in PVNS, but in severe pain spreading from the temporomandibular region, physical examination should be done carefully for slight swelling, and the possibility of pigmented villonodular synovitis should be considered. Because of the high recurrence rate, en bloc resection is necessary.

Surgical Techniques and Functional Reconstruction for Complex Tenosynovial Giant Cell Tumor of Temporal Bone and Middle Skull Base

Objectives: Temporal tenosynovial giant cell tumors (TGCTs) are often large and have invaded the middle skull base. It is difficult to protect the important neurovascular structures around the tumor and perform functional reconstruction on the basis of complete tumor resection. This study aimed at analyzing the surgical techniques and functional reconstruction during the operation of complex TGCT of temporal bone and middle skull base. Methods: Five patients with pathologically confirmed TGCT of different complex types in the temporal bone and middle skull base were treated in our hospital from December 2020 to February 2023. We collected and retrospectively analyzed their medical records, including medical imaging, surgical procedures, and follow-up data. Results: The tumors invaded beyond the temporal bone and destroyed the middle skull base in all cases, involving the intracranial space and other important neurovascular structures. The internal carotid artery, infratemporal fossa, pterygopalatine fossa, and parapharyngeal space were also involved in 1 case. All the patients' tumors were completely removed, and the operations were performed mainly via modified infratemporal fossa approach, or combined with expanded middle cranial fossa approach. All cases with temporal and skull base destruction were repaired using the temporalis muscle flap with no occurrence of intracranial complications. The dura mater, condyle of temporomandibular joint, facial nerve, and internal carotid artery were fully preserved. Normal maxillofacial morphology was also preserved. The air conductive hearing of 2 patients was preserved. Conclusions: We found and summarized some surgical techniques that can help safeguard the important structures around massive TGCTs of temporal bone and middle skull base, and reconstruct the defects after tumor resection. The techniques are effective and feasible.

Management of tenosynovial giant cell tumour of the temporomandibular joint: a systematic review

Diffuse type tenosynovial giant cell tumour of the temporomandibular joint (D-TGCT-TMJ) is a rare proliferative disorder. The aim of this study was to perform a systematic review of the literature to summarize D-TGCT-TMJ management regimes and recurrence rates with at least 12 months of follow-up. Our secondary aim was to propose a minimum period of post-operative follow-up. A medline search for any D-TGCT-TMJ case detailing treatment, follow-up of at least 12 months, and presence of recurrence was undertaken. The following variables were extracted from the studies: patient's age and sex, presence of middle cranial fossa invasion, treatment undertaken, total length of follow-up, and presence of recurrence. All studies were assessed for bias as per the Joanna Briggs Institute systematic reviews appraisal tool. There were 63 cases reviewed and were predominantly managed with total resection (60.3%). Other modalities included: arthroplasty, subtotal resection with or without postoperative radiotherapy, medical therapy and surveillance. The recurrence rate was 9.52% and the longest follow-up period where recurrence was observed was at 60 months. Total resection and arthroplasty are common D-TGCT-TMJ management regimes. Patients with D-TGCT-TMJ should be followed up annually for at least 5 years postoperatively to assess for recurrence.

Image-guided, intensity-modulated radiotherapy for the treatment of diffuse-type tenosynovial giant cell tumor of the knee: Case report and review of the literature

RATIONALE

Tenosynovial giant cell tumor (TGCT) is a neoplastic, inflammatory disease with a benign but aggressive course that often presents as localized (TGCT-L) and diffuse (TGCT-D) forms based on the growth pattern and clinical behavior. For TGCT-L, simple excision of the diseased synovial tissue is the preferred treatment option, while for TGCT-D, adequate synovectomy is usually tricky but is essential. However, approximately 44% of TGCT-D cases will relapse after surgery alone. Thus, the optimal treatment strategy in patients with TGCT-D is evolving, and standalone surgical resection can no longer be regarded as the only treatment. The previous studies have shown that postoperative adjuvant radiotherapy can reduce recurrence in TGCT, especially in patients with incomplete synovectomy.

PATIENT CONCERNS

In the first case, a 54-year-old male presented with recurrent pain and swelling of the right knee with a protracted disease course (≥10 years). The other patient is a 64-year-old male who developed swelling, pain, abnormal bending, and limited movement of the left knee without obvious inducement.

DIAGNOSES

Clinical and imaging examinations can provide a definitive diagnosis, and pathology is the gold standard. TGCT-D was confirmed by postoperative pathology. After the operation, the patients underwent an MRI re-examination and showed that the lesions of the knee were not completely resected.

INTERVENTIONS

Arthroscopic synovectomy was performed on the patients, and postoperative pathology was confirmed as TGCT-D. Because of incomplete synovectomy, the 2 cases received image-guided, intensity-modulated radiotherapy (IG-IMRT) after the operation.

OUTCOMES

The follow-up time was 1 year, no evidence of disease progression was found in MRI. No obvious adverse effects associated with radiotherapy were detected during the follow-up period.

LESSONS

These cases and reviews illustrate the necessity of radiotherapy for TGCT-D and that IG-IMRT is a safe and effective method for treating TGCT-D of the knee.

Chondroid tenosynovial giant cell tumour of the temporomandibular joint

Chondroid tenosynovial giant cell tumour (TGCT) is an extremely rare disease affecting the temporomandibular joint (TMJ). This report details the peri-operative findings and treatment with custom TMJ replacement of an initially misdiagnosed chondroid TGCT involving the TMJ.

Diffuse-Type Tenosynovial Giant Cell Tumor Arising in the Temporomandibular Joint Extending to the External Auditory Canal: A Case Report and Literature Review

A 74-year-old Japanese woman with a 1-year history of right preauricular pain and a 2-month history of bleeding from the right ear was admitted to our department. Tumor was observed in the anterior wall in the right external auditory canal. Bony swelling of the right preauricular area was palpated. Computed tomography revealed an ill-defined, osteogenic tumor around the mandibular condyle with a destructive bony lesion involving the temporal bone. Magnetic resonance imaging revealed a 2.0 × 1.5 × 1.3-cm solid tumor around the mandibular condyle, exhibiting a low-intensity signal on T1-weighted imaging and an isointense central area surrounded by low-signal intensity on T2-weighted imaging. Histological examination of biopsy specimens revealed diffuse-type tenosynovial giant cell tumor (D-TGCT). After the feeding arteries for the tumor were embolized, the patient underwent surgery with combined temporal craniotomy and mandibular condylectomy. The soft and cystic tumor with calcification located in the extradural space was totally resected along with the mandibular condyle. No facial paralysis or recurrence was evident as of 6 months postoperatively. To date, only 23 cases of D-TGCT arising in the temporomandibular joint (TMJ) with ear involvement have been reported since 2011. We report successful resection of a rare case of D-TGCT arising in the TMJ.

Tenosynovial Giant Cell Tumor of the Retropharynx: A Case Report With Literature Review

Tenosynovial giant cell tumor (TSGCT) represents a family of benign tumors that arise from the synovial tissue of a joint, tendon sheath, or bursa. It usually involves the joints of the extremities and rarely occurs in the head and neck region. Here, we describe a case of a 32-year-old man with a submucosal mass bulging in the posterior pharyngeal wall since one month. The lesion was removed and diagnosed with localized type of TSGCT based on histopathological investigations and clinical presentation. It is very rare that TSGCT occurs in the retropharynx, which reminds clinicians to consider this entity as a possible diagnosis.

Clinical and immunohistochemical analysis of diffuse tenosynovial giant cell tumour of the temporomandibular joint

The objective of this study was to summarize diagnostic points and treatment strategies for diffuse tenosynovial giant cell tumours (D-TSGCTs) of the temporomandibular joint (TMJ), and to evaluate the expression of proteins related to bone destruction and recurrence. The clinical and histopathological characteristics of 24 cases were analysed retrospectively. TRAP staining and immunohistochemical staining for MMP-9, MMP-13, and Ki-67 were performed. The median age of the patients was 45.5 years; the female to male ratio was 1.7:1. In 11 cases (45.8%), skull base destruction seen on computed tomography was confirmed by surgery. Computer-assisted navigation was performed in six cases. Four patients received adjuvant radiotherapy after first surgery. Five patients had recurrent lesions. Multinucleated giant cells were positive for TRAP, MMP-9, and MMP-13. The average Ki-67 index of the recurrent cases was significantly higher than that of the non-recurrent ones (P<0.05). This study demonstrates the aggressive and recurrent nature of D-TSGCT occurring in the TMJ. Computer-assisted navigation is helpful to protect vital structures and determine margins. Adjuvant postoperative radiotherapy is recommended for local control of residual or recurrent tumour. In conclusion, MMP-9 and MMP-13 may play a role in bone destruction of D-TSGCT, and the Ki-67 index has predictive significance for recurrence.

Soft Tissue Special Issue: Giant Cell-Rich Lesions of the Head and Neck Region

Giant cell-rich lesions represent a heterogeneous group of tumors and non-neoplastic lesions, usually arising in bone, which harbor varying number of reactive osteoclastic-type multinucleate giant cells as a common feature. Among these entities, some are confined to the head and neck region (e.g., central giant cell granuloma and mimicking lesions, i.e., peripheral giant cell granuloma and cherubism) or show a relative predilection for this region (e.g., aneurysmal bone cyst and brown tumor of hyperparathyroidism), while others are rare but associated with distinct underlying disease (e.g., giant cell tumor of bone) or histology (e.g., tenosynovial giant cell tumor of the temporomandibular joint and phosphaturic mesenchymal tumor of the jaws) when occurring in the head and neck. Collectively, these lesions pose great challenge in the pathologic diagnosis, which often requires combinatory assessment from the clinical, histopathologic, and/or molecular aspects. This review provides a summary of pertinent clinical and pathologic features and an update of recent molecular and genetic findings of these entities. The considerations in differential diagnosis as well as the effects of the emerging therapeutic RANKL-antagonizing antibody denosumab will also be addressed.