Diffuse pigmented villonodular synovitis in knee joint: diagnosis and treatment / Sinovite vilonodular pigmentada difusa no joelho: diagnóstico e tratamento

ABSTRACT Pigmented villonodular synovitis is a rare proliferative condition of the synovium. Although the condition can present in any joint, the knee is the most commonly affected site. Despite being a benign condition, pigmented villonodular synovitis is often aggressive, with marked extra-articular extension in some cases. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate. There is no standard method of management of this lesion. Open surgery is a classical and effective method for treatment. Arthroscopic synovectomy, however, has gained popularity, and has several advantages over the open technique particularly in exclusively articular cases. The combined approach is suggested in cases with extra-articular involvement. Synovectomy through any approach may prevent secondary osteoarthritis and subsequent joint arthroplasty. Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy appears to decrease the rate of local recurrence in diffuse cases. The authors observed a great heterogeneity in reporting of functional results, and specific conclusions should not be drawn. Each patient should be managed in accordance with his/her particular condition.

RESUMO A sinovite vilonodular pigmentada é uma rara condição proliferativa da membrana sinovial. Apesar de a doença poder estar presente em qualquer articulação, o joelho é o local mais frequentemente afetado. Ainda que doença benigna, geralmente tem comportamento agressivo, pode ter extensão extra-articular em alguns casos. O acometimento monoarticular ocorre em duas formas: localizada ou difusa. A forma difusa é mais comum e tem alta taxa de recorrência. Não há método padronizado para o manejo dessa lesão. O tratamento cirúrgico aberto é o método clássico e efetivo. A sinovectomia artroscópica, entretanto, tem ganhado popularidade e tem diversas vantagens sobre a técnica aberta, principalmente em casos exclusivamente articulares. A abordagem combinada é sugerida em casos com envolvimento extra-articular. A sinovectomia pode prevenir a osteoartrose secundária e o subsequente tratamento reconstrutivo. A radioterapia usada como tratamento adjuvante à sinovectomia parece diminuir a taxa de recorrência local na forma difusa da doença. Os autores encontraram grande heterogeneidade na forma como os resultados funcionais foram reportados e não se deve chegar a conclusões específicas. Cada paciente deve ser manejado de acordo com suas particularidades.

Imaging Diagnosis of Pigmented Villonodular Synovitis of Spine / 中国医学影像学杂志

PurposeTo explore CT and MRI findings of pigmented villonodular synovitis (PVNS) of spine, and to improve the preoperative diagnosis.Materials and MethodsCT and MRI findings of 7 cases of PVNS of spine confirmed by surgery and pathology were retrospectively analyzed. Seven cases underwent CT scan and 5 of them underwent MRI scan. The location of the lesions, tumor size, shape, density (signal), bone destruction and enhanced features were analyzed.ResultsExcept one case with small lesion, the remaining 6 cases showed lobulated soft tissue masses centering at the facet joint area, with lytic, expansive bone destruction. On CT images (n=7), 3 cases showed the masses density similar to that of the surrounding muscles, and 4 cases showed the tumor density slightly lower than that of the surrounding muscles. On MRI images (n=5), 1 small lesion demonstrated low signal at the peripheral, 1 lesion was isointensity without obvious low-density in it, 3 cases showed characteristic multiple visible low signal nodules in the lesions.ConclusionThe possibility diagnosis of the PVNS should be considered when spinal lesions are characterized by osteolytic bone destruction centering at facet joints and soft tissue masses with distinctive MR signals.

The study of differential diagnostic value between pigmented villonodular synovitis and rheumatoid arthritis in active age with clinic and ultrasound / 中华医学超声杂志（电子版）

ObjectiveTo explore the value of differential diagnosis between pigmented villonodular synovitis (PVNS) and rheumatoid arthritis (RA) in active stage with clinic and ultrasound. MethodsWe analyzed retrospectively the characters of clinic and ultrasound of sixteen patients with PVNS and sixteen patients with rheumatoid arthritis inactive stage.ResultsIn aspects of patient’s age (T=185), pain scores (T=136) history of trauma (P=0.029), functionally uncompensated conditions (P=0.001) type (P=0.000) and sum (P=0.000) of involved joints、bright spot-echoes in hydrops (P=0.001) tendons nearby involved (P=0.001) and the Adler’s grade of Doppler ultrasound blood flow (P=0.009), the differences between PVNS and RA in active stage had statistical significance (P0.05).ConclusionThe clinical characters including Patient’s age, pain scores, history of trauma, functionally uncompensated conditions, and the characters of ultrasound including type and sum of involved joints, bright spot echoes in hydrops, tendons nearby involved and the Adler’s grade of Doppler ultrasound blood flow, are helpful for the differential diagnosis of PVNS and RA in active stage.

Total knee replacement and arthroscopic treatment for pigmented villonodular synovitis of the knee joint / 中国组织工程研究

BACKGROUND:Surgical treatment for pigmented vil onodular synovitis can maximize the excision of synovial lesions and recovery of joint function. OBJECTIVE:To investigate the knee joint function and relapse rate fol owing treatment of pigmented vil onodular synovitis with total knee replacement and arthroscopic synovectomy. METHODS:We retrospectively analyzed 34 cases of knee pigmented vil onodular synovitis admitted for surgical treatment in the Department of Orthopedics, Xiangya Hospital of Central South University, China from December 2006 to December 2011. In these cases, 24 patients received arthroscopic synovectomy and 10 patients were subjected to total knee replacement. Adjuvant radiotherapy was conducted according to postoperative patient’s conditions. Lysholm scoring was employed in the arthroscopic synovectomy group, and American Knee Society scoring was used in the total knee replacement group. Knee function in two groups was compared before and after treatment. Fol ow-up observation was performed to compare knee function recovery and relapse rate between two groups. RESULTS AND CONCLUSION:Thirty-four patients were effectively fol owed up for 12-66 months, mean 41.3 months. Statistical analysis showed that in the arthroscopic synovectomy group, the postoperative Lysholm score was (86.3± 10.3) points, significantly higher than the preoperative score which was (55.5±13.2) points (t=3.81, P=0.016, P<0.05). In the total knee arthroplasty group, the American Knee Society score was increased from (40.7±2.2) points preoperatively to (90.2±1.1) points postoperatively (t=6.27, P<0.01). In the arthroscopic synovectomy group, the American Knee Society score was increased from (34.2±3.9) points preoperatively to (80.8±1.9) points postoperatively (t=16.58, P<0.01). Arthroscopic synovectomy combined with adjuvant radiotherapy can achieve better outcomes in pigmented vil onodular synovitis patients, while the total knee replacement for advanced with advanced knee diffuse pigmented vil onodular synovitis is better to restore knee function and the recurrence rate is low.

Sinovite vilonodular pigmentada localizada: relato de caso / Localized pigmented villonodular synovitis: case report

O caso em questão é o de uma paciente do sexo feminino que apresentava queixa de dor na região anterior do joelho esquerdo durante e após atividades esportivas, seguidas de bloqueio articular havia três meses. Exames de imagem: radiografias simples do joelho normais e ressonância magnética mostrando formação expansiva sólida podendo corresponder a condroma de partes moles ou a sinovite nodular focal. Realizada ressecção artroscópica da lesão com diagnóstico de tumor de células gigantes difuso símile/sinovite vilonodular pigmentada localizada (SVNPL) após resultado do exame anatomopatológico. A paciente apresenta boa evolução clínica com desaparecimento dos sintomas e retorno às atividades físicas.

This case concerned a female patient with a complaint of pain in the anterior region of her left knee during and after sports activities, followed by joint blockage three months ago. From imaging examinations, simple radiography of the knee was normal and magnetic resonance showed a solid expansive mass, possibly corresponding to soft-tissue chondroma or focal nodular synovitis. Arthroscopic resection of the lesion was performed, and the diagnosis of diffuse giant cell tumor resembling localized pigmented villonodular synovitis (PVNS) was made from the result of the anatomopathological examination. The patient presented good clinical evolution, with disappearance of symptoms and return to physical activities.

Angiomyomatous Hamartoma of Popliteal Lymph Nodes Occurring in Association with Diffuse Pigmented Villonodular Synovitis of Knee

We report the first case of an angiomyomatous hamartoma (AH) of the popliteal lymph nodes (LNs) occurring in association with diffuse pigmented villonodular synovitis (PVNS) of the knee. AH is a rare benign vascular disease with a predisposition for the LNs of the inguinal region. Twenty-five cases of AH have been reported to date; however, the precise pathogenesis is still undetermined. In the present case, an open synovectomy revealed two of three popliteal LNs in close proximity to the extra-articular component of diffuse PVNS. These LNs demonstrated irregularly distributed thick-walled blood vessels in the hilum. These vessels extended into the medulla and cortex and were associated with haphazardly arranged smooth muscle cells in the sclerotic stroma. These findings are compatible with an AH. Our observations raise the possibility that AH of the popliteal LNs may represent an abnormal proliferative reaction against the inflammatory process caused by PVNS of the knee.

Tumores del tejido sinovial de la rodilla / Synovial tissue tumors of knee

Fundamento: los tumores afectan el tejido sinovial de la rodilla se presentan de forma muy similar independientemente de su tipo histológico por lo que en ocasiones su diagnóstico preciso es muy difícil. Desarrollo: se realizó una revisión bibliográfica sobre los tumores benignos y malignos que afectan el tejido sinovial de la rodilla. Se mostraron los aspectos más importantes de cada tipo de tumor como aspectos generales, presentación clínica, exámenes diagnósticos y tratamiento, comenzando por los benignos como el hemangioma sinovial, lipoma arborescens, condromatosis sinovial, sinovitis vellonodular pigmentada y concluimos con el sarcoma sinovial. Conclusiones: el tratamiento definitivo de estos tumores esta en dependencia de su tipo histológico y diagnóstico oportuno.

Background: tumors affect synovial tissue of the knee, they are presented independently in a very similar way of their histological type for what in occasions their precise diagnosis is very difficult. Development: a bibliographical review on benign and malignant tumors that affect synovial tissue of knee was carried out. The most important aspects in each tumor type were shown as general aspects, clinical presentation, diagnostic examination and treatment, beginning with the benign ones as the synovial hemangioma, lipoma arborescens, synovial chondromatosis, pigmented villonodular synovitis and we conclude with synovial sarcoma. Conclusions: the definitive treatment of these tumors depends on their histological type and opportune diagnostic.

Sinovitis pigmentada vilonodular da coluna torácica: relato de caso e revisão da literatura / Sinovitis vellonodular pigmentada de la columna torácica: informe de un caso y revisión de la literatura / Pigmented villonodular synovitis of the thoracic spine: case report and review of the literature

Pigmented Villonodular Synovitis (PVNS), a lesion of the synovial tissues, is rarely found in the spine. We present a 73-year-old male with increasing lower extremity weakness and paresthesias. MRI scans revealed disc herniation and spinal cord compression at the T11-T12 and T12- L1 levels. Intraoperative exploration revealed an epidural mass originating in the T12 lamina, compressing the spinal cord at T11-T12. Pathologic examination was consistent with pigmented villonodular synovitis.

Sinovitis pigmentada vilonodular (PVNS) é uma lesão do tecido sinovial e raramente é encontrada na coluna vertebral. Apresentamos o caso de um homem de 73 anos de idade com aumento de fraqueza da extremidade inferior e parestesia. O exame de imagem por ressonância magnética revelou hérnia de disco e compressão no nível T11-T12 e T12-L1. A exploração cirúrgica evidenciou massa epidural orginária em T2 e compressão da medula espinhal no nível de T11-T12. O exame patológico foi compatível com sinovitis pigmentada vilonodular .

Sinovitis vellonodular pigmentada (PVNS) es una lesión del tejido sinovial y raramente se encuentra en la columna vertebral. Presentamos el caso de un hombre de 73 años de edad que mostró aumento de la flaqueza de la extremidad inferior y parestesias. El examen de imagen por resonancia magnética indicó una hernia de disco y compresión en el nivel de T11-T12 y T12-L1. La exploración quirúrgica evidenció una masa epidural originaria en T2 y compresión de la médula espinal a nivel de T11-T12. El examen patológico fue compatible con sinovitis vellonodular pigmentada.

High-frequency ultrasonic features of pigmented villonodular synovitis / 中华超声影像学杂志

Objective To study high-frequency ultrasonic features of pigmented villonodular synovitis (PVNS).Methods High-frequency ultrasonic findings in 17 cases with PVNS were analyzed and a comparison between surgical and pathological results was made.Results Of 17 cases,10 cases were diffuse type,7 cases were local type.The main high-frequency ultrasonic signs were as follows: the diffused type synovial PVNS demonstrated as hypoecho,local synovial proliferation was revealed as nodulated and heterogeneous echo,hydrarthrosis of the knee joint was present in 10 cases,the involvement of meniscus occurred in 4 cases,intra-articular cartilage and cortex erosion were showed in 5 cases.Local type PVNS was mainly demonstrated as the nodulated and hypoechoic proliferation of synovium,hydrarthrosis of the joint and cartilage erosion were not found.Conclusions High-frequency ultrasound is a valuable imaging method for diagnosing PVNS in preoperative routine screening.

The value of MRI in diagnosing pigmented villonodular synovitis / 中华放射学杂志

Objective To evaluate the value of MRI in diagnosing pigmented villonodular synovitis (PVNS). Methods MRI appearance of 23 pathologically proven cases of PVNS was analyzed. Results In 23 patients with PVNS, 9 cases occurred in knee joint, 9 cases in hip, 3 cases in ankle, 1 in elbow, and 1 in wrist. X ray of the 23 patients could only show the joint effusion, and bony erosion was found in 19 cases. CT scan showed joint effusion and bony erosion more clearly than X ray in 4 cases. The typical MRI appearance included intra articular joint effusion and extensive synovial proliferation which led to progressive destruction of cartilage and bone. The pigmented villonodules showed nodular low signal on both T 1WI and T 2WI, especially in FFE/T 2WI. Conclusion MRI is the most effective modality in the diagnosis of PVNS.