The Role of Early Temporomandibular Joint Arthroscopy in the Detection, Diagnosis, and Surveillance of Synovial Neoplasms: A Massachusetts General Hospital Experience and Algorithm of Care

Abstract

PurposeSynovial neoplasms that affect the small joints, such as the temporomandibular joint (TMJ), are uncommon.1 Of the neoplasms that affect the TMJ, pigmented villonodular synovitis (PVNS), synovial chondromatosis (SC), and juxta-articular myxoma are the most prevalent. To date, there have been only 115 and 360 reported cases of PVNS and SC of the TMJ in the literature, respectively.2 These lesions are locally destructive with the capacity to invade the cranial base and often demonstrate an inconspicuous growth pattern, a high degree of recurrence, and presentation that is confounded with other forms of temporomandibular joint disorder. TMJ arthroscopy has been established as a minimally invasive surgical modality to establish diagnosis and reduce patient morbidity. The purpose of the present study was to evaluate the role and impact of TMJ arthroscopy in the early detection, diagnosis, treatment, and surveillance of PVNS and SC of the TMJ. Patients and methodsThis is a retrospective case series. Inclusion criteria were patients with synovial neoplasms: specifically, PVNS and SC at Massachusetts General Hospital. Exclusion criteria were patients with malignant tumors involving the TMJ and cranial base and tumors arising from extra-articular, non-synovial origin. Patients were categorized into 2 groups: Group I (who did not undergo early TMJ arthroscopy prior to lesion excision) and Group II (who did undergo early TMJ Level II [multi-port] arthroscopy prior to lesion excision). Pre-operative time to definitive lesion excision surgery, pre-operative biopsy status, extent of surgery (arthroscopic removal vs. open arthrotomy with or without craniotomy), and lesion recurrence were evaluated. ResultsA total of 6 patients were included in the present study (3 men and 3 women), all unilateral involvement for a total of 6 sides. The mean age was 31 (15-61). Patients were categorized into 2 groups: Group I-3 PVNS patients identified. All patients did not have a pre-operative biopsy prior to lesion excision. Mean pre-operative time duration to definitive lesion removal from initial presentation was 12 months. One isolated open arthrotomy and 2 open arthrotomy with craniotomy were required due to tumor growth and invasion of the middle cranial fossa. Recurrence of the lesion was present in 2 cases requiring repeat excision. Group II consisted of 3 patients: 2 PVNS (Figure 1) and 1 SC (Figure 2). All patients had pre-ablative biopsy diagnosis yielded from arthroscopic synovial biopsy. Mean pre-operative time duration to definitive lesion removal from initial presentation was 7 months. One PVNS case was excised arthroscopically. One isolated open arthrotomy and 1 open arthrotomy with craniotomy were required for definitive lesion excision. No lesion recurrence was noted, with 1 second-look arthroscopy conducted. ConclusionThe results from the present study demonstrated that the early TMJ arthroscopy has efficacy in the early detection, diagnosis, and surveillance of synovial neoplasms PVNS and SC. Visualization and synovial biopsy of the lesion provide diagnostic and surgical planning benefit in conjunction with standard pre-operative workup. One lesion was arthroscopically removed. No recurrence has occurred, and TMJ arthroscopy proffers a minimally invasive means for disease surveillance if recurrence is suspected. Larger studies with continued follow-up are needed to further establish the algorithm established by this work to continue to minimize patient morbidity with lesion excision and reduce recurrence rates.