Histoputhology 1992, 20, 2 13-220

Tendon sheath tumours: a pathological study of the relationship between giant cell tumour and fibroma of tendon sheath M. B. SATTI Departrnerit of Pathology. King Faisal University Damman, Saudi Arabia Date of submission 2 9 May 1991 Accepted for publication 9 October 1991

SATTI M . B .

(1992) Histopathology 20, 213-220

Tendon sheath tumours: a pathological study of the relationship between giant cell tumour and fibroma of tendon sheath Thirty-nine soft tissue lesions occurring on the distal aspect of the limbs have been selected because of histological features consistent with those recognized for giant cell tumour of tendon sheath or fibroma of tendon sheath. In spite of the frequent occurrence of such lesions at the stated sites, they were rarely correctly diagnosed pre-operatively. Using a scoring system to grade specified histological features, a blind evaluation to re-classify these 39 lesions was undertaken. This resulted in 2 9 cases of giant cell tumour of tendon sheath, six fibromas of tendon sheath and four ‘transitional stage’ lesions. Despite the heterogeneous morphology of these categories, there were no significant differences in the clinical features of affected patients. The existence of a ‘transitional stage’ lesion, combined with the homogeneous clinical picture of all categories, supports the concept that fibroma of tendon sheath is the end and sclerosing stage of giant cell tumour of tendon sheath, probably consequent on progressive vascular impairment. There is a need for pathologists to recognize the transitional stage lesions so as to avoid their inclusion with other diagnostic entities. For this group the name ‘giant cell tumour of tendon sheath-transitional stage lesion’ is suggested. Keywords: fibroma, giant cell, tumour. tendon sheath

Introduction Giant cell tumour of tendon sheath, also known as fibrous histiocytoma of synoviuml, pigmented nodular synovitis2 and nodular t e n o s y n o ~ i t i s ~is, ~ the , most common soft tissue tumour arising in the hands5. It shares common features with the lesion characterized by Chung & Enzinger as fibroma of tendon sheathh or as tenosynovial fibroma by others’. These features include the location, multi-nodularity, attachment to tendon or tendon sheath and the recurrence rate. The lesions, however, differ histologically’,h, except for a varying degree of collagen formation and hyalinization that is present in both lesions. Based on these observations,

Address for correspondence: Dr M.B.Satti. Professor & Consultant Pathologist, PO Box 40029. AL-Khobar 31952. Saudi Arabia.

some workers suggested that fibroma of tendon sheath is probably one end of the morphological spectrum of regression of giant cell tumour of tendon sheath, evidenced by the hyalinization characteristic of the former’,’. This view, however, is not fully accepted by Chung & Enzinger6,1”on the basis, in their opinion, of some differences in the clinical settings and lack of transitional stages between the two lesions on histological examination. This study was carried out with two objectives. The first was to determine the relative frequency of these lesions and to find out how often they are correctly diagnosed pre-operatively. The second was to test the hypothesis that tumours histologically recognized as fibroma of tendon sheath are probably one end of the morphological spectrum of those histologically recognized as giant cell tumour of tendon sheath. If this 213

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hypothesis is correct, a transitional stage must exist with morphology intermediate between that of the two lesions.

Materials and methods All lesions of acral location, diagnosed histologically as giant cell tumour of tendon sheath, fibroma of tendon sheath, fibrous histiocytoma or nodular tenosynovitis were selected, in a review of all soft tissue tumours received in the laboratory during the period 19831990. Paraffin blocks from all selected lesions were retrieved and 5 pm thick sections were cut and stained routinely using haematoxylin and eosin (H & E). Additional stains used included Verhof elastic van Gieson (EvC)for elastic and collagen fibres. Perls' for iron, alcian blue at pH 2.5 for acidic mucopolysaccharides and the diastase-periodic acid-Schiff (D-PAS)stain for basement membrane of vascular channels. The diagnostic criteria adopted for the diagnosis of giant cell tumour of tendon sheath and fibroma of tendon sheath were as laid down by Enzinger & Weiss"' and Chung & Enzinger" respectively. A histological scoring system (Table 1 ) was utilized to test the hypothesis that these lesions represent the opposite ends of a morphological spectrum. Identification of a 'transitional stage' lesion during the evolution of this morphological spectrum would lend support for this hypothesis. The histological features selected for the scoring system included those which are necessary for the diagnosis of either lesion, For giant cell tumour of tendon sheath these were the presence of: multinucleated giant cells, mononuclear phagocytic cells, foamy histiocytes, haemoTable 1. Diagnostic histologjcal features of giant cell tumour of tendon sheath (GCTTS) and fibroma of tendon sheath (FTS)

Score ~~

~~

GCTTS __

~~

~-

Giant cells Foamy histiocytes Mononuclear cells Fibroblasts/stellate cells Collagen Haemosiderin Slit-like spaces Attachment to tendon/sheath Total

~~

FTS ~

3 3 3 2 2 3

0 Yes 3 14

~

0 0 0 2 3

0 2 Yes

17

0 = not seen: 1= seen in < 10 medium-power fields (MPF: x 2 5 objective): 2 =seen in 10-40 MPF: 3 =seen in > 40 MPF.

siderin, fibroblasts, collagen and tendon sheath attachment (Figure 1).For fibroma of tendon sheath they were: fibroblasts, a collagenous stroma, slit-like vascular spaces, and attachment to tendon sheath (Figure 2). Adopting this system, the H & E-stained sections and, where necessary, the special stains from all 39 lesions available were examined blindly, without knowledge of the clinical data or the pathological diagnosis. A score value was given for each histological feature shown in Table 3. A diagnosis of giant cell tumour of tendon sheath was considered when the total score was 2 1 4 and fibroma of tendon sheath was diagnosed when the total score was

Tendon sheath tumours: a pathological study of the relationship between giant cell tumour and fibroma of tendon sheath.

Thirty-nine soft tissue lesions occurring on the distal aspect of the limbs have been selected because of histological features consistent with those ...
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