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Case Report - Pigmented Villonodular Synovitis Great Toe

Case Report:-

Here we are reporting a 14-year-old Yrs. boy presented with swelling over dorsal

aspect of the Rright Ggreat toe for the last 4 yearsYrs.., which was whenIt was

initially noticed for the first time when it was of peanut size. It kept on gradually

increasing to almost walnut size. The Ppatient did not have any constitutional

symptoms or pain in swelling and ,there was no pain or swelling of other joints. On

examination, the general condition was normal, while local examination of Ggreat toe

revealed firm, slightly tender swelling over dorsal aspect of meta tarso phallangeal

and inter phallangeal joint of the great toe. There was no fluctuation, no skin changes

over swelling, and no change with movement of the great toe. There was no pain in

the joint on movement of the great toe. Clinically, swelling was encircling the

extensor hallucis longus tendon. The Ppatient was pre- operatively worked up. All

routine investigations were with in normal range. X- ray of the great toe region was

essentially normal;, no obvious bony lesion was seen. So, the patient was subjected to

surgery under sub- arachnoid block. On the dorsal aspect, S- shaped incision was

given and flaps were raised from the base of nail to the dorsum of the foot crossing

both meta tarso phallangeal and inter phallangeal joints. Swelling was well exposed.

It was found to be arising from the synovial cavity of the joint, golden brown in

colour, also encircling the extensor tendon (extensor hallucis longus right great toe).

First of all extensor tendon was separated fromoff the swelling and brown material

was separated and excised piece meal from MTP and& IP joints. Wound healed in 10


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days time. Histopathology came out to be PVNSPigmented Villo nodular synovitis.

Post- operation follow- up after 1 and a half years,yr. 6mths. the great toe fortunately

did not show any recurrence of swelling.

Fig. 1 -- Great toe lesion & Fig. 2 -- Histopathology high power


Discussion:-

Giant cell tumour of tendon sheath also labelled as nodular tenosynovitis, localized

villonodular synovitis, fibrous histiocytoma of the synovium ,([1]), is a benign

solitary tumour which usually arises in the limbs . It mostly affects hands butand less

common in the foot and ankle [(1]). Usually, lesion is solitary , pain less, slow

growing, soft tissue swelling, but some times it is painful [(1]). It has been found to

be slightly more in females and affects in young age group. PVNS is rare but

potentially aggressive lesion, which attacks synovium of the joints, tendon, sheath or

bursae. 2.5% cases occur in the foot and ankle. Granovitz and& Mankin divided

PVNS in to two forms: a(1) nodular ,and (2b) diffuse [(2]). Both forms can occur in

the foot and ankle. The Ppatient which we are reporting has a nodular variety of great

toe lesion. This disease was considered in past as a low grade synovial malignancy,

which is now considered asto be a benign disease [(2]). Most of the cases are mono

articular and do not metastasise though they may be locally destructive [(2]). MRI has

been found to be most useful investigating tool in diagnosing PVNS [(1,2,..]). PVNS

has been found to have substantial recurrence rate [(1,2,..]). In the foot due to large

number of joints and lack of integrity of superficial muscle layers, disease spreads

into adjacent joint spaces, and it is difficult to be excised surgically completely [(1,

2]). Radiotherapy has been advised for recurrent lesion but radiation oncologists are


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reluctant to advise radiotherapy to such non- malignant diseases [(2]). Alternatively,

injection of radio active Yttrium 90 locally has been advocated [(2]). In our patient,

we did near total excision of the lesion surgically but didnt not given radiotherapy.

Radiotherapy 2600 CGy dose ishas been usually given [(1,2,3..]).


Conclusion :-

Swelling of toes, and small joints might come out to be unusual &and

PVNSpigmented Villonodular synovitis is one of them. Though it is benign lesion but

has propensity to recur. Surgical excision is the treatment of choice, but frequent

recurrence may require low dose radiotherapy at site. Some advocates injections of

radio active Yttrium 90 locally.


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References:-

1. CLMH Gibbons CLMH, HA Khwaja HA, ASCole AS, PH Cooke PH, NA

Athanasou NA. Giant cell tumour of the tendon Sheath in the foot and ankle. The

J.ournal of Bone and Joint Surg. Sept. 2002;Vol.84-B,No.(7): ,2002,Sept. P

1000-1003.

2. M Lee M, S Maharoof S, J Pringle J, SC Short SC, et al,. Diffuse pigmentedvillonodular tenosynovitis of the foot and ankle, treated with surgery and

radiotherapy.Int. Orthop. 2006.

3. Farzan M, Mortazavi SM J, Yousef Sibdari S, Rafiee E., Pigmented villonodular

synovitis of the great toe metatarsophalangeal joint (case report). [Article in

Persian] 2007;. 65(5): 84-87.

4. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis, and

tenosynovitis.Arch. Pathol. 1941;31:731765.

5. Somerhausen NS, Fletcher CD. Diffuse-type giant cell tumor: clinicopathologic

and immunohistochemical analysis of 50 cases with extraarticular disease.Am. J.

Surg. Pathol. 2000;24:479492.

6. Ferrer J, Namiq A, Carda C, Lopez-Gines C, Tawfik O, Llombart-Bosch A.

Diffuse type of giant-cell tumor of tendon sheath: an ultrastructural study of twocases with cytogenetic support. Ultrastruct. Pathol. 2002;26:1522.

7. Alguacil-Garcia A, Unni KK, Goellner JR. Giant cell tumor of tendon sheath and

pigmented villonodular synovitis:. an ultrastructural study.Am. J. Clin. Pathol.1978;69:617.

8. O'Connel JX, Fanburg JC, Rosenberg AE. Giant cell tumor of tendon sheath andpigmented villonodular synovitis:. immunophenotype suggests a synovial cell

origin.Hum. Pathol. 1995;26:771775.


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9. Tashiro H, Iwasaki H, Kikuchi M, Ogata K, Okazaki M. Giant cell tumors of

tendon sheath:. a single and multiple immunostaining analysis.Pathol. Int.

1995;45:147155.

10. Darling JM, Goldring SR, Harada Y, Handel ML, Glowacki J, Gravallese EM.Multinucleated cells in pigmented villondular synovitis and giant cell tumor of

tendon sheath express features of osteoclasts.Am. J. Pathol. 1997;150:13831393.

11. Chung EB, Enzinger FM. Fibroma of tendon sheath. Cancer. 1979;44:19451954.

12. Maluf HM, DeYoung BR, Swanson PE, Wick MR. Fibroma and giant cell tumorof tendon sheath:. a comparative histological and immunohistological study.Mod.

Pathol. 1995;8:155159.

13. Bertoni F, Unni KK, Beabout JW, Sim FH. Malignant giant cell tumor of the

tendon sheaths and joints (malignant pigmented villonodular synovitis).Am. J.Surg. Pathol. 1997;21:153163.

14. Ushijima M, Hashimoto H, Tsuneyoshi M, Enjoji M, Miyamoto Y, Okue A.

Malignant giant cell tumor of tendon sheath:. report of a case.Acta. Pathol. Jpn.1985;35:699709.

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