A Giant Cell Tumor of the Tendon Sheath Masquerading as a Dorsal Wrist Ganglion: Avoiding Dorsal Wrist Mass Misdiagnosis
Stephanie Holzmer, MD1, Christopher Bobbitt, MD1, Alex Chang2, Walter Chang, MD2 1Loma Linda University, Loma Linda, CA 2Kaiser Permanent San Bernardino Fontana, CA
Background: Giant cell tumors of the tendon sheath (GCTTS) are the second most common benign tumor of the hand, behind ganglions. Clinically, GCTTS most commonly present as a slow-growing, firm, non-tender mass on the digits. GCTTS are known to occur in the wrist and proximal hand, but these are uncommon. Even more uncommonly described are multicompartmental GCTTS of the wrist or carpometacarpal region. We present a rare case of an invasive, multi-lobulated, multicompartmental GCTTS masquerading as a dorsal wrist ganglion (DWG), highlighting the importance of pre-operative work up even for seemingly simple diagnoses in a busy hand practice. This is supplemented with a review of the literature regarding the workup of ganglions and GCTTS, treatment algorithms, and recurrence prevention.
Methods: A 47-year-old male who presented with a dorsal wrist mass, initially diagnosed as a DWG, was taken to the operating room for excision. Operative exploration revealed an invasive, multicompartmental, nodular-type GCTTS requiring dorsal and volar approaches and extensive dissection. Our case was unique in that the tumor itself appeared to be of the nodular type, but was not only in an unusual location, also invaded multiple compartments. This made it a surgical challenge to excise fully without damaging critical structures. Literature was reviewed regarding the workup of ganglions and GCTTS, treatment algorithms, and predictors of recurrence of GCTTS.
Results: Complete excision was achieved, and the patient has had no recurrence 11.5 years post-operative. Our literature review highlighted critical points in the workup and management of DWG and GCTTS. Pre-operative transillumination and/or aspiration should be employed to avoid misdiagnosis of DWGs prior to operative intervention. Aspiration may be therapeutic in some patients (20-30%) and provide reassurance, thus decreasing the number of patients that elect for surgical excision (18%). Pre-operative MRI should be considered in patients with a negative aspiration. GCTTS have a reported recurrence rate of 4-44%, which is also linked to incomplete excision or the presence of satellite lesions. Adjuvant radiation may be considered in the prevention or treatment of recurrence, however one study that prospectively analyzed adjuvant radiation therapy concluded that the most important determinant in recurrence is complete excision and adjuvant radiation should only have a role if complete excision is not accomplished.
Conclusion: The commonness of the dorsal wrist ganglion can cause the surgeon to lose vigilance, but other tumors may also present as a dorsal wrist mass, such as a GCTTS. Pre-operative transillumination and aspiration of all suspected dorsal wrist ganglions should be considered. For the patient, aspiration can provide long-term relief to some and provide reassurance and avoid surgery in many. For the surgeon, it can provide reassurance or alert the surgeon to another diagnosis. Nodular-type GCTTS can still be invasive and multicompartmental. Meticulous surgical excision of GCTTS is the most critical component of recurrence prevention, even if it is multilobulated and multicompartmental.
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