Giant cell tumor of the tendon sheath
Types
Ganglion
Giant cell tumor tendon sheath
Neurofibroma / Schwannoma
Fibroma /Plantar fibromatosis
Lipoma
Glomus tumor
PVNS / Synovial osteochondromatosis
Ganglion
Firm subcutaneous nodule
- fluctuate in size
- arise from joint capsule or tendon sheath
- transilluminate
Treatment options
- observe
- multiple aspirations / cortisone injections
- surgical excision
Surgical excision
- need to find neck
- may arise from ankle joint / subtalar joint / tibialis posterior tendon
- tie off neck or excise segment of capsule to prevent recurrence
- systematic review of recurrence rates after treatment of foot and ankle ganglion
- aspiration 78%
- aspiration and steroid injection 62%
- steroid injection 38%
- surgical excision 18%
Closing neck of ganglion arising from tear in capsule
Giant cell tumor of the tendon sheath
Slow growing benign tumor arising from tendon sheath
- most common 3 - 5th decade
- more common in hand & wrist than in foot & ankle
Diagnosis
- heterogenous mass on MRI
- biopsy - abundant giant cells
GCT flexor tendon sheath
GCT flexor tendon sheath
GCT of tibialis posterior tendon sheath
Treatment
- observe
- local excision
Zhang et al J Foot Ankle Surg 2013
- surgical excision of 20 giant cell tumour tendon sheath foot & ankle
- recurrence rate 20%
Neurilemmoma / Schwannoma
Well encapsulated solitary tumor originates from nerve sheath
- slow growing
- nerve fibres spread over its surface
MRI - hyperintense rim on T2
Schwannoma on tibialis posterior nerve
Management
- marginal excision
- excise neurilemmoma and attempt to preserve normal nerve fibres
Schwannoma on tibialis posterior nerve
Neurofibroma
www.boneschool.com/neurofibroma
Singular or multiple lesions extending along course of the nerve
- half not associated with NF
- often local pain especially with compression
- may affect distal nerve function
- malignant change rare in solitary lesion (occurs with NF)
MRI - target sign, which can be seen with neurilemmoma
Treatment
- tumour arises from within the nerve
- excision usually cause further loss of function
Fibroma / plantar fibromatosis
Discrete nodule on sole or dorsum of foot
www.boneschool.com/plantar-fibromatosis
Lipoma
Most common on dorsum of foot
- subcutaneous
- soft feeling / mobile / grape like
Treatment
- marginal excision
Glomus tumour
Presents as painful toe, sensitive to cold
- pain with local pressure
- usually subungual
X-ray - may scallop adjacent bone on x-ray
MRI
Treatment - marginal excision for pain
PVNS
Common around the ankle or midfoot
- may involve multiple bones
- usually in young adults
X-ray
- may show bony erosions
- brown villonodular synovium
Treatment
- excision include complete synovectomy
- recurrences common but not all symptomatic
- DXRT if severe
Solitary Hemangioma
Present with episodes of dependent swelling
- often after local trauma
- diffuse edges / can be difficult to palpate
Diagnose on MRI
- hyper-intense on T2 FS
Treatment
- only needs excision if limits function
- often incomplete - recur
Synovial osteochondromatosis