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Giant Cell Tumour of Tendon Sheath (Lump on a Finger or Thumb)

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A giant cell tumour of tendon sheath is a common, benign (non-cancerous) lump on a finger or thumb. What causes it, how it is diagnosed and removed, and how often it comes back.

Updated Oct 20265 citations

A giant cell tumour of tendon sheath is a benign, firm lump, usually on the side or front of a finger. Kieran Hirpara 4.0

What you're feeling

Most people notice a lump on a finger or thumb that does not hurt. It is usually firm, and it grows slowly. Some lumps sit right next to a joint, often the joint closest to the fingertip, and they can appear on the top, side or palm side of the finger. The index finger is the most common spot.

The lump itself is painless in almost every case. When there is discomfort, it tends to come from the lump pressing on nearby structures as it grows. A small number of people notice tingling or numbness in the finger if the lump presses on a nerve. Some people find the finger catches or clicks when it moves, a bit like a trigger finger, where the finger briefly sticks and then jumps free. If the lump is near a joint, bending that finger fully can be hard because the lump gets in the way.

Everyday tasks that use that finger can become awkward. Picking up small coins, doing up buttons, holding a pen or gripping a jar lid may feel clumsy if the lump sits where your grip lands. The lump can also catch on gloves or pockets.

The lump often has been there a long time before it bothers you enough to ask about it. Many people wait months or years, watching it slowly change.

A few things about this condition are worth knowing. It is benign, which means it does not spread to other parts of the body. It is slightly more common in women than men, and it usually appears between the ages of 32 and 51. Most people have a single lump, though some have more than one in different spots.

Watch for a finger or hand that becomes hot, red, swollen and painful, especially with a fever. If that happens, go to the emergency department the same day. If the lump keeps growing, starts to hurt, or the finger is not working as it should, see your GP or ask for a specialist review.

What's actually happening

Your tendons are the strong cords that join muscle to bone and let your fingers bend. Each tendon runs inside a thin sleeve called a tendon sheath, which works a bit like a gasket around a rope, keeping the cord slippery so it can glide as the finger moves.

In this condition, the cells in that sleeve start growing more than they should. The result is a soft tissue lump that sits on or beside the tendon, often close to a joint. It is benign, which means it does not spread, and it grows slowly. Most lumps are small, around 1.35 cm on average, though some grow larger.

The lump is made up of a few things crowded together: inflammatory cells, giant cells (which are simply cells with several nuclei), and a dark pigment called haemosiderin, the same stuff that colours an old bruise. That pigment is why these lumps can look brownish if they are ever seen during surgery.

The symptoms you noticed in the section above come from the lump being in the way. As it grows it can press on the tendon, the joint or a nerve, which explains the catching, the stiffness and the occasional tingling. Most of the time it does not hurt at all, and only about 16 in 100 people report pain.

A few points worth knowing. Most people have a single lump, but about 21 in 100 have two or more separate ones. The lump usually sits next to a joint, and in about a third of finger cases it is at the joint closest to the fingertip. Very rarely, the lump can press into the bone itself, which shows up on an x-ray.

There is also a rarer, more diffuse form of the same condition that spreads along the tendon in thin fronds rather than forming one neat lump. That form is much less common in a finger and tends to behave differently, which is why your surgeon will want a clear picture of exactly what kind of lump this is before planning anything.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your hand and arrange imaging where it is needed to work out exactly what kind of lump this is.

Because this lump is benign and grows slowly, doing nothing is a real option. For a small, painless lump, simply watching it can be the right choice. If the lump is getting in the way, hand therapy can help with the stiffness and the catching. Therapy aims to keep the finger moving and make everyday tasks easier. We usually suggest giving it a fair trial before thinking about surgery.

This condition has no medication that shrinks it, so pain tablets and anti-inflammatories only settle discomfort from the lump pressing on nearby tissue. They do not make the lump smaller.

Surgery is the usual treatment when the lump is large, painful, or stopping the finger working properly. The aim is to remove the whole lump along with its attachment on the tendon sleeve, because leaving that attachment behind is what allows it to grow back. We plan carefully before operating, use magnification during the operation, and remove the lump completely. Recurrence is the main risk with this condition, and it typically happens within 36 months of excision. In a group of 605 people who had a finger lump removed, 14.8% had it come back. Another way to put that: most people, about 85 in 100, do not have it return. If it does come back, removing it again with extra steps to discourage regrowth can still sort the problem out.

What to expect

The outlook for this lump is steady rather than dramatic. It is benign, so it does not spread anywhere else in your body. Left alone, a small painless lump usually keeps growing slowly, or simply stays as it is. It rarely settles on its own, and it does not turn into anything dangerous.

The main thing this condition does over time is come back after removal. Recurrence is the primary risk with this lump, and it typically happens within 36 months of excision. Some lumps are more likely to return than others: ones made up of two or more separate pieces that are not joined together, and ones that have grown into the tendon itself or the lining of the joint. When the whole lump is removed along with the spot where it attaches, that risk drops a long way.

Function after treatment tends to be good. People who have had one of these lumps removed from a finger score, on average, 92% of normal limb function on a standard measure of how the limb works. In reported cases, people have kept full movement in the finger, and the shape of the finger bone on x-ray has returned to normal by the two-year check.

If the lump is the rarer, more spreading kind that wraps around the tendon in fronds, it is harder to remove completely and more likely to return. In those cases, radiation therapy aimed at the area can help control the lump while keeping your hand working.

If you choose to simply watch a small, painless lump, the realistic picture is a lump that grows slowly or stays the same, and that may gradually make bending the finger or using it for small tasks more awkward. If it starts to hurt, keeps growing, or the finger stops working as it should, that is the point where treatment usually earns its place.

When to see someone

Most lumps like this are not urgent, and treatment is never a race. See your GP if a lump is not settling, is growing over weeks, starts to hurt, or stops you using the finger or hand normally. Ask for a specialist review if the finger catches or clicks when it moves, if you notice tingling or numbness, or if bending the finger fully has become hard because the lump is in the way. These are the things worth having looked at sooner rather than later, because a lump that has grown into the tendon or the joint lining is harder to remove completely and is more likely to come back.

One set of signs does need same-day care. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department. You do not need a GP referral first. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department.

In more depth

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. Giant cell tumour of the tendon sheath is worth the extra reading because its defining problem is recurrence, and the evidence suggests recurrence is driven more by the biology of the individual tumour than by anything about how it is removed.

Recurrence is a property of the tumour, not only of the surgery

The instinctive explanation for a lump coming back is that some was left behind. A systematic review of 605 digital cases concluded otherwise: the intrinsic biology of the tumour appears to play a more fundamental role in recurrence than tumour location or local invasiveness, with the authors calling for larger prospective studies to identify which tumours are prone to recurrence [1].

That is a genuinely useful thing to be told before an operation. Recurrence after a well-performed excision is a recognised behaviour of this tumour rather than evidence that something went wrong.

Treatment is elective, and doing nothing is a real option

It is easy to lose sight of this once an operation is being planned. The principle of first-line treatment is complete resection, but treatment is never urgent, and the indication should be weighed against symptoms, progression, location and your own circumstances [4].

For a small, painless, slowly growing nodule, watching it is a legitimate choice. The tumour is benign and does not spread, so the argument for operating is about function, size and nuisance — not about danger.

But two surgical factors do matter

Biology is not the whole story. In 941 patients with localised-type tenosynovial giant cell tumour, the factors associated with recurrence after resection were larger tumour size and initial treatment with arthroscopy. Given relatively low complication rates and good functional outcomes, the authors recommend an open approach with complete resection where possible to reduce recurrence in high-risk cases [2].

The counterpoint is that arthroscopic excision has been shown effective for the localised type across four joints in a review of 1,448 patients, while in the diffuse type, arthroscopic synovectomy has demonstrated efficacy only at the knee [3].

Reconciling these: for a small, localised, well-defined lesion, either approach can work. As size increases, and for the diffuse form, complete open excision is better supported. The reason is mechanical, this tumour extends in fronds around tendon, nerve and joint, and the parts most easily missed are the ones tucked behind structures that must be lifted and inspected directly.

Why the naming matters

The condition now sits under tenosynovial giant cell tumour, which covers both the localised form in the hand and the diffuse intra-articular form previously called pigmented villonodular synovitis [4]. They are the same entity in different locations and growth patterns.

This is worth knowing if you read around the subject, because a search will return material about knees and hips that is describing your condition in its diffuse form, and the recurrence rates quoted for the diffuse disease are considerably higher than those for a localised digital lesion. Applying knee figures to a finger lump overstates the risk.

Where radiotherapy sits

For diffuse disease that has recurred or cannot be completely excised, adjuvant radiotherapy is sometimes considered. A meta-analysis found that open synovectomy, or synovectomy combined with perioperative radiotherapy, was associated with a reduced rate of recurrence in diffuse pigmented villonodular synovitis, while calling for large long-term prospective studies to confirm it [5].

For a localised digital tumour, which is the great majority of hand cases, this does not arise. It belongs to the diffuse, recurrent, joint-based end of the spectrum, and is mentioned here only because a search on the condition name will surface it.

What it is not

Despite the name, this is a benign tumour. It does not spread elsewhere in the body. The word "tumour" carries weight it does not deserve here, and the concern with recurrence is about repeated local surgery, stiffness and nerve proximity, not about cancer.

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Reviewed by Kieran Hirpara · 28 April 2026.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading

1. Fotiadis E, Papadopoulos A, Svarnas T, Akritopoulos P, Sachinis NP, Chalidis BE. Giant cell tumour of tendon sheath of the digits. A systematic review. Hand (N Y). 2011;6(3):244-9.
2. Mastboom M, Staals E, Verspoor F, Rueten-Budde A, Stacchiotti S, Palmerini E, 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 Joint Surg Am. 2019;101(14):1309-18.
3. Noailles T, Brulefert K, Briand S, Longis P, Andrieu K, Chalopin A, et al. Giant cell tumor of tendon sheath: open surgery or arthroscopic synovectomy? A systematic review of the literature. Orthop Traumatol Surg Res. 2017;103(5):809-14.
4. Gouin F, Noailles T. Localized and diffuse forms of tenosynovial giant cell tumor (formerly giant cell tumor of the tendon sheath and pigmented villonodular synovitis). Orthop Traumatol Surg Res. 2017;103(1):S91-S97.
5. Mollon B, Lee A, Busse JW, Griffin AM, Ferguson PC, Wunder JS, et al. The effect of surgical synovectomy and radiotherapy on the rate of recurrence of pigmented villonodular synovitis of the knee. Bone Joint J. 2015;97-B(4):550-7.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• The diagnosis and treatment of suspected hand neoplasms should proceed in an orderly fashion similar to accepted methods applied to tumors in other locations of the extremities [1].
• Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk [3, 4].
• Recurrence of giant cell tumors of the tendon sheaths typically occurs within 36 months of excision [3].
• The fundamental consideration in the management of hand tumours is to reconcile adequate tumour clearance with the maintenance of function and appearance [20].
• Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors [15].
• Diffuse tenosynovial giant cell tumor disease presents challenges due to high recurrence rates [15].
• Curettage, cryosurgery, and cementation performed by experienced surgeons appears to be a safe, effective, and reliable method for treating selected giant cell tumors of the hand [5].
• In cases of infiltrative giant cell tumor of the tendon sheath, radiation therapy may provide local tumor control with preservation of hand function [12].
• En bloc resection of the tumour and reconstruction with a fibular graft where necessary should be considered as the treatment of choice in giant cell tumour of the hand [10].
• En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand [8].
• En bloc resection and matched nonvascularized toe phalangeal transfer for Campanacci Grade 2 or 3 giant cell tumor of the phalanges resulted in a functional tumor-free digit with a low complication rate and no recurrences [35].
• Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence [28].

Anatomy & Pathophysiology

Clinical Presentation and Demographics

• Giant cell tumour of tendon sheath (GCTTS) is the second most common benign proliferative tumour in the upper extremities after ganglion cysts [102].
• GCTTS are usually slow-growing, painless, benign soft tissue tumours [102].
• GCTTS are most commonly found in the fingers and among women in their fourth and fifth decades [102].
• The male-to-female ratio for GCTTS of the digits is 1:1.47 [23].
• The mean age range for GCTTS of the digits is 32 to 51 years [23].
• Pain was reported in 15.7% of GCTTS cases and sensory disturbances in 4.57% of cases [23].
• A definite history of trauma was recorded in 5% of GCTTS lesions [23].
• The most frequent tumour location for GCTTS of the digits is the index finger (29.7%) [23].
• In a series of 64 cases, the most frequent location for GCTTS was the long finger (23.5%), followed by the thumb, index finger, and hand (20.3% each) [49].
• Patients with GCTTS arising in the fingers complained of a painless mass in almost every instance [24].
• The duration of symptoms for finger GCTTS ranged from two weeks to fifteen years, with an average duration of thirty-eight months [24].
• GCTTS are usually firm, lobulated, and non-tender masses [24].
• As the tumour grows, patients may present with swelling, pain, and limitation of movement [102].

Anatomical Distribution and Morphology

• Fifty-three xanthomas (GCTTS) arose adjacent to joints in the fingers, whereas twenty-nine bore no relation to joints [24].
• Thirty-one of ninety-one finger GCTTS occurred at the distal joints [24].
• Of the thirty-one distal joint GCTTS, eighteen were on the dorsal aspect and thirteen were distributed evenly on the radial, ulnar, and volar aspects [24].
• Type I GCTTS (single lesions) were more frequently detected (78.7%) than Type II tumours (two or more distinct tumours that were not joined together) (21.3%) [23].
• Type 1 GCTTS 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 [102].
• The average size of GCTTS was 1.35 cm, with a range of 0.3 cm to 5 cm [49].
• Bone erosion was found in 3 patients (4.7%) in a series of 64 GCTTS cases [49].
• Tendon involvement with flexors/extensors ratio of 4:3 was found in 7 cases (10.9%) in a series of 64 GCTTS cases [49].
• Involvement of the neurovascular bundle was presented in 7 patients (10.9%) in a series of 64 GCTTS cases [49].
• A case report describes the first patient with three separate GCTTS developing from both flexor and extensor tendons in a single digit [7].

Histology and Pathogenesis

• Microscopically, all GCTTS contained multinucleated giant cells, histiocytes, and haemosiderin deposits [49].
• GCTTS originates from the synovial membrane, tendon sheath, or synovial bursa [102].
• Inflammation resulting from reactive or regenerative hyperplasia is the generally accepted theory of pathogenesis for GCTTS [102].
• Genetic factors have been observed in previous studies regarding GCTTS pathogenesis [102].
• Fibroma of tendon sheath is histologically distinct from giant cell tumor of tendon sheath, a lesion with which it is commonly confused [16].

Diagnostic Imaging

• Radiography can be helpful in evaluating cortical destruction but is not helpful in the definitive diagnosis of GCTTS [102].
• Magnetic resonance imaging (MRI) is the most useful examination for the diagnosis and treatment planning of GCTTS [102].
• Al-Qattan classified GCTTS with MRI into two types according to the risk of recurrence [102].

Classification

• Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk [4].
• Recurrence for giant cell tumors of the tendon sheaths typically occurs within 36 months of excision [3].
• The Al-Qattan classification divides giant cell tumours of tendon sheath into two main types based on whether the entire tumour is surrounded by one pseudocapsule as assessed by the surgeon during surgery [90].
• Type I tumours are defined as those where the entire tumour is surrounded by one pseudocapsule [90].
• Type II tumours are defined as those where the entire tumour is not surrounded by one pseudocapsule [90].
• Type I tumours are sub-classified according to the thickness of the capsule, lobulation of the tumour, the presence of satellite lesions, and the diffuse or multicenteric nature of the tumour [90].
• Type II tumours are sub-classified according to the thickness of the capsule, lobulation of the tumour, the presence of satellite lesions, and the diffuse or multicenteric nature of the tumour [90].
• In a prospective study of 43 consecutive cases, none of the type I tumours (n=30) recurred [90].
• In a prospective study of 43 consecutive cases, recurrence occurred in five out of 13 type II tumours [90].
• Second recurrences were seen with type II B and C tumours, but not type II A tumours [90].
• Type I tumours (single lesions) were more frequently detected (78.7%) than type II tumours (two or more distinct tumours that were not joined together) (21.3%) in a systematic review of 605 patients [23].
• Type II tumours were associated with higher recurrence rates compared to Type I tumours in a systematic review of 605 patients [23].
• Direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence [43].
• Preoperative diagnosis and meticulous surgical technique were found to be the only predictive factor of recurrence in a series of 14 cases [34].
• The overall recurrence rate in a systematic review of 605 patients was 14.8% [23].

Clinical Presentation

• Patients with fibrous xanthomas arising in the fingers complained of a painless mass in almost every instance [24].
• The duration of symptoms for finger tumors ranged from two weeks to fifteen years, with an average duration of thirty-eight months [24].
• The tumors were usually firm, lobulated, and non-tender [24].
• Fifty-three xanthomas arose adjacent to joints in the fingers, whereas twenty-nine bore no relation to joints [24].
• Thirty-one of the ninety-one tumors in the fingers occurred at the distal joints [24].
• Eighteen of the thirty-one distal joint tumors were on the dorsal aspect of the joint, and thirteen were distributed about evenly on the radial, ulnar, and volar aspects of the joint [24].
• The most frequent tumour location for giant cell tumour of tendon sheath of the digits was the index finger (29.7%) [23].
• Pain was reported in 15.7% of cases and sensory disturbances in 4.57% of cases [23].
• A definite history of trauma was recorded in 5% of lesions [23].
• Type I tumours (single lesions) were more frequently detected (78.7%) than type II tumours (two or more distinct tumours that were not joined together) (21.3%) [23].
• The male-to-female ratio for giant cell tumour of tendon sheath of the digits was 1:1.47 [23].
• The mean age for giant cell tumour of tendon sheath of the digits ranged from 32 to 51 years [23].
• A tendon tumour can present as a trigger finger [18].
• Trigger wrist caused by a giant cell tumour of tendon sheath has been reported [26].
• The trigger phenomenon in trigger wrist caused by a giant cell tumour of tendon sheath probably occurred when the tumour entered and left the distal carpal tunnel [26].
• Fibroma of tendon sheath is a benign soft tissue tumor that has a predilection for the hand [16].
• Fibroma of tendon sheath may be more common than has been previously recognized [16].
• The differential diagnosis of a soft tissue tumor in the digits and hand is usually limited to a ganglion, an inclusion cyst, or a giant cell tumor of tendon sheath (xanthofibroma) [16].
• Fibroma of tendon sheath should be included in the differential diagnosis of a soft tissue tumor in the digits and hand [16].
• A case of fibroma of tendon sheath presented as a 6-year history of a slowly enlarging palmar mass of the left index finger [16].
• Examination of a fibroma of tendon sheath case demonstrated a soft, compressible, lobulated, nontender mass extending from the second web space to the tip of the finger [16].
• Flexion of the digit was limited by the bulge in a case of fibroma of tendon sheath [16].
• The unusual location of a fibroma of the tendon sheath and atypical nature of the triggering phenomenon can lead to it being reported as a rare cause of median nerve compression at the wrist [50].
• Giant cell tumor of tendon sheath and pigmented villonodular synovitis are benign, locally invasive tumors involving synovium, tendon sheaths, and bursae [47].
• Patients with giant cell tumor of tendon sheath or pigmented villonodular synovitis may present with a discrete mass or with joint swelling, pain, or locking or catching [47].
• The knee and digits of the hand are the most common locations of lesions for giant cell tumor of tendon sheath and pigmented villonodular synovitis [47].
• Multifocal lesions of giant cell tumor of tendon sheath and pigmented villonodular synovitis are rare [47].
• The authors report the uniqueness of a case of multicentric giant cell tumor in the upper extremity [9].
• Radiological changes in the form of bony indentation was seen in only 2 cases of giant cell tumor of tendon sheath in a series of 12 patients [34].
• The most common presentation for giant cell tumor of tendon sheath in a series of 12 patients was with a mass over the hand, with a predilection to the thumb [34].
• A 65-year-old man presented with a slowly enlarging mass on the dorsal aspect of the left thumb consistent with a recurrent giant cell tumor of the tendon sheath [33].

Investigations

• The differential diagnosis of a soft tissue tumor in the digits and hand is usually limited to a ganglion, an inclusion cyst, or a giant cell tumor of tendon sheath [16].
• Fibroma of tendon sheath should be included in the differential diagnosis as it may be more common than has been previously recognized [16].
• Fibro-osseous pseudotumor of the digit should be considered in the differential diagnosis of rapidly enlarging digital lesions [64].
• Although MRI findings and location might help in the diagnosis of tenosynovial giant cell tumors, careful assessment is mandatory, especially in unusual locations [129].

Treatment

General Principles

Surgical Excision

• Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, though diffuse disease presents challenges due to high recurrence rates [15].
• En bloc resection of metacarpal giant cell tumors with reconstruction by iliac graft appears to be an effective treatment [14].
• En bloc resection and matched nonvascularized toe phalangeal transfer resulted in a functional tumor-free digit with a low complication rate and no recurrences for Campanacci Grade 2 or 3 giant cell tumors of the phalanges [35].
• Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years for fibroma of tendon sheath [11].
• Local excision of the tumour appears to be a satisfactory method of treatment for Nora’s lesion [109].
• Preoperative planning aided by a tissue diagnosis with fine needle aspiration cytology, wide surgical exposure, and meticulous dissection with help of magnification are imperative for a successful outcome in giant cell tumor of tendon sheath [34].
• In all cases of giant cell tumor of tendon sheath, magnifying loupe or operating microscope was used during surgical excision [49].
• In cases of infiltrative giant cell tumor of tendon sheath, radiation therapy may provide local tumor control with preservation of hand function [12].

Recurrence and Adjuvant Therapy

• Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk, typically occurring within 36 months of excision [3].
• In a study of 64 cases of giant cell tumor of tendon sheath, the recurrence rate was 4.7% (n=3) [49].
• In a systematic review of 605 patients with giant cell tumor of tendon sheath of the digits, 14.8% of patients had tumour recurrence [23].
• Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent giant cell tumor of the small bones of the hands and feet [105].
• Intralesional excision with cautery and methylmethacrylate provides a reliable method of treatment of giant cell tumors with good long-term functional results [71].
• Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision [98].
• Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss [29].
• Based on data obtained from the number of studies available, intralesional excision appears to be more appropriate for the treatment of local lesions (eg, Grades 1 and 2) than Grade 3 giant cell tumors of the distal radius [52].
• Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence in giant cell tumor of tendon sheath [28].

Reconstruction and Resection Options

• Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control [6].
• Aggressive and malignant bone tumors of the second through fifth metacarpals generally require en bloc bone excision [17].
• Ray excision is usually best for lesions of the second and fifth metacarpals [17].
• If bone graft has been used for reconstruction, carpometacarpal arthrodesis and MCP ligament reconstruction or silicone arthroplasty may be practical [17].
• Whatever level is chosen for reconstruction, it is essential that an adequate, safe margin of normal tissue first be excised en bloc with the tumor [17].
• Aggressive tumors of the second through fifth metacarpals that have invaded soft tissue or sustained pathologic fractures often require excision of not only the involved ray but also the contiguous ray or rays radial and ulnar to the involved digit [17].
• If a malignant tumor has broken into the midpalm and extends across the metacarpals, removal of all digital rays may be needed to gain an adequate soft tissue margin [17].
• Retention of a sensate and relatively mobile thumb may be considerably more esthetic and functionally satisfactory than a forearm- or wrist-level amputation [17].
• If a tumor extends proximally from the metacarpal level, a more proximal level of hand, wrist, or forearm amputation is required for safe tumor management [17].
• Malignant soft tissue tumors in the palm or carpal tunnel often require at least partial hand amputation [17].
• If treated by only local or limited excision, the chance of recurrence is extremely high particularly in the setting of a positive margin for malignant soft tissue tumors in the palm or carpal tunnel [17].
• Below-elbow amputation is necessary to treat larger tumors of the palm or carpal tunnel [17].
• Wide en bloc excision of soft tissue sarcomas with negative margins is required to achieve local control of the lesion [17].
• At a minimum, aggressive soft tissue tumors, such as bone tumors, require ray resection or removal of multiple rays [17].
• Central palmar lesions more likely require sacrifice of three rays; those on the border are more likely than those in the center to be salvageable by removing just two rays [17].
• In the presence of proximal, broader, and larger lesions, all four digits or the entire hand may have to be sacrificed to save the patient [17].
• The use of a massive biocompatible bipolar unconstrained prosthesis is a viable treatment option for distal radius reconstruction after en-bloc resection of a giant cell tumour, offering rapid functional improvement without donor-site morbidity [68].
• Reconstruction after wide excision by nonvascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications [111].
• En bloc resection is recommended for aggressive giant cell tumours (GCT) of the bone involving the distal end of the radius to minimize the risk of recurrence [91].
• The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome [48].
• This is a simple and effective modality of reconstruction after resection of distal radial tumors using centralization of the ulna [30].

Complications

• Recurrence is the primary risk associated with giant cell tumors of the tendon sheaths in the hand [3].
• The overall recurrence rate for giant cell tumour of tendon sheath of the digits is 14.8% [23].
• Type II tumours (two or more distinct tumours that were not joined together) are associated with a higher risk of recurrence compared to Type I tumours [23].
• Direct involvement of the extensor tendons, flexor tendons, or joint capsule places patients in a high-risk category for recurrence [43].
• Surgical treatment of pigmented villonodular synovitis led to good functional results with an average Enneking score of 92% of normal limb function [32].
• A tendon tumour arising from the superficialis tendon can present as a trigger finger [18].
• A giant cell tumour of the tendon sheath can cause a trigger wrist phenomenon when the tumour enters and leaves the distal carpal tunnel [26].
• A fibroma of the tendon sheath in an unusual location can cause a triggering phenomenon and median nerve compression at the wrist [50].
• Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) for fibroma of tendon sheath resulted in no local recurrences at a mean follow-up of 3.2 years [11].
• Patients with giant cell tumor of bone in the hand who are at higher risk of recurrence should be clinically followed more closely [41].
• Both curettage and resection/amputation are acceptable treatment options for giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control [6].
• Below-elbow amputation is necessary to treat larger malignant soft tissue tumors in the palm or carpal tunnel [17].
• Patients who received preoperative radiotherapy for hand tumors had a decrease in functional outcomes and grip strength that averaged 66% compared with the contralateral hand [55].
• None of the patients who underwent single-ray amputation for tumors of the hand, including giant cell tumors of bone, had local recurrences [55].
• A 29-year-old patient with recurrent giant-cell tumor of the digit was treated by phalangeal excision and toe phalanx transplant [54].

Recovery

• Recurrence of giant cell tumors of the tendon sheaths in the hand typically occurs within 36 months of excision [3].
• Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years [11].
• In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function [12].
• At 2-year final follow-up examination, no recurrence was noted, finger range of motion was full, and the x-ray film contour of the phalanx had returned to normal [13].
• Surgical treatment led to good functional results with an average Enneking score of 92% of normal limb function [32].
• En bloc resection and matched nonvascularized toe phalangeal transfer resulted in a functional tumor-free digit with a low complication rate and no recurrences [35].

Key Evidence

• [L5] The diagnosis and treatment of suspected hand neoplasms should proceed in an orderly fashion similar to accepted methods applied to tumors in other locations of the extremities. [1] (10.1016/s0363-5023(83)80277-9)
• [L4] Giant cell tumors of the tendon sheaths in the hand are benign lesions where recurrence is the primary risk, typically occurring within 36 months of excision. [3] (10.1016/j.otsr.2013.03.008)
• [L4] Giant cell tumors of the synovial sheaths in the hand are benign lesions in which recurrence is the primary risk. [4] (10.1016/j.jhsa.2013.08.051)
• [L4] Curettage, cryosurgery, and cementation performed by experienced surgeons appears to be a safe, effective, and reliable method for treating selected giant cell tumors of the hand. [5] (10.1053/jhsu.2001.22525)
• [L4] Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control. [6] (10.1177/17531934211007820)
• [L5] We believe this case report describes the first patient with three separate GCTTS developing from both flexor and extensor tendons in a single digit. [7] (10.1142/s2424835518720189)
• [L4] En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand. [8] (10.1016/s0266-7681(98)80197-6)
• [L5] The authors report the uniqueness of this case of multicentric giant cell tumor in the upper extremity. [9] (10.1016/j.main.2011.11.006)
• [L4] En bloc resection of the tumour and reconstruction with a fibular graft where necessary should be considered as the treatment of choice in giant cell tumour of the hand. [10] (10.1016/s0266-7681(96)80161-6)
• [L4] Total surgical excision ensuring removal of the attachment site (flexor sheath/palmar fascia) resulted in no local recurrences at a mean follow-up of 3.2 years. [11] (10.1177/1753193412469146)
• [L4] In cases of infiltrative GCTTS, radiation therapy may provide local tumor control with preservation of hand function. [12] (10.1016/j.jhsa.2012.01.011)
• [L5] At 2-year final follow-up examination, no recurrence was noted, finger range of motion was full, and the x-ray film contour of the phalanx had returned to normal. [13] (10.1016/s0363-5023(05)80151-0)
• [L5] En bloc resection of metacarpal giant cell tumors with reconstruction by iliac graft appears to be an effective treatment. [14] (10.1016/s1297-3203(03)00042-8)
• [L5] Complete surgical resection remains the treatment of choice for most patients with tenosynovial giant cell tumors, though diffuse disease presents challenges due to high recurrence rates. [15] (10.5435/jaaos-d-24-01255)
• [L5] [16] (10.1016/s0363-5023(84)80031-3)
• [L5] At operation a tumour arising from the superficials tendon was found and removed. [18] (10.1016/0266-7681(86)90283-4)
• [L5] The fundamental consideration in the management of hand tumours is to reconcile adequate tumour clearance with the maintenance of function and appearance. [20] (10.1016/0266-7681(91)90159-l)
• [L1] [23] (10.1007/s11552-011-9341-9)
• [L4] [24] (10.2106/00004623-196951010-00005)
• [L5] [26] (10.1016/s0266-7681(85)80038-3)
• [L3] Well-designed studies combining the recurrence rates of several hand surgery centers implementing a standardized treatment are needed to better demonstrate the associated risk factors for recurrence. [28] (10.1186/s12891-019-2866-8)
• [L3] Intralesional excision remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. [29] (10.1007/s11999-014-4054-3)
• [L4] This is a simple and effective modality of reconstruction after resection of distal radial tumors. [30] (10.1016/j.jhsa.2022.05.011)
• [L4] Surgical treatment led to good functional results with an average Enneking score of 92% of normal limb function. [32] (10.1097/01.blo.0000224051.01873.fb)
• [L4] [33] (10.1016/j.jhsa.2012.11.001)
• [L4] [34] (10.1007/s12593-010-0020-9)
• [L4] En bloc resection and matched nonvascularized toe phalangeal transfer resulted in a functional tumor-free digit with a low complication rate and no recurrences. [35] (10.1016/j.jhsa.2024.06.013)
• [L4] Our observations suggest there are subsets of patients with giant cell tumor of bone who are at higher risk of recurrence and should be clinically followed more closely. [41] (10.1007/s11999-011-2172-8)
• [L3] Direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence. [43] (10.1016/j.jhsa.2009.12.004)
• [Case_report] [47] (10.1016/j.jhsa.2014.11.010)
• [L3] The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome. [48] (10.1177/1558944717743598)
• [L4] [49] (10.11138/gchir/2013.34.5.149)
• [L5] The unusual location of the fibroma of the tendon sheath (FGT) and the atypical nature of the triggering phenomenon led to the reporting of this observation as a rare cause of median nerve compression at the wrist. [50] (10.1016/j.main.2006.03.001)
• [L3] Based on data obtained from the number of studies available, intralesional excision appears to be more appropriate for the treatment of local lesions (eg, Grades 1 and 2) than Grade 3 GCTs of the distal radius. [52] (10.1007/s11999-012-2464-7)
• [L5] [54] (10.1016/s0363-5023(79)80134-3)
• [Paper] Fibro-osseous pseudotumor of the digit should be considered in the differential diagnosis of rapidly enlarging digital lesions. [64] (10.1177/15589447261481209)
• [Case_report] The use of a massive biocompatible bipolar unconstrained prosthesis is a viable treatment option for distal radius reconstruction after en-bloc resection of a giant cell tumour, offering rapid functional improvement without donor-site morbidity. [68] (10.1016/j.otsr.2013.04.001)
• [L4] Intralesional excision with cautery and methylmethacrylate provides a reliable method of treatment of giant cell tumors with good long-term functional results. [71] (10.1097/01.blo.0000128280.59965.e3)
• [L3] [90] (10.1054/jhsb.2000.0522)
• [L4] [91] (10.1177/17531934211068622)
• [L3] Intralesional excision with local adjuvant therapy is recommended for the treatment of giant cell tumor of bone because it results in a good functional outcome compared to extralesional excision. [98] (10.1007/s004020100317)
• [L4] [102] (10.1177/17531934231222401)
• [L3] Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet. [105] (10.1302/0301-620x.95b6.30876)
• [L5] Local excision of the tumour appears to be a satisfactory method of treatment. [109] (10.1016/s0266-7681(97)80269-0)
• [L4] Reconstruction after wide excision by nonvascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications. [111] (10.1007/s00402-010-1059-6)
• [L4] Although MRI findings and location might help in the diagnosis of a T-GCT, careful assessment is mandatory, especially in unusual locations. [129] (10.1186/s12891-016-1050-7)

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