Swelling

Briefly discuss about:

HOPI
Investigation
Management

Swelling at Right Thumb

Case discussion
Patients details:
Name: Mr X
Gender:Male
Age: 50 y/o
Occupation: Lecturer

HOPI
Mr X is right hand dominant,NKMI and NKA. Nonsmoker.
Mr X is well until 3 years ago, he noticed a small
swelling at his right thumb.
Patient is claimed the small swelling gradually increase
in size within 2 weeks. After 3 years it became grape
size.
The swelling is non-tender.
There is no restricted joint movement and he is able to
perform all ROM of thumb.
Pt denied of other swelling and afebrile.
No constitutional sx of malignancy

Local examination of Swelling at

Right Thumb
LOOK:
Single nodule swelling at
proximal phalanx
Grape size ( w/o using
measuring tape)
Surrounding no skin colur
change
No punctum and can pinch the
skin (excluded sebacous cyst)
No
sinus,redness,deformity,dilate
d vein, skin colour changes

Feel

MOVE
No restricted
Normal temperature with surrounding
joint movement
Able to perform
Non-tender
ROM of thumb
Lobulated

Firm in consitency
Immobile( up ,down, lateral)

MEASURE
7cm X 10cm

Non-compressible ( excluded
hemangioma)
Non-reducible ( swelling not arising
from joint)
Non-transluminate(excluded ganglion
cyst)

GIANT CELL
PROVISIONAL
TUMOR OF
DIAGNOSIS
TENDON
SHEATH

Introduction
Abenign nodular tumorthat is found on the
tendon sheath of thehands and feet
Also known as pigmented villonodular tumor of
the tendon sheath (PVNTS)
Epidemiology
present in 3rd-5th decade of life
incidence
second most commonsoft-tissue tumor seen in
the hand, following ganglion cyst

location
it is most common on palmar surface of radial
three digits near DIPJ

Presentation
Symptoms
enlarging mass
pain, worse with activity (or wearing shoes, for foot lesions)

Physical exam
firm, nodular mass that does not transilluminate

Differential diagnosis
ganglion cyst
cystic component

pigmented villonodular synovitis

histologically identical
involves larger joints

desmoid tumor
fibroma/fibrosarcoma
glomangioma

Investigation:
X-ray at right hand taken in 22/9/2015

Blue
Red arrow:
arrow:
Oblique view
AP view
Soft t/s swelling

Long blue
arrow :
osteolytic
lesion

 X-ray shows involvement of proximal

phalanx
? Intramedullary extension of mass
within the PP of thumb
Chest X-ray : CLEAR

MRI In Right Hand

Features in keeping with giant cell
tendon sheath of Rt flexor pollicis
longus tendon.
DDX: fibrous histocytoma and
fibroma tendon sheath
Why order MRI?
Bcz this swelling is from soft
tissue.
Xray cannot show extension of soft

What we saw in OT
Excision of GCT
at Right
curet
Thumb
te

Giant Cell
Tumor of
Tendon Sheath
Introduction
Presentation
Imaging
Treatment

Introduction
Abenign nodular tumorthat is found on the
tendon sheath of thehands and feet
Also known as pigmented villonodular tumor of
the tendon sheath (PVNTS)
Epidemiology
present in 3rd-5th decade of life
incidence
second most commonsoft-tissue tumor seen in
the hand, following ganglion cyst

location
it is most common on palmar surface of radial
three digits near DIPJ

Presentation
Symptoms
enlarging mass
pain, worse with activity (or wearing shoes, for foot lesions)

Physical exam
firm, nodular mass that does not transilluminate

Differential diagnosis
ganglion cyst
cystic component

pigmented villonodular synovitis

histologically identical
involves larger joints

desmoid tumor
fibroma/fibrosarcoma
glomangioma

Imaging
Radiographs
pressure-type bone erosion can be seen in up to 5% of
patients on radiographs

Ultrasound
able to demonstrate relationship of lesion with adjacent
tendon
homogeneously hypoechoic, although some heterogeneity
may be seen in echo-texture in a minority of cases
most have some internal vascularity

MRI
MRI may be helpful diagnostically
appearance of the focal form is generally decreased signal
intensity on both T1-and T2-weighted MR imaging

Treatment
Operative
marginal excision
5-50% recurrence rate
more common if tumor extends into joints and
deep to the volar plate
local recurrence is usually treated with repeat
excision

operative approach is dependant on location

and extent of the tumor