types of Surgery 

TGCT can destroy healthy joints, erode bone, and grow to a large size. Typically, treatment involves surgery as the first-line treatment approach. There may be a single tumor or multiple. Surgery attempts to remove the tumor(s) and damaged portions of the joint lining. Depending on the extent of the damage to tendons and ligaments, your surgeon may also repair those during the procedure. Various surgical approaches are used and will be discussed with you by your healthcare provider. There are two main tumor and joint lining removal (synovectomy) techniques: the arthroscopy and the open surgery.

Arthroscopy

Open surgery

In both diffuse and localized/nodular TGCT, arthroscopic surgery can be used to remove the damaged joint lining. This approach uses a few small incisions around the joint with one incision used to insert a camera, known as the the arthroscope. The arthroscope allows the surgeon to see the joint lining projected on a larger screen to guide the other surgical instruments (1). In many localized/nodular TGCT cases, this surgery is curative. Arthroscopic surgeries may involve shorter recovery time and hospital stays.

Open surgery

In diffuse TGCT, open surgery can be used based on the accessibility of the tumor location, size of tumor, and extent of the damage in the joint. The open surgery uses a single large incision to gain full access to the joint to remove the tumor and synovial tissue. Depending on the tumor location, joint dislocation may be required to gain access (like in the case of the hip) (2). Open surgeries may require longer hospital stays and longer recovery time. ​

Combined approach

In difficult-to-access locations, such as the knee, a combined approach may be attempted. This surgical approach utilizes an open surgery for the back of the knee (posterior) to remove the tumor(s) and joint lining, while an arthroscopic surgery is done in the front (anterior) to remove the joint lining. With the use of the arthroscopic surgery in the front, this can reduce the recovery time and magnitude of the surgery (3). These two approaches may be done at the same time or weeks apart.

ABLATION

Ablation is the surgical technique of applying extreme cold or extreme heat to destroy the TGCT cells that may not be found during these surgical approaches. Ablation is used in combination with a synovectomy to attempt to ensure the tumor cells are dead. Cryoablation (also known as cryosynovectomy) is the use of extreme cold where a small needle is inserted into the tissue and a liquid nitrogen spray is added to freeze the tissue (4).  There is no evidence to suggests this provides more benefit than surgery alone. 

Joint Replacement

TGCT can cause extensive damage to the joint leading to secondary osteoarthrosis. A joint replacement may be required to improve function and reduce pain caused by the bone damage. This procedure removes the damage joint lining, cartilage, and bone while remaking a functional prosthetic out of metal, ceramic, or plastic material. It is important to note that tumors may recur following joint replacements and replacements only address the damage to the bone and joint (4). Therefore, the joint replacement is recommended when the damage to the joint and bone is beyond repair and a replacement is warranted, rather than as a strategy to avoid recurrence. During a replacement, a synovectomy may be preformed to remove the tumor(s).

Ankle fusion

Ankle fusion, also known as an ankle arthrodesis, is a procedure where the ankle is fused into a single piece. Fusions are used following advanced joint damage and bony erosion, predominantly in the ankle. Severity of bone involvement in TGCT of the ankle tends to be high, this is due to pressure erosion from swelling and growth in a narrow joint space. In these cases, an invasive surgery may be necessary. However, this approach does lead to irreversible structural and functional changes (5,6). 

amputations

Due to the high recurrence rates of diffuse TGCT (40-70%), operations are often repeated. TGCT can cause irreversible damage that is not amenable to any other options. Following all treatment failures or severe complications, limb-salvage surgeries may be impossible. In these situations, removal of the limb is used to reduce pain and improve quality of life (7). This is becoming increasingly less common with the advent of targeted therapies. To learn more about medications, go to Medication.

Which option is best?

Currently, there is no consensus on the most effective surgical approach that reduces recurrence rates, particularly for patients with diffuse TGCT. The recurrence rate for localized TGCT is around 15%, whereas, the recurrence rate for diffuse TGCT is roughly around 50% (8). 
​
Several studies have attempted to determine the effectiveness of arthroscopic surgery vs open surgery. For instance, several studies have shown no difference in recurrence rates among TGCT patients treated with arthroscopic vs open synovectomy (9,10). Another study in 2013 showed that patients with TGCT of the knee, arthroscopic approach to the front and an open approach to the back had less recurrence rates than an all-arthroscopic or all-open surgery (11). However, in 2019, another study used a pooled database of patients and found that recurrence free survival was highest after an open surgery vs an arthroscopic surgery (12). Noteworthy, this study combined diffuse and localized TGCT patients, possibly leading to bias in the findings (12). Given the mixed results, there is no consensus on surgical approach recommended to reduce recurrence for TGCT.

Surgical technique should be based on individual characteristics, tumor size, and access to the tumor location. Please consult with your doctor to determine which is best for you.​

NCCN Clinical Practice Guidelines. Soft Tissue Sarcoma. V.4.2020. https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf. 2. Palmerini E et al. Eur J Cancer. 2015;51:210-217. 3. Ma X et al. Int Orthop. 2013;37:1165-1170.

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References

1.     Dwidmuthe S, Barick D, Rathi T. Arthroscopic Management of Pigmented Villonodular Synovitis of the Knee Joint. J Orthop Case Reports. 2015. doi:10.13107/jocr.2250-0685.262
2.      Green D, Figgie M. Synovectomy: Surgery for Inflammatory Arthritis. HSS J. 2020.
3.      Treatment for Pigmented Villonodular Synovitis (PVNS): What to Expect. Healthline. https://www.healthline.com/health/tgct/pvns-treatment#takeaway. Published 2019.
​4.      Pinheiro Junior LFB, Cenni MHF, Leal RHS, Teixeira LEM. Total knee replacement in patients with diffuse villonodular synovitis. Rev Bras Ortop (English Ed. 2017. doi:10.1016/j.rboe.2017.08.002
5.      Li X, Xu Y, Zhu Y, Xu X. Surgical treatment for diffused-type giant cell tumor (pigmented villonodular synovitis) about the ankle joint. BMC Musculoskelet Disord. 2017. doi:10.1186/s12891-017-1824-6
​6.      Ankle Fusion. John Hopkins Medicine. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ankle-fusion. Published 2021.
7.    Mastboom MJL, Verspoor FGM, Gelderblom H, Sande MAJ van de. Limb Amputation after Multiple Treatments of Tenosynovial Giant Cell Tumour: Series of 4 Dutch Cases. Case Rep Orthop. 2017. doi:10.1155/2017/7402570
​8.     Bernthal NM, Ishmael CR, Burke ZDC. Management of Pigmented Villonodular Synovitis (PVNS): an Orthopedic Surgeon’s Perspective. Curr Oncol Rep. 2020. doi:10.1007/s11912-020-00926-7
9.     Palmerini E, Staals EL, Maki RG, et al. Tenosynovial giant cell tumour/pigmented villonodular synovitis: Outcome of 294 patients before the era of kinase inhibitors. Eur J Cancer. 2015. doi:10.1016/j.ejca.2014.11.001
​10.    Gu H feng, Zhang S jun, Zhao C, Chen Y, Bi Q. A comparison of open and arthroscopic surgery for treatment of diffuse pigmented villonodular synovitis of the knee. Knee Surgery, Sport Traumatol Arthrosc. 2014. doi:10.1007/s00167-014-2852-5
​11.   Colman MW, Ye J, Weiss KR, Goodman MA, McGough RL. Does combined open and arthroscopic synovectomy for diffuse PVNS of the knee improve recurrence rates? Tumor. In: Clinical Orthopaedics and Related Research. ; 2013. doi:10.1007/s11999-012-2589-8
​12.    Mastboom MJL, Staals EL, Verspoor FGM, et al. Surgical Treatment of Localized-Type Tenosynovial Giant Cell Tumors of Large Joints: A Study Based on a Multicenter-Pooled Database of 31 International Sarcoma Centers. J Bone Jt Surg - Am Vol. 2019. doi:10.2106/JBJS.18.01147

Ⓒ TGCT Support
Updated 2022