Excision of a Giant cell tumour of the thumb
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Giant cell tumours of the tendon sheath are the second commonest lumps in the hand after ganglion cysts. They are common in the 30-60 year age group and are more common in women. Though these are benign lumps, there is a high risk of local recurrence(up to 45% in some series). There is no significant risk of malignant transformation in these tumours though a very rare malignant variety has been described in literature. The most common presentation is a painless lump in the hand. In about 5% of patients, there can be accompanying sensory disturbance in the digits.
The most common locations in the hand are thumb, index and middle fingers followed by other fingers. The ratio of flexor: extensor involvement is 4:3.
Al Qattan classified them into two types. Type 1 has a distinct capsule and after excision has a lower recurrence rate. Type 2 does not have a clearly defined capsule and therefore complete excision is not possible. They have a higher rate of local recurrence.
The risk factors for local recurrence are a location close to joints, proximity to neurovascular bundles, erosion of bone and a diffuse lesion with no defined capsule.
Histologically they are composed of multinucleated giant cells, histiocytes polyhedral, fibrotic material and hemosiderin deposits.
They can be diagnosed based on clinical examination and typical ultrasonographic findings. If in doubt an MRI scan be used to confirm the diagnosis.
If there is any suspicion after imaging, biopsy can be done to get a histological diagnosis.
The treatment is complete excision under loupe magnification, however, when the lesion is asymptomatic it is acceptable to manage it conservatively.
The case presented here is a female who presented with a painless lump over her right thumb of one-year duration. On examination, there was a 2.5 X 2xm firm smooth lump over the ulnar aspect of the right thumb. The lump had limited mobility and was non-tender.
X-rays of the thumb were normal. Ultrasound scan showed a solid lump arising close to the ulnar neurovascular bundle. The diagnosis based on the clinical examination and ultrasonographic findings was a giant cell tumour. As there were no suspicious features clinically or on ultrasound scan, an MRI scan was not proceeded to.
Author:Rajive Jose FRCS
Institution: The Queen Elisabeth Hospital, Birmingham, UK.