Abstract
In this retrospective study, we evaluated the impact of tumour-related and surgical factors on the recurrence of giant cell tumours of tendon sheath. A total of 95 patients were treated at our institution between February 2012 and March 2021. We identified the factors most likely to be associated with recurrence from evaluation of classification, neurovascular invasion, bone erosion and joint invasion. Based on these criteria, we identified 49 patients with a high risk of recurrence. Of the 95 patients, recurrence was observed in 17. Among the 49 patients classified as high-risk, 13 were found to have recurrence. This study demonstrates that recurrence is more common in the high-risk patient group.
Introduction
Giant cell tumours of tendon sheath (GCTTS) are the second most common benign proliferative tumours in the upper extremities after ganglion cysts (Darwish and Haddad, 2008; Lucas, 2012). These tumours are usually slow-growing, painless, benign and consist of soft tissue (Adams et al., 2012). They are most commonly found in the fingers and among women in their fourth and fifth decades (Ushijima et al., 1986). While this type of tumour originates from the synovial membrane, tendon sheath or synovial bursa, its pathogenesis remains unclear. Inflammation resulting from reactive or regenerative hyperplasia is the generally accepted theory of pathogenesis (Koutserimpas et al., 2018) and genetic factors have been observed in previous studies (Temple, 2012; West et al., 2006).
GCTTS is usually asymptomatic; however, as the tumour grows some patients may present with swelling, pain and limitation of movement. The diagnosis is usually made from clinical examination. While radiography can be helpful in evaluating cortical destruction, it is not helpful in the definitive diagnosis. Magnetic resonance imaging (MRI) is the most useful examination in terms of diagnosis and treatment planning. The most commonly accepted treatment is surgical excision.
The recurrence rate after excision varies with the type and location of the tumour. Al-Qattan (2001) classified GCTTS with MRI into two types according to the risk of recurrence. Type 1 includes a nodular or multinodular lesion surrounded by a capsule, while type 2 describes tumours with no connective tissue membrane and satellite, diffuse or multicentric nodules. The latter are stated to be at high risk for recurrence. Other factors affecting the development of recurrence include bone erosion (Jalgaonkar et al., 2011; Reilly et al., 1999), tumour invasion into the joint (Williams et al., 2010) and compression of neurovascular structures (Di Grazia et al., 2013).
We hypothesized that surgical factors would have an effect on the recurrence of GCTTS. The aim of the present study was to evaluate the effects of surgical factors in patients undergoing excision of a GCTTS on recurrence. Our secondary aim was to re-examine the effect of each of the previously mentioned risk factors for recurrence in our relatively large series.
Material and methods
This retrospective study was approved by the ethics committee of our hospital (approval no. 0710202177/543). Patients with a diagnosis of GCTTS treated with surgical excision in our hospital between February 2012 and March 2021 were evaluated using our hospital’s data system. The exclusion criteria included the treatment of a recurrent tumour or one in a region other than the finger, patients aged below 18 years, a follow-up period of less than 2 years and biopsy results that were incompatible with GCTTS. Recurrence rate, postoperative sensory examination findings, the total active range of motion of the affected finger and any other documented complications were assessed at the final follow-up visit. The age, sex, dominant hand and anatomical localization of the tumours were recorded.
Radiography and MRI scans taken during the preoperative period were examined. Bone erosion, neurovascular invasion and joint invasion were then assessed. The preoperative MRI scans were evaluated by our hospital’s radiology department, which consisted of professionals who were experienced in musculoskeletal tumours. By evaluating the MRI images and intraoperative findings, the patients were categorized as type 1 or type 2 according to the Al-Qattan classification. We grouped patients who had any tumour with neurovascular invasion, joint invasion, bone erosion or Al-Qattan type 2 tumour as high risk of recurrence, and patients without any of these criteria as low risk of recurrence.
The surgical factors recorded included method of anaesthesia, surgeon’s speciality, tourniquet application and loupe use. Patients who were operated on using 3.5× loupe magnification were separated from those operated on without using a loupe, with a tourniquet and without a tourniquet were then separated. The anaesthesia techniques performed included axillary block and digital block methods, with these patients being divided into two groups. Other anaesthesia methods were excluded from the study. Finally, the patients were grouped according to whether the surgery was performed by an orthopaedic or a hand surgeon. Two hand surgeons had an expertise level of 4 and one had an expertise level of 3 (Tang and Giddins, 2016). Two orthopaedic surgeons had expertise levels of 3 and 2, respectively. The effects of all these surgical factors on recurrence were evaluated.
Statistical analysis
The numerical data were presented as means, while the standard deviation was represented by minimum and maximum values. The distribution of the data was examined using histograms, and categorical data were expressed as numbers and percentages. To compare the parameters between the two groups, Mann–Whitney U and chi-square tests were employed. Multivariate regression analysis was used to evaluate the relationship between surgical factors and recurrence. A probability (p-value) ≤0.05 was deemed statistically significant to reject the null hypothesis.
Results
The records of 188 patients who underwent surgical excision were accessed, and 95 patients who met the inclusion criteria were included in the study. The mean age of the patients included in the study was 41.3 years (range 18–80). The mean follow-up period was 72 months for the last control group of patients (range 24–124). Recurrence was observed in 17 (17.8%) of the patients in the final examination. The mean range of motion was found to be 264.1° (range 245–270). No sensory deficit was detected in the preoperative sensory examination. In the postoperative follow-up, 11 patients had hypoesthesia in the distal area of the operation field. There was no statistical difference between them in the recurrence rate between patients with normal sensory examinations and those with hypoesthesia (p = 0.388). The general data of the patients are summarized in Table 1. According to the multivariate regression analysis, surgical factors did not have a significant impact on recurrence (Table 2).
General data of patients and comparisons by recurrence.
The impact of surgical factors on recurrence according to the multivariate regression analysis.
CI: confidence interval; Exp(B): the exponentiation of the B constant, which is an odds ratio.
A total of 49 patients met the high-risk criteria and 46 patients were considered to be low risk. Recurrence was observed in 13 (26.5%) patients in the high-risk group and 4 (8.6%) patients in the low-risk group; there was a significant difference between these two groups in terms of recurrence (p = 0.023). Surgical factors were evaluated in patients who we considered to be at a high risk of recurrence; no factor was found to be significant. The effect of surgical factors of high-risk patients on recurrence rate are shown in Table 3.
The effect of surgical factors of high-risk patients on recurrence rate.
Discussion
One of the most important complications of GCTTS is the development of recurrence, the rate of which is in the range of 5%–40% (Di Grazia et al., 2013; Grover et al., 1998; Moore et al., 1984; Williams et al., 2010). The conditions that pose a risk for the development of recurrence include tumours classified as type 2 according to the Al-Qattan classification (Al-Qattan, 2001), tumour invasion into neurovascular structures or into the joint (Di Grazia et al., 2013; Williams et al., 2010), and the presence of bone erosion (Jalgaonkar et al., 2011; Reilly et al., 1999). Because of the invasion of the tumour into these structures, difficulties arise in its dissection and removal, as well as in maintaining soft tissue balance. In our study, we found that these criteria did not constitute a significant risk factor for recurrence. However, we concluded that the recurrence rate increased significantly in the group we classified as high risk (p = 0.023). We believe that the risk of recurrence increases in the case of the coexistence of the risk factors mentioned above. Otherwise, we maintain that the most important risk factor for the development of recurrence is incomplete surgical excision.
Many authors recommend operating on GCTTS with microscopic magnification. Specifically, Ozalp et al. (2004) advised that surgery be performed with loupe magnification in a GCTTS case series of 141 patients. In this way, complete excision could be achieved with less recurrence. Ozben and Coskun (2019) have also suggested that using a loupe provides better surgical vision, more meticulous dissection and a lower recurrence rate. In an earlier study, Ikeda et al. (2007) applied microscopic excision to 18 patients with GCTTS and reported that recurrence developed in one patient. In our study, we found that loupe use did not have a statistically significant effect on recurrence (p = 0.232). However, we maintain, along with the other authors identified above, that using the loupe provides better surgical vision, allows for more meticulous dissection and facilitates total excision. With respect to tourniquet use, Zhou et al. (2022) reported that curettage of benign bone tumours using a tourniquet reduced the recurrence rate. In another study, Gholve et al. (2007) evaluated cases of GCTTS in a paediatric patient group and recommended the use of tourniquets in children. In our study, we found that using a tourniquet had no statistical effect on the development of recurrence (p = 0.695). Considering the rare complications that a tourniquet may cause, we think that its use should be decided on a patient-by-patient basis, depending on the surgeon’s preference.
GCTTS should be treated by experienced surgeons because of the high risk of recurrence. In their review article, Kitagawa and Takai (2020) reported that only well-trained and experienced surgeons should treat GCTTS. In our study, there was no statistical difference between the two groups. Regardless of who treats these tumours, we maintain that complete excision of the tumour and the assurance of adequate soft tissue balance will reduce the risk of recurrence.
The limitation of our study is its retrospective design. However, the sufficient number of patients and the treatment of all patients within a single centre by experienced surgeons are the strengths. We believe that our study will contribute to the literature in terms of evaluating the risk factors for recurrence in GCTTS and assessing the effects of surgical factors on such recurrence.
In conclusion, the high-risk group exhibited a higher incidence of recurrence. Our study findings indicate that surgical factors do not demonstrate a statistically significant impact on recurrence.
Footnotes
Declaration of conflicting interests
The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Ethical approval for this study was obtained from University of Health Sciences Turkey, M.S. Baltalimani Bone Diseases Teaching and Research Hospital of Ethics committee (approval no. 0710202177/543).
Informed consent
Written informed consent was obtained from the patients for their anonymized information to be published in this article.
