Abstract
Background/Aim: The recurrence rate following the excision of tenosynovial giant cell tumors (TSGCT) of the hand is very high. Intraoperative application of a surgical microscope has been reported. However, to date, there are no reports of medium-term outcomes related to this technique. This study aimed to evaluate the medium-term outcomes of tumor excision using surgical microscope for TSGCT of the hand. Patients and Methods: A total of 27 patients, who underwent an initial surgery for histologically-confirmed TSGCT of the hand, between 2008 and 2020, were included and evaluated. The mean follow-up time postoperatively was 6.8 years. Tumor recurrence and preoperative tumor characteristics were assessed. Results: All tumors were adherent to tendons, tendon sheaths, neurovascular structures or periarticular ligaments and capsules. Bony lesions were observed in 11 tumors. The surgical microscope was used in 13 tumors. Recurrences were observed in three tumors (overall recurrence rate: 11%). Tumor characteristics were similar in both groups, but the recurrence rate in the group treated using the surgical microscope was 0%, whereas the recurrence rate in the group treated without the surgical microscope was 21%. Re-operations using the surgical microscope for recurrent tumors were performed, without recurrence postoperatively. Conclusion: Among patients with TSGCT of the hand treated with tumor excision using the surgical microscope, the postoperative recurrence rate was 0%. Based on the results of this study, the surgical microscope might be used for excision of TSGCTs of the hand.
A tenosynovial giant cell tumor (TSGCT) is a benign tumor that frequently occurs in the hand; it is a painless and slow-growing tumor (1, 2). Although the standard treatment is tumor excision, it has been associated with a high recurrence rate following excision (3, 4). To prevent tumor recurrence, a complete surgical excision is necessary (5-7). Therefore, efficient preoperative and intraoperative techniques are essential. Intraoperative application of a surgical microscope has been reported (8, 9). However, there have been few reports on the application of the surgical microscope in the excision of TSGCT of the hand. The medium-term recurrence rates related to this technique have also not been discussed. The present study aimed to evaluate the medium-term outcomes, particularly the recurrence rate of TSGCT of the hand, treated with excision using a surgical microscope.
Patients and Methods
This study was conducted in accordance with the Standards of the Committee on Human Experimentation of the institution and was approved by the Research Ethics Committee, Graduate School of Medical Science, Kanazawa University (approval No.1786). The patients provided their written informed consent to participate in this study.
This was a retrospective study including patients who underwent an initial surgery for histologically-confirmed TSGCT of the hand at two orthopedic surgery centers between 2008 and 2020. The patients underwent follow-up for at least two years postoperatively. Patients who underwent surgery for recurrent TSGCT were excluded. The records of 27 patients were retrieved from the database; the patients were interviewed via a telephone call. There were 18 female and nine male patients with a mean age of 42 years (range=11-78 years). The mean follow-up time was 6.8 years (range=2.0-13.8 years). The tumors were located in the thumb in three patients, the index finger in four, the middle finger in 11, the ring finger in one, the little finger in five, and wrist joints in three.
Preoperative radiographs were taken to confirm the presence of bony erosion, bony contour deformity, and osteoarthritis at the tumor site. Plain magnetic resonance imaging (MRI) was also performed to evaluate the extent of the tumor (Figure 1A and B). Based on the X-ray and MRI findings, the tumors were classified as localized or diffuse type (8). The surgery was performed using a surgical loupe with 3× magnification. As much as possible, the tumor was excised in one piece while the digital nerves, arteries, and tendons were preserved (Figure 1C). Tumors, invading the bone, were curettaged away. Segments that were adherent to the joint capsule, volar plate, collateral ligament, or tendon sheath were excised together with the main tumor. Finally, the surgical microscope was used to check for residual tumors, which were subsequently excised (Figure 1D and E). The primary outcome was tumor recurrence. The preoperative tumor characteristics were recorded from the database. Parts of the tumor adjacent to tendons, tendon sheaths, neurovascular structures, or periarticular ligaments and capsules on MRI or surgery were defined as soft tissue tumor adhesions.
Surgical procedure of tumor excision using the surgical microscope. (A) The tumor (arrow) is located in the middle finger. (B) The tumor is adherent to the tendon and neurovascular structures. (C) Since the tumor is firmly adherent to the tendon sheath, the A4 pulley is excised along with the tumor. (D) The remnant tumors around the tendon are excised using a surgical microscope. (E) Upper: The tumor is excised using the surgical loupe. Lower: The tumor is excised using the surgical microscope.
Data are expressed as mean values. The statistical analysis was performed using the SPSS software version 23.0 (IBM Corp.). The Mann–Whitney U-test and Fisher’s exact test were used to evaluate the tumor characteristics, tumor excision with or without a surgical microscope, and tumor recurrence. Probabilities of less than 0.05 were considered statistically significant.
Results
The mean tumor diameter was 20 mm (range=9-54 mm). There were 17 localized tumors and 10 diffuse tumors. Soft tissue tumor adhesions were observed in all cases. There were 18 tumors with adhesions to the tendons, 12 with adhesions to neurovascular structures, and 22 with adhesions to the periarticular ligaments and capsules. Bony lesions were observed in 11 tumors. The mean operative time was 76 min (range=20-210 min), and the surgical microscope was used in 13 cases. Recurrences were observed in three patients (overall recurrence rate: 11%). However, no recurrence was observed among patients whose tumors were excised using the surgical microscope (Table I). The mean interval for recurrence was 6.0 years (range=4.6-8.2 years). All recurrent tumors were adherent to tendons, ligaments, and capsules. Two of the three patients underwent reoperation using the surgical microscope, and no recurrence was observed postoperatively. The proportions of diffuse-type tumors and bony lesions were similar between the groups treated with and without the surgical microscope. However, the recurrence rate in the group treated using the surgical microscope was 0%.
Clinical findings regarding the use of the surgical microscope.
Discussion
TSGCT is a benign tumor that frequently occurs in the hand. It affects the range of motion of the fingers due to its gradual growth. The standard treatment of TSGCT is surgical excision. However, a simple tumor excision has been associated with a high recurrence rate of 12-27% (3, 4, 10, 11). Based on this, the tumor was not completely excised during the initial surgery. In particular, tumors invading the bony cortex, intra-articular tumors, or tumors adherent to tendons, tendon sheaths, neurovascular structures, or tissues around the joint, were associated with recurrence (4, 7, 11). In these cases, residual tumors were detected. In this study, tumor adhesions to the neurovascular structures, tendons, and periarticular tissues were detected in all cases. In particular, adhesions to the tendons and tendon sheaths were common. The recurrence rate is higher in tumors involving the tendons (3). Thus, observing presence of invasion in these tissues during the preoperative MRI and surgery is critical.
The intraoperative surgical loupe and microscope, as well as postoperative radiotherapy, reportedly prevented growth of residual TSGCT tumors of the hand (5, 8, 9, 12). The recurrence rates were 6-6.5% among patients treated with the surgical loupe (5, 9), 5.5% among those treated using the surgical microscope (8), and 0% among those treated with postoperative radiation therapy (12). These rates were significantly lower than those in patients treated with simple tumor excision. Molecularly targeted drugs against colony-stimulating factor 1 have been recently developed (13-15). Clinical trials are being conducted to determine their effectiveness in reducing the tumor recurrence rate. However, not all patients are suitable candidates for radiation therapy and molecularly targeted drug therapy due to their medical history and general condition. Radiation causes joint and skin damage, while molecularly targeted drugs have a high incidence of severe drug-related side effects. Meanwhile, the surgical loupe and microscope can be used in all patients regardless of their medical history or general condition.
In this study, the recurrence rate after a mean follow-up period of 6.8 years postoperatively was 11%. However, the recurrence rate among patients treated with the surgical microscope was 0%. This treatment option was effective, even when there was a risk of recurrence. None of the patients who were treated with the surgical microscope developed recurrence because the tumors in the bones, joints, neurovascular structures, and tendons were successfully detected and removed due to the enlarged surgical field. It was specifically useful for detecting tumors located posterior to the tendons and inside the joints. Additionally, there was no patient burden associated with using a surgical microscope. Thus, the use of the surgical microscope in the excision of TSGCT of the hand might be recommended.
One strength of the present study was that it focused on the effect of using the surgical microscope in treating TSGCT. There have been few reports on the application of this treatment modality and its medium-term outcomes. However, our study has several limitations. First, due to the small number of patients, the observed difference in the outcomes in patients who were treated with and without the surgical microscope was not significant. However, recurrence was not observed in any patients treated using the surgical microscope. Based on this, the surgical loupe alone was insufficient. Additionally, the surgical microscope was useful for locating the residual tumors. Second, some patients were interviewed via a telephone call. Thus, the presence of smaller tumors was not confirmed by physical examination. However, this was not a critical issue because TSGCT is a benign tumor, and small tumors do not result in functional impairment.
In conclusion, among patients with TSGCT of the hand treated with tumor excision using the surgical microscope the postoperative recurrence rate was 0%. Based on the results of this study, the surgical microscope might be used for the excision of TSGCT of the hand.
Acknowledgements
The Authors would like to thank Editage (www.editage.com) for the English language editing.
Footnotes
Authors’ Contributions
Y.N. and K.T. drafted the original manuscript and conceived the idea of the study. M.A. contributed to the interpretation of the results. S.H., S.H., and K.I. collected the data. H.T. supervised the conduct of this study. All Authors reviewed and approved the final version of the manuscript.
Conflicts of Interest
The Authors have no relevant financial or non-financial interests to disclose.
Funding
The Authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
- Received October 31, 2023.
- Revision received November 20, 2023.
- Accepted November 21, 2023.
- Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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