Figure 6: Post-operative image of the thumb at 1 month of GCTTS
excision.
Discussion
This case was intended to report
a rare case of giant cell tumor tendon sheath of distal phalanx. Giant
cell tumors most commonly affect the first three fingers, with the index
finger being the most frequently involved and in this patient, thumb was
the site of lesion [5,7,8]. These tumors are most commonly found in
the region of the distal interphalangeal (DIP) joint, followed by the
proximal phalanx similar to this study [9,10].
GCTTS manifests clinically as a firm, painless, gradually growing focal
mass likely to impair the function of the involved tendon and joint
[3,4]. A plain radiograph commonly detects any soft tissue swelling
and also determine whether a fracture, dislocation, or destructive
lesion exists [5]. In this case, there was no joint restriction,
fracture, dislocation or bony destruction which may be due to early
presentation to the hospital. Sonography can be used to distinguish
between solid and cystic lesions, its relationship with the surrounding
structures and to detect satellite lesions [5,11]. MRI is the
preferred imaging modality, particularly for evaluating extra-articular
manifestations [5,12]. In this specific case, a hypoechoic complex
solid looking cystic lesion was detected on ultrasonography, however MRI
was not performed due to unaffordability of the patient.
In this patient, GCTTS and ganglion cyst were the differential diagnoses
we came up with based on the history, clinical and radiological
examination. An ultrasound revealed that a ganglion cyst was more likely
than a giant cell tumor. Complete surgical excision is the primary
treatment for GCTTS [5]. In this case, the mass was excised in toto.
Because of the presence of a pseudocapsule, the tumor is frequently
removed as a whole [5]. However, after surgical excision, the
tumor’s characteristics were more suggestive of a giant cell tumor,
indicating histopathological confirmation. A histopathological
examination of the excised tissue was performed, which confirmed the
diagnosis of GCTTS. Hence, histopathological examination is a must to
confirm the diagnosis [6,13].
Recurrence is a major risk factor. Given the reported high recurrence
rate of up to 45%, long-term follow-up after excision is
advised [6,7]. The recurrence was significantly higher at the thumb
interphalangeal (IP) and distal digital interphalangeal (DIP)
joints [1]. The reason may be the difficult excision of the tumor
distally at the proximal interphalangeal (PIP) joint or the thumb IP and
DIP joint due to the proximity of neurovascular structures to tumor
margins [14].
The patient was then evaluated 10
days later in the out patient department. The patient had an uneventful
post-operative course and continues to do well at 1 month post surgery
with no complaints and no signs of recurrence which was in line with a
similar study by Boeisa and Khalaf [7].
Conclusions
This study presents a rare case of giant cell tumor tendon sheath of
distal phalanx thumb and its diagnosis and treatment in a resource
constraint country. This study also emphasizes on the significance of
histopathological examination for the confirmation of diagnosis.
Conflict of interest: None
Source of funding: No source of funding
Acknowledgement: I would like to show my gratitude to Dr Anand
Chaurasia, Department of Pathology, for providing the diagnostic
histopathological findings.
Ethical clearance: Not applicable.
Consent: Written informed consent was obtained from the patient for
publication of this case report and any accompanying images.
Data availability statement: Data available on request from the authors.
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