30/M
2006: Lt thumb soft tissue mass at proximal phalynx near web.
Excion done
HPR: NA
2008: Recurrent lesion
Excision done
HPR:Giant cell tumour of tendon sheath ( No e/o malignancy)
2010:Recurrent lesion
Excision done with silastic implant placement
HPR:Giant cell tumour of tendon sheath ( benign synovioma)
Will RT help prevent further recurrence?
Look at our own jayant's results article on this specific type of tumour ;
http://www.brachyjournal.com/article/S1538-4721%2808%2900607-7/abstract
Do consider dropping him an email I am sure he will be able to help you a lot
Literature is conflicting on the issue
A study from AIIMS reported good control after low dose radiotherapy http://www.jbjs.org.uk/cgi/content/abstract/82-B/4/571
Full text is available. Bone invasion/Mitotic figures/ Incomplete excision formed the indications for PORT
Factors predicting recurrence risk in hand are detailed in this series
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJK-45WGHKM-X&_user=2622728&_coverDate=11%2F30%2F1999&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1311168590&_rerunOrigin=scholar.google&_acct=C000057891&_version=1&_urlVersion=0&_userid=2622728&md5=835e4032b72c816bebbc33f5630e6a49
I did not have full text access here so only reading from abstract
Some lines from the full text of article that Sanatam mentioned:
It has been variously labeled xanthoma, xanthogranuloma, xanthosarcoma, fibrous xanthoma, fibroma of tendon, myeloid endothelioma, endothelioma, villous arthritis, benign synovioma, sclerosing hemangioma, fibrohemosideric sarcoma, giant cell fibrohemangioma, pigmented villonodular tenosynovitis, and localized nodular synovitis.
Despite a well-recognized propensity for local recurrence, no well-documented case of pigmented villonodular synovitis or GCTTS has demonstrated truly malignant behavior or metastases.
The most widely accepted cause of GCTTS is that of a reactive or regenerative hyperplasia associated with an nflammatory process, which is based on the landmark study of Jaffe et al.13 These investigators coined the terms pigmented villonodular synovitis, bursitis, and tenosynovitis to emphasize their belief that this disease was a manifestation of inflammation and not neoplasia.
Treatment is careful local excision. Recurrence has been a consistent problem and varies from 9% to 44%.
The authors identified 107 patients with histologically proven GCTTS were identified.
Usual presentation is painless mass.
On X ray 9% patients had bony pressure erosion though none directly invaded bone.
Long-term follow-up evaluation was conducted in 70 patients, averaging 3 years 4 months (range, 7 months to 11 years 6 months).
There were no remarkable differences between the groups that did or did not recur in terms of operative findings, specimen appearance, or histopathology.
Fifteen of 19 recurrent tumors (79%) were located at the distal interphalangeal (DIP) joint of the fingers or the IP joint of the thumb, while only 11 of 51 lesions (22%) in the nonrecurrent group occurred at this location (Table 1). The difference was statistically significant, as determined by chi-square analysis (p , .001). Taking both groups together, 15 of 26 lesions (58%) around the IP/DIP joint recurred, while only 4 of 44 lesions (9%) at all other sites combined recurred.
Pressure erosion of bone was noted on radiographs in 5 of 19 recurrent cases (26%) and in only 3 of 51 nonrecurrent cases (6%). These values were significantly different, as determined by Fisher’s exact test (p , .025).
Degenerative joint disease (cartilage space narrowing, osteophytes, or subchondral cysts) was noted in the radiographs of 8 of 19 patients (42%) who developed recurrence and in 9 of 51 patients (18%) who did not. These values were also significantly different using Fisher’s exact test (p , .03).
They did not mention anything about use of radiation.
Overall even factors that had significant differences were primarily due to surgical contraints rather than true differences in biology.
HI Nilesh, you seem to get all the interesting cases. Again a tough case, no right answer. Pranshu/Santam has already given a good literature review. I would tend to observe. If the surgeons feel that the 3/4th operation is out of question if this comes back then explain the patient. Functional outcome is of paramount importance here. Need to consider what is his profession. After understanding the risk/ benefit if the patient agrees then you can consider treating.
The literature review was all Santam's. I just provided summary of the article Santam mentioned.
I think what is important to realise here is that this condition has negligible [would want to write "No".. but haven't done a complete review to claim that.. hence "negligible"] malignant potential.
So we need to compare risk of radiation induced second malignancy in a 30 Yr old male as against risk of loss of functionality due to morbid surgery/ amputation done in future for a recurrent lesion. I would like to step in with Radiation if a surgeon plans such extensive procedure at any point of time. If however, the surgeon can keep resecting this lesion with close or even frankly positive margin without loss of functionality, then observational/surgical approach would be preferable. From articles mentioned above, recurrent surgeries in these location are technically feasible since there is not much of local invasion. As Nikhilesh, rightly commented, patient preference and profession, handedness etc would need to be considered.
I have discussed with the patient and surgeon and he is confident of a revision excision in case of future rec without impairing functionality.
So I am reserving RT for future
Good, let's wait and see how he does, we will all learn from your patient. thanks