|Year : 2019 | Volume
| Issue : 2 | Page : 262-264
Giant cell tumor tendon sheath at inguinal region masquerading as enlarged lymph node
Minakshi Chouhan1, Sheetal Arora1, Neetika Gupta2, Rashmi Arora1
1 Department of Pathology, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||05-Jun-2019|
|Date of Decision||22-Aug-2019|
|Date of Acceptance||26-Aug-2019|
|Date of Web Publication||16-Dec-2019|
Dr. Sheetal Arora
Department of Pathology, VMMC and Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Giant cell tumor of the tendon sheath (GCTTS) is a benign tumor and is the second most common tumor of the hand after ganglion cysts. It is a slow-growing benign lesion of the soft tissues. The etiology of GCTTS is not clear. Although GCTTS most commonly presents in a digit of the hand, it may also present in the palm, wrist, foot, knee, ankle, elbow, or hip. Here, we present a rare case of GCTTS originating at the inguinal region, which has not been previously reported. A 52-year-old male presented with a 2 cm × 1 cm swelling at the right inguinal region. The clinical impression was inguinal lymph node enlargement. Ultrasonography (USG) showed the presence of large inguinal lymph node. Fine-needle aspiration cytology (FNAC) showed the features suggestive of giant cell lesion, possibly GCTTS. Repeat ultrasound revealed a large oblong-shaped hypoechoic lesion with mild internal vascularity in the right inguinal region above the external oblique aponeurosis, suggestive of aponeurotic giant cell tumor. Histopathology was confirmatory. Here, we report this case to highlight the role of FNAC in diagnosing GCTTS at a rare site, i.e., inguinal region. Due to its location at inguinal region, along with clinical suspicion of tubercular lymphadenitis and USG findings showing large inguinal lymph node in the right inguinal area, it needs to be differentiated from other causes of lymph node enlargement. It would be prudent to state that FNAC along with radiology can help reach the final diagnosis.
Keywords: Giant cell tumor, inguinal region, masquerading lymph node, tendon sheath
|How to cite this article:|
Chouhan M, Arora S, Gupta N, Arora R. Giant cell tumor tendon sheath at inguinal region masquerading as enlarged lymph node. Arch Med Health Sci 2019;7:262-4
|How to cite this URL:|
Chouhan M, Arora S, Gupta N, Arora R. Giant cell tumor tendon sheath at inguinal region masquerading as enlarged lymph node. Arch Med Health Sci [serial online] 2019 [cited 2020 Nov 30];7:262-4. Available from: https://www.amhsjournal.org/text.asp?2019/7/2/262/273073
| Introduction|| |
Giant cell tumor of the tendon sheath (GCTTS) is a benign tumor and is the second most common tumor of the hand after ganglion cysts. It is a slowly growing, usually painless benign lesion of the soft tissues. It was first described by Chassaignac in 1852 as fibrous xanthoma and has since been referred to by multiple names, including localized nodular tenosynovitis, pigmented villonodular proliferative synovitis, sclerosing hemangioma, benign synovioma, proliferative synovitis, xanthoma, xanthogranuloma, xanthosarcoma, myeloid endothelioma, fibrohemosideric sarcoma, giant cell fibrohemangioma, pigmented villonodular tenosynovitis, fibroma, myeloma, myeloxanthoma, and fibrous histiocytoma.
The etiology of GCTTS is not clear. While some authors believe that it is a neoplastic disorder, others accept it only as a nonneoplastic tumor. It can be roughly classified by Byers into diffuse type (mostly extra-articular, common in joints) and localized type (mostly intra-articular, common in hands). The localized type (tenosynovial giant cell tumor) occurs frequently and represents the most common subset arising from the synovial joint, bursa, or tendon sheath with 85% of the cases occurring in the fingers according to literature, while occurrence at other sites has been relatively less common. The tumor affects individuals aged between 30 and 50 years and is found more often in women than in men. Although GCTTS most commonly presents in a digit of the hand, it may also present in the palm, wrist, foot, knee, ankle, elbow, or hip. Here, we present a case of GCTTS originating at the inguinal region which is one of the rarest sites.
| Case Report|| |
A 52-year-old male was seen in the outpatient clinic with a 2 cm × 1 cm swelling at the right inguinal region [Figure 1]. The mass was firm and nontender to palpation. There was no discoloration or ulceration of the overlying skin. The clinical impression was inguinal lymph node enlargement. The swelling was slow growing for 1½ years. Ultrasonography (USG) showed the presence of large inguinal lymph node. To reach the final diagnosis and rule out other differential diagnoses of lymph node enlargement, fine-needle aspiration cytology (FNAC) was attempted which yielded blood mixed aspirate. The smears were prepared and stained with Giemsa and Papanicolaou stain.
Smears examined were moderately cellular showing mononuclear stromal cells scattered singly along with multinucleated osteoclast-like giant cells [Figure 2] and [Figure 3]. Mononuclear stromal cells were polygonal-to-spindle shaped and had uniform nuclei with bland chromatin and round-to-ovoid cytoplasmic boundaries. Cell nuclei had smooth, round, or oval contour with fine nuclear chromatin with indistinct nucleoli and showed no pleomorphism. Atypical mitosis was not seen in these cells. Multinucleated giant cells contained 10–50 nuclei and had moderate-to-abundant cytoplasm showing vacuolation at many places [Figure 4]. Cystic macrophages scattered in the background could also be identified along with few hemosiderin laden macrophages. Cytological features were suggestive of giant cell lesion, possibly GCTTS. Repeat ultrasound was done which revealed a large oblong-shaped hypoechoic lesion with mild internal vascularity in the right inguinal region above the external oblique aponeurosis, suggestive of aponeurotic giant cell tumor. Excision biopsy was performed, and histopathological examination revealed partially encapsulated tumor showing lobules separated by collagenous septa. Within lobules, mononuclear histiocyte-like cells admixed with osteoclast-type giant cells, foamy histiocytes, chronic inflammatory cells, and hyalinized stroma were seen [Figure 5].
|Figure 2: Smear showing numerous multinucleated osteoclast-like giant cells in hemorrhagic background (Pap stain, ×10)|
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|Figure 4: Smear showing mononuclear stromal cells scattered singly along with multinucleated osteoclast giant cells (Giemsa, ×10)|
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|Figure 5: Histopathological section showing mononuclear cells, osteoclast-type giant cells, foamy histiocyte, and chronic inflammatory cells along with hyalinized stroma (H and E, ×40)|
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| Discussion|| |
GCTTS or localized-type tenosynovial giant cell tumor is a benign slow-growing lesion of the soft tissues arising from the complex of the tendon sheath and peri-articular soft tissues of small joints. It presents as a firm, nodular mass occurring more commonly on the volar aspect of fingers and hands. This tumor usually presents as a painless soft tissue mass. The various etiological factors include trauma and neoplastic, inflammatory, and metabolic disease. Usually, the lesions are asymptomatic, painless, palpable soft tissue mass that gradually increases in size over a period of time.
Here, we present a case of localized tenosynovial giant cell tumor at inguinal region, which is a rare site. The patient presented with swelling in the inguinal region. The differential diagnosis of which includes lymphadenopathy, undescended testis, inguinal hernia, and lipoma of the spermatic cord. The most common cause of inguinal swelling is inguinal lymphadenopathy. Infectious causes of inguinal lymph node enlargement need to be excluded first which includes tuberculosis, filariasis, chancroid, lymphogranuloma venereum, and syphilis. The neoplastic etiology includes lymphoma, leukemia, and metastatic disease from primary tumors in the lower limb, external genitalia, or perianal region. Then, the tumor needs to be differentiated clinically and morphologically from other benign and malignant tumors occurring at the same site, which vary in their biologic behavior and treatment. Because of its location at the periphery of the extremities, epithelioid sarcoma, synovial sarcoma clear-cell sarcoma, melanoma, and rhabdomyosarcoma are malignant neoplasms that may be considered in the differential diagnosis.
The hand is the most common site (77%) of GCTTS with predominant involvement of the volar aspect and fingers at the distal interphalangeal joint. They are very rare on foot (3%). Although the involvement of feet is rare, it is the second most common site. Rarely, other sites including the vertebral column may be affected. The localized-type tenosynovial giant cell tumor occurs frequently and represents the most common type arising from the synovial joint, bursa, or tendon sheath, with 85% of the cases occurring in the fingers.
As GCTTS is a slow-growing tumor, the duration ranges from weeks to years, and the maximum duration of 48 years is mentioned in the literature. In our case, the duration was 1½ years. Usually, GCTTS is tendon based, well circumscribed, and localized. However, some of them may grow diffusely or expand. Qattan presented the most popular classification of the GCTTS into two types on the basis of a pseudocapsule surrounding it. Each type was further classified depending on the thickness of the capsule, lobulation of the tumor, the presence of satellite lesions, and the diffused or multicentric growth of the tumor.
Histopathology is usually diagnostic, but cytodiagnosis has been found useful. GCTTS occurring at ordinary sites, e.g., hands and feet, also shows similar cytology. Smears are cellular and comprise varying proportions of stromal cells and giant cells. Stromal cells are polygonal-to-spindle shaped with round nuclei and nucleoli having abundant cytoplasm, and some of them show nuclear grooves, convolutions, and intranuclear cytoplasmic inclusions. Hemosiderin laden macrophages and abundant foamy vacuolation of the stromal cells were also seen along with multinucleated osteoclast-like giant cells.
Complete surgical excision remains the mainstay of treatment. Careful dissection and exploration for satellite nodules are important. Most common complication of the tumor is recurrence, which is seen in 45% cases. FNAC can be used as an important diagnostic tool for early detection of GCTTS as the cytological features are specific for the lesion and helps in preoperative planning of the lesion to prevent recurrence. Although it is a benign lesion, local recurrence after excision has been reported. It has still no defined treatment protocol, and local excision with or without radiotherapy remains the treatment of choice till date.
We report this case to highlight the role of FNAC in diagnosing GCTTS at a rare site, i.e., inguinal region. It would be prudent to state that FNAC along with radiology can help reach the final diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Darwish FM, Haddad WH. Giant cell tumour of tendon sheath: Experience with 52 cases. Singapore Med J 2008;49:879-82.
Walsh EF, Mechrefe A, Akelman E, Schiller AL. Giant cell tumor of tendon sheath. Am J Orthop (Belle Mead NJ) 2005;34:116-21.
Qin Y, Zhang B, Song-Cen LV. A rare localized giant cell tumor of the tendon sheath in hip joint: A case report and review of the literature. Biomed Res 2017;28:6510-3.
Suresh SS, Zaki H. Giant cell tumor of tendon sheath: Case series and review of literature. J Hand Microsurg 2010; 2:67-71.
Monaghan H, Salter DM, Al-Nafussi A. Giant cell tumour of tendon sheath (localised nodular tenosynovitis): Clinicopathological features of 71 cases. J Clin Pathol 2001;54:404-7.
Tambe SA, Bhobe M, Jerajani HR. Giant cell tumor of the tendon sheath mimicking a plexiform neurofibroma. Indian Dermatol Online J 2015;6:201-3.
] [Full text]
Kotwal PP, Gupta V, Malhotra R. Giant-cell tumour of the tendon sheath. Is radiotherapy indicated to prevent recurrence after surgery? J Bone Joint Surg Br 2000;82:571-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]