Klein,2 Noel Weidner,3 ... Women's Hospital, 75 Francis St., Boston, MA 021 15. ... BAKER. ET AL. Microscopically pigmented villonodular synovitis consists of.
1228
Case Report
L Pigmented Calcifications Nancy
D. Baker,1
We present
Villonodular
Jeffrey
0. Klein,2
a case of pigmented
Synovitis
Noel Weidner,3
villonodular
Barbara
synovitis
in
which coarse calcification was identified on nadiographs and CT scans. This feature of the disease has not been described
before.
Containing N. Weissrnan,1
digitorum
brevis
and Gregory
muscle.
Four weeks
W. Brick2
later, the mass
was completely
excised.
The gross (aggregate) specimen was composed of firm, lobulated soft tissue, which was gritty and tan-white.
Microscopically,
the mass
was variably cellular and fibrotic, the latter portion containing foci of dystrophic
calcification features
histiocytic
a 45-year-old
man presented
with
knee
pain and skin
discoloration on the great toe, an ill-defined soft-tissue noted on the dorsum of his foot. Upon questioning,
mass was he vaguely
remembered that he first became aware of the mass 8 months earlier after he had dropped a piece of firewood on his foot. He recalled that the mass had persisted after the swelling, tenderness, discoloration had resolved. Plain film examination of the foot revealed a well-corticated
and
skin
CT scans
multiple,
showed
scattered,
a cleft
between
punctate the
calcifications
second
and
(Fig. 1C).
third
cuneiform
in addition to the soft-tissue mass with calcifications (Fig. i D). An incisional biopsy was performed. A 5 x 3 cm yellow-tan mass with diffuse margins appeared to be arising from the joint between the second and third cuneiform bones. The mass was located beneath bones
the common
extensor
tendons
and appeared
to be infiltrating
the tibialis anterior tendon medially and into the bulk of
the
and
spindled to polygonal
benign-appearing
Admixed were osteoclastlike
oval
December
1989 0361-803X/89/1536-1228
nuclei.
giant cells, focal sheets of xanthoma
cells, and foci of hemosiderin deposition (Fig. 1 F). Tumor was noted to abut, without invading, skeletal muscle. The findings were those of pigmented villonodular synovitis. (Authorities
at the Armed Forces Institute of Pathology concurred with
the diagnosis.)
under extensor
Discussion Pigmented
villonodular
synovitis
of joints,
0 American
tendon
sheaths,
and bursae represents a spectrum of benign lesions arising from synovium. Early investigators [1 -3] linked it to an inflammation recent
of the synovium
resulting
from
hemorrhage.
However,
studies [4] favor a neoplastic cause, either a fibnohistiocytic or synovial cell differentiation. The soft-tissue mass may be localized on diffuse, intnaarticulan on extnaarticular. It
Received April 26, 1989; accepted after revision May 15, 1989. I Department of Radiology, Brigham & Women’s Hospital, 75 Francis St., Boston, MA 021 15. Address reprint requests to N. D. Baker. 2 Department of Orthopeds, Brigham & Women’s Hospital, Boston, MA 02i 15. 3 Department of Pathology, Brigham & Women’s Hospital, Boston, MA 02115. AJR 153:1228-1230,
cells with fibro-
to vesicular
erosion
between the second and third cuneiform bones, without cartilage space loss (Figs. i A and 1B). The soft-tissue mass was seen in profile on tangential fluoroscopic spot films. The mass was ill-defined and contained
(Fig. i E).
The cellular areas contained
Case Report When
Coarse
Roentgen Ray Society
AJR:153,
PIGMENTED
December1989
VILLONODULAR
1229
SYNOVITIS
A
Fig. 1.-A and B, Oblique (A) and lateral (B) plain films of foot show erosion (arrowheads) between second C, Tangential film shows soft-tissue mass (arrowheads) over second and third cuneiform bones. 0, CT scan shows mass on dorsum of left foot. E, Photomicrograph shows calcifications within fibrotic portion of mass. F, Photomicrograph shows cellular area of mass containing spindled to polygonal cells and hemosiderin.
arises from the synovial tissue in a joint, a tendon sheath, on, rarely, a bursa. Of those arising from tendon sheaths, 90% occur in the hand [4]. The most common intnaarticular site is the knee
[5]. The hip, ankle,
shoulder,
or any synovial
joint
intraarticular
osteoporosis,
configuration,
also
accounts
for
the
various
because they are similar histologically. bone lesions in association with villonodulan
clinical
presentations,
Specific vitis of the knee were described first Additional bone lesions were observed
syno-
by Lewis [2} in 1947. by Breimer and Frei-
bergen [3]. Smith and Pugh [5] subsequently (1 962) reported the following radiographic findings: soft-tissue mass (either
on extnaarticular)
with
cuneiform
bones.
or without
lobulation
and
with various densities (because of hemosidenin deposition); cortical erosions (either intraarticular or juxtaarticular); and subcortical cysts. Rare radiographic findings consisted of
may be involved, including the spinal facet joints. The latter can present either as an extradural on a paravertebral mass lesion [4]. Bunsal sites include the knee, hip, and shoulder [4]. The anatomic location of the tumor, as well as gross apparently
and third
narrowed
joint
space,
and
hypertrophic
Iipping.
No soft-tissue calcifications were described [5]. The presence of hemosiderin can account for the various densities can
of the mass be
detected
on plain radiognaphs. with
CT [6].
The hemosidenn
Coarse
calcifications,
however, according to Goldman and DiCanlo [7], “do not occur.” Lewis [2] indicated earlier that the presence of discrete calcifications distinguished synovial sarcoma from villonodular synovitis of the knee [2]. In our case, the calcifications are dystrophic changes within a fibrous portion of the tumor
mass (Fig. 1 E).
1230
BAKER
Microscopically
pigmented
villonodular
synovitis
consists
of
various amounts of stnomal cells, histiocytes as well as hemosidenn
giant cells, and lipid-laden and collagen [3]. Recent MR studies of two lesions in the knee and two in the foot showed predominantly low-to-moderate signal intensity in all
pulse sequences.
Also, there was a striking
absence
of high
images. Varied inhomogeneity was seen from case to case, causing the authors to speculate that these differences were due to the varied preponderance signal
intensity
of hemosidenin,
on T2-weighted
lipid, and collagen
[8, 9].
REFERENCES
ET AL.
2. Lewis RW. Roentgen diagnosis of pigmented
villonodular synovitis and synovial sarcoma of the knee joint. Radiology, 1947;49:26-37 3. Breimer CW, Froiberger RH. Bone lesions associated with villonodular synovitis. AJR 1958;79:618-629 4. Weidner N, Challa vR, Bonsib SM, Davis CH, Carroll TJ. Giant cell tumors of synovium (pigmented villonodular synovitis) involving the vertebral column. Cancer 1986;57:2030-2036 5. Smith JH, Pugh DG. Roentgenographic aspects of articular pigmented vilionodular synovitis. AJR 1962;876:1146-1156 6. RosenthalDl, Aronow 5, Murray WT. Iron content ofplgmented villonodular synovitis detected by computed tomography. Radiology 1979;33:409-41 1 7. Goldman AB, DiCarlo EF. Pigmented villonodular synovitis: diagnosis and differential diagnosis. Radiol Clin North Am 1988;26:1327-1347 8. Kottal RA, Vogler JB III, Matamoros A, Alexander AH, Cookson JL Pigmented villonodular synovitis: a report of MR imaging in two cases. Radiology
1 . Jaffe HL. Tumors and tumorous conditions ofthe bones andjoints, 30. Philadelphia: Lea & Febiger, 1968
Chapter
AJR:153, December 1989
1987;163:551-553
9. Sherry CS, Harms SE. MA evaluation of giant cell tumors of the tendon sheath. Magn Reson Imaging 1989;7: 195-201
