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Excision of a Giant cell tumour of the thumb

    Overview

    Learn the Excision of a Giant cell tumour of the thumb surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Excision of a Giant cell tumour of the thumb surgical procedure.
    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.

    Indications

    INDICATIONS
    The indication to remove a lump from the hand are:
    To establish a diagnosis. Clinical examination and imaging can often give a conclusive diagnosis. If in doubt a biopsy can be done to confirm the diagnosis. In cases where there is still a suspicion regarding the nature of the lump excision can be performed.
    To relieve the symptoms from the lump. Majority of the lumps are asymptomatic. These usually pressure are symptoms on the neurovascular bundle. When present on the palmar side of the digits they can sometimes cause functional problems while gripping.
    SYMPTOMS & EXAMINATION
    Giant cell tumours commonly present as an asymptomatic lump in the hand. The location of the lump can be on the palmar side, dorsum or on the radial or ulnar side of the digit. Sometimes they can present as a diffuse lump which can occupy the hemi-circumference of the digit. They progressively increase in size but the rate of growth is slow. In about 5% of cases, there can be associated pressure symptoms on the adjacent nerves. When present on the palmar side of the fingers or on the sides, they can cause discomfort while gripping.
    The differential diagnoses are:
    Ganglia: Commonly on the dorsum or radial side of wrist or over the base of the finger near A1 pulley. They can also occur near DIP joint, where it is called a mucous cyst. Smooth surface with firm consistency. In larger lumps, trans-illumination may be seen.
    Schwannomas: They arise close to digital nerves or their branches. They are often painful and on tapping them tingling may be felt along the digital nerve.
    Lipomas: They can occur on the palm as painless lumps but are rare in digits. They have an irregular surface with soft to firm consistency.
    Soft tissue sarcomas: They are rare tumours and present as firm to hard lumps which grow in size over a short period of time. MRI scan and biopsy should be done to make a diagnosis.
    Bony tumours: Benign and malignant bony tumours in the digits may present as painless lumps. They could be enchondromas, osteochondromas or chrodrosarcomas. Plain X-Rays are useful to make a diagnosis and in doubt and MRI scan is required.
    IMAGING
    X-Rays are unremarkable except when there is resorption of the adjacent bone from pressure effects.
    An ultrasound scan can help make a diagnosis and can differentiate it from a ganglion which is a close differential diagnosis.
    MRI is the gold standard for imaging and helps to define the extent of the tumour. On MRI, T1 and T2 weighted images often show scattered foci of low signal due to haemosiderin deposition. The tumour is seen as a well-defined lump with a complete or incomplete capsule. The capsule is of low intensity due to fibrosis or haemosiderin deposition. The signal intensity of the tumour is variable but in most cases they are iso-intense to muscle.
    NON-OPERATIVE MANAGEMENT
    In asymptomatic lumps, once the diagnosis is confirmed with imaging and biopsy, conservative treatment can be tried. Whilst the lump does not spontaneously regress, it is may not increase significantly in size for a long time.
    Adjuvant radiotherapy after surgery has been tried in some studies for primary infiltrative tumours and for recurrences.
    CONTRAINDICATIONS
    Just the usual ones around wound healing, and patient compliance.

    Setup

    Surgery can be performed under Regional anaesthesia(Brachial plexus block) or General anaesthesia. Local anaesthesia is not advised as the tumescence of the local anaesthetic makes dissection difficult. Also if there is any involvement of the neurovascular bundle incision may need to be extended.
    Patient is in supine position with the arm extended and laid on a hand table. An upper arm tourniquet is applied. Pre-operative antibiotics are not required.

    Operation – 1

    The lesion is marked out using a surgical marker pen and the dorsal nerve is also marked out.
    The hand is positioned on a rolled up cotton towel and secured on a lead-hand.
    An upper arm tourniquet is applied and is not inflated at this stage.
    It is important to be aware of the structures in the vicinity of the lump.
    This lump is located in the dorso-ulnar aspect of the thumb near the metacarpophalangeal joint. The extensor appartus of the thumb lies on the dorsum with extensor pollicis longus on the ulnar side and extensor pollicis longus on the radial side. On the flexor aspect the flexor pollicis longus tendon is enlosed within the flexor sheath. The neurovascular bundles lie on either side of the flexor sheath.
    In this case the structure closest to the lump is a dorsal digital nerve branch of the radial nerve which supplies the dorsal skin. This has been marked out.

    A 3cm long incision is marked over the lump in the junction of the glabrous and non-glabrous skinWhile making incisions over the web spaces, one of the considerations is the risk of a scar contracture. In this case a longitudinal incision over the junction between the glabrous(non-pigmented palmar skin) and pigmented skin has been used.
    A zig-zag incision may have a lower risk of scar contracture. However, I have chosen a longitudinal incision here as it has the advantage of a lower incidence of injury to the neurovascular structures.

    The hand is positioned
    The tourniquet is inflated at this stage. In the case of suspected malignant tumours it is important not to exsanguinate the hand. In this case, though it is confirmed to be a benign tumour through clinical examination and ultrasound findings, the arm is elevated to drain the venous blood before inflating the tourniquet.
    A No.15 blade is most suitable for making incisions in the hand. This allows more precise control of the incisions.

    The incision is deepened down to subcutaneous tissues. A skin hook can be used to retract the skin edges. The neurovascular bundles are deep to the tumour and therefore the dissection can be done using a No.15 blade.

    Using sharp dissection the capsule of the tumour is exposed.It is important not to breach it as it will increase the risk of recurrence. Whilst it is tempting to use scissors it is easier to find the plane using the blade.
    The capsule of the tumour is seen as a thin distinct whitish layer easily distinguishable from the yellowish fat layer.

    An Arm’s self-retaining retractor is useful to maintain the exposure during the dissection. This is especially important if surgery is performed without an assistant.

    The dissection is continued around the tumour using sharp dissection. and is separated from the surrounding soft tissues.Gentle traction is applied on the tumour capsule using a non-toothed forceps as the blade is used to separate it from the surrounding fat.

    The tumour is separated off the deeper tissues, lying close to the dorsal sensory nerve and the ulnar neurovascular bundle these structures have to be watched out for.

    Diagramatic representation of the anatomy of the thumb and tumour
    A: Extensor pollicis brevis(EPB)
    B: Extensor pollicis longus(EPL)
    C: Dorsal digital nerve
    D: Flexor pollicis longus(FPL)
    E: Neurovascular bundle
    F: Tumour

    The neurovascular bundle adjacent to the tumour is visualised and avoidedThe ulnar digital artery can be seen in the depth of the wound.

    Small blood vessels can be seen entering the capsule of the tumour. These are cauterized using bipolar cautery.

    The dorsal digital nerve can be seen under the tumour. It is better not to do blunt scissor dissection to separate the nerve as this can cause scarring of the nerve and may cause neuropathic pain later.
    Once the nerve is visualised it is better to do a sharp dissection to separate the lump from the nerve (loopes are of course being used for this dissection).

    The tumour is sharp dissected away from the vessels and underling joint capsule, leaving both intact. The Giant cell tumour capsule should also not be breached.A close inspection of the tumour reveals the irregular surface and the brownish appearance which is characteristic of giant cell tumour. It is firm in consistency.

    The excised tumour can be seen displayed on a gauze. It is sent for histology in a formalin solution.
    In this case the tumour has been completely excised with the capsule. If the capsule is breached one has to make sure that there is no tumour spillage into the soft tissues. If in doubt, another layer of subcutaneous tissue can be excised where one suspects the remaining tumour could be.

    The deeper structures can be seen. Ulnar neurovacular bundle, adductor pollicis muscle and the dorsal digital nerve can be seen.
    A: Adductor pollicis muscle
    B: Dorsal digital nerve
    C: Ulnar digital artery

    Tourniquet is released and haemostasis secured.The tourniquet is released at this stage. It is important to release the tourniquet and achieve accurate haemostasis. If the wound is closed with the tourniquet inflated, there is a risk of a haematoma building up in the cavity.
    As this cavity is small it does not need a drain but a compression dressing after the wound closure is sufficient. If the cavity is large a closed suction drain can be used.

    Small bleeding vessels are stopped using bipolar electrocautery.

    The wound is now closed in layers. Interrupted 4-0 Monocryl sutures are used as a dermal layer.

    Skin is approximated using 4-0 Monocryl running subcuticular sutures.

    The completed wound closure.

    As mentioned previously, there is a risk of scar contracture with a linear wound over the first webspace. If this were to happen a z-plasty procedure can be done at a later date. This photograph demonstrates the incision for a z-plasty, for explanatory purposes only.

    The first layer is jelonet, which is a non-adherent dressing.

    Dressing gauze is applied next.

    Velband is applied as the third layer.

    Dressings completedThe completed dressing with crepe bandage can be seen. This multilayers dressing is important in situations where hematoma formation is a risk.

    Operation – 2
    Post Operative

    Post-operatively hand is elevated in a Bradford sling for 24 hours.
    Once the block wears off, patient is advised to start mobilizing the fingers. Dressings are changed in one week and the patient is allowed to start mobilization of the thumb. Hand therapy exercises and scar massage is started after two weeks.
    Driving and normal activities can start after two weeks.
    The patient is followed up after 6 weeks and the webspace is monitored for evidence for contractures. If there is any tendency for contracture a spacer can be made by the hand therapists and used for the next three months during rest and night time.

    Recommended Reading

    1.Di Grazia S, Succi G, Fragetta F, Perrotta RE. Giant cell tumor of tendon sheath: study of 64 cases and review of literature. G Chir. 2013;34(5-6):149–152. d
    This article presents a review of literature of the last 15 years about GCTTS to assess the demographic, clinical and histological profile. We compared the information obtained from literature with our experience of 64 cases between 2000 and 2012. Our study showed similar results to those reported in literature, except for the recurrence rate: only 3 cases (4.7%) of 64 patients reported recurrence (versus about 15% on average in literature). Among the various possible factors that predispose to recurrence, it is necessary that the surgeon ensures complete excision of the tumor and removal of any residual satellite nodules.
    2. Lancigu R, Rabarin F, Jeudy J, Saint Cast Y, Cesari B, Fouque PA, Raimbeau G. Orthop Traumatol Surg Res. 2013 Jun; 99(4 Suppl):S251-4. Epub 2013 Apr 23.
    This was a retrospective study of 96 patients (57 women, 39 men) operated between February 1982 and October 2005 for GCT of the tendon sheaths in the hand. The average follow-up at the time of review was 12.1±3.8 years (range 5-29). There were eight recurrences in seven patients (8.3%). The average time to recurrence was 2.75±2 years (range 1-6.5). In every case of recurrence, there had been intra-articular tumor development and/or tendon destruction (P<0.01). There was one functional complication: one DIP joint fusion secondary to one of the recurrences. The average QuickDASH was 2.3/100 (range 0-31).
    3.Giant cell tumor of tendon sheath in the hand: analysis of risk factors for recurrence in 50 cases. Ozben H, Coskun T.BMC Musculoskelet Disord. 2019 Oct 21; 20(1):457. Epub 2019 Oct 21.
    Fifty patient were included in the study. The average follow-up time was 84 months. Three recurrences (6%) were recorded. The only significant risk factor for the recurrence was tumor adjacency to the interphalangeal joints of the fingers other than thumb. No major or minor complications were encountered in the postoperative period.

    4. Al-Qattan MM. Giant cell tumours of tendon sheath: classification and recurrence rate. J Hand Surg Br.2001 Feb;26(1):72-5
    Forty-three consecutive cases of giant cell tumour of tendon sheath were included in a prospective study. The tumours were classified into two main types, depending on whether the entire tumour was, or was not, surrounded by one pseudocapsule as assessed by the surgeon during surgery. Each type was then sub-classified according to the thickness of the capsule, lobulation of the tumour, the presence of satellite lesions, and the diffuse or multicenteric nature of the tumour: these factors were also assessed by the surgeon. The mean follow-up period was 4 (range, 2-6) years. None of the type I tumours (n=30) recurred, but recurrence occurred in five out of 13 type II tumours. Second recurrences were seen with type II B and C, but not type II A tumours.



    Reference

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