Giant cell tumors of the tendon sheath may present radiologically as intrinsic osseous lesions

The purpose of this study was to explain radiographic features of giant cell tumors of the tendon sheath (GCTTS), in particular, osseous extension, by correlating imaging findings with histology in order to increase the accuracy of radiological diagnosis. In a series of 200 consecutive osseous (pseudo) tumors of the hand, on radiography, six patients presented with an intrinsic osseous lesion caused by a histologically confirmed neighboring GCTTS. Available radiographs, computed tomography (CT), and contrast-enhanced magnetic resonance (MR) images were correlated with histology. Radiography showed osseous lesions consisting of well-defined cortical defects in four (one of whom also demonstrated cortical scalloping) and a slightly expansile, well-defined osteolytic lesion in two patients. MR obtained in four patients showed the extraosseous tumor invading/eroding bone and causing cortical scalloping (three and one patients, respectively). Extension depicted on MR was confirmed on the two available resection specimens. All lesions were polylobular (cauliflower or mushroom like) and neighbored tendon sheaths. Dense collagen and hemosiderin-loaded macrophages explained the high CT attenuation and the low MR signal intensity on T2-weighted images that was observed in all four MR and in all two CT scans. The high density of proliferative capillaries explained the marked enhancement observed in all four patients with gadolinium (Gd)-chelate-enhanced MR imaging. GCTTS is a soft tissue (pseudo) tumor that may invade bone and as a consequence mimick an intrinsic osseous lesion on radiographs. In such cases, specific MR and CT features that can be explained by histological findings can be used to suggest the correct diagnosis.