Diffuse Pigmented Villonodular Synovitis Research Articles

Combined arthroscopic and open synovectomy for diffuse pigmented villonodular synovitis of the knee.

There are few reports detailing recurrence rates or functional outcomes after combined arthroscopic and open synovectomy to treat diffuse pigmented villonodular synovitis (DPVNS) of the knee. Patients with DPVNS of the knee treated with combined synovectomy, followed for a minimum of 12 months at a tertiary orthopaedic oncology centre, were identified. We extracted data pertaining to demographics, complications, clinical outcomes and recurrence. Functional status was evaluated prospectively using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society (MSTS) 1987 and 1993 surveys. Data were reported descriptively as mean (SD) unless otherwise specified. Fifteen patients [80% female; mean age 38.9 (SD 14.2) years] representing 15 knees were treated with combined synovectomies and followed for 81 (SD 55) months. Posterior arthroscopy was utilized in 73% of patients. External beam radiation was utilized post-operatively in 73% of patients. Two patients (13%) experienced symptomatic disease recurrence. The mean post-operative knee range of motion was 1° (range 0-10°) to 115° (range 90-135°). TESS and MSTS 1987/1993 scores all suggested excellent patient function. Post-operative complications included one posterior wound dehiscence, one case of femoral condyle avascular necrosis and one patient with lymphedema. Combined synovectomy resulted in a low rate of symptomatic disease recurrence and good to excellent functional outcomes for diffuse PVNS of the knee. A literature review identified this as largest case series focusing on combined synovectomies for DPVNS of the knee and the only one describing functional outcomes or the use of external beam radiotherapy. Retrospective case series, Level IV.

Pigmented villonodular synovitis

Pigmented villonodular synovitis

Long-term follow-up results of primary and recurrent pigmented villonodular synovitis.

Adequate documentation of the outcome of treatment of pigmented villonodular synovitis (PVNS) is sparse. Available case series show relatively short follow-up times and often combine locations or subtypes to increase patient numbers. This article describes the long-term follow-up of a single institution's large consecutive series of PVNS. Retrospectively, 107 PVNS patients were identified between 1985 and 2011 by searching pathology and radiology records. Treatment complications, recurrences and quality of life were evaluated. Most patients (85.2%) were primarily or secondarily treated at our institution. Both subtypes, localized PVNS [29 (27%)] and diffuse PVNS [75 (70%)] were represented. The knee was affected in 88% of patients. Treatments received were surgery, external beam radiotherapy, radiosynovectomy, targeted therapy, immunotherapy or combinations of these. Forty-nine (46%) patients had prior treatment elsewhere. The mean follow-up from diagnosis until last contact was 7.0 years (range 0.3-27.4) for localized PVNS and 14.5 years (range 1.1-48.7) for diffuse PVNS. The 1- and 5-year recurrence-free survival rates for diffuse PVNS were 69% and 32%, respectively. Quality of life, estimated by 36-item Short Form Health Survey (SF-36) scores, were not significantly different between localized and diffuse PVNS. However, both patient groups scored lower than the general population norms on the general health component (59.2 and 56.3, respectively, P < 0.05). Recurrence rates of PVNS increase with time. Long-term follow-up shows, particularly in diffuse PVNS, it is a continually recurring problem, and over time it becomes increasingly difficult to cure. The quality of life is decreased in patients with PVNS compared with the general population.

Pigmented Villonodular Synovitis for Combined Therapy

Pigmented villonodular synovitis (PVNS), inflammatory proliferative disease resulting from synovial cells, has progressive course similar neoplastic local expansion. We followed up a case with effective combined therapy for diffuse PVNS despite incomplete response to its components and reviewed therapies based on MedLine for PVNS. Due to US data residue synovitis after open radical synovectomy, we made decision about external beam radiotherapy. Photon radiation with linear accelerator energy of 6 MV was applied for two fields: anterior and posterior. The total dose was 20 Gy, delivered in 2 Gy a day, five times a week. Due to postoperative pain and the rest of synovial tissue on US study, pharmacologic therapy with salazopyrine and celecoxib was added. For several weeks, the knee pain became episodic and further disappeared. Six months later, the patient feels healthy and continues to take salazopyrine permanently and celecoxib as needed. We conclude high rate response analyzing literature data and our case to combined therapy: arthroscopic or open surgery followed by RT along with complimentary pharmacotherapy. J Med Cases. 2014;5(3):147-151 doi: http://dx.doi.org/10.14740/jmc1656e

Clinical and oncological outcomes after surgical excision of pigmented villonodular synovitis at the foot and ankle

Pigmented villonodular synovitis (PVNS) is a rare benign neoplastic disease of the synovium of joints and tendon sheaths, which may be locally aggressive. It can be broadly classified into localised disease or more diffuse forms, with the latter more prone to recurrence after surgical excision. We describe our experience in the management of foot and ankle PVNS, focusing on the diffuse type. Patients with PVNS were identified from a histology database from 2000 to 2010 at the University Hospitals of Leicester. The primary aim was to determine oncological outcomes and evaluate clinical outcomes with the Toronto Extremity Salvage Score (TESS) and the American Academy of Foot and Ankle Surgeons (AOFAS) scores. 30 patients, 16 males and 14 females with a mean age of 37±15 years, who underwent surgery, were identified. There were 22 nodular PVNS and 8 diffuse PVNS. The diffuse PVNS was more likely to be in the hindfoot (75%, 6/8), of which 50% (3/6) had osteoarthritis at presentation. The localised PVNS was mostly located in the forefoot (91%, 20/22). None of the localised PVNS had a recurrence. The surgical recurrence rate in this series was similar to the pooled recurrence rate from the literature [12.5% (1/8) compared to 12.2% (6/49)]. The mean TESS and AOFAS scores were 86 and 78, respectively. Diffuse PVNS is more likely to occur in the hindfoot and nodular PVNS is more common in the forefoot. Aggressive synovectomy alone is an effective treatment for diffuse PVNS, with good oncological and clinical outcomes.

A comparison of open and arthroscopic surgery for treatment of diffuse pigmented villonodular synovitis of the knee

To compare the outcomes of diffuse pigmented villonodular synovitis (PVNS) of the knee treated with routine anteroposterior open surgery or modified multi-directional arthroscopy. Medical records of patients with diffuse PVNS who underwent surgery between 2002 and 2010 were reviewed. Patients were followed up at 3, 6, 12, 24, and 36 months. Operative time, blood loss, length of hospital stay, recurrence rate, and International Knee Documentation Committee (IKDC) scores and Lysholm knee scores at 1- and 3-year postoperatively were compared between the open surgery and arthroscopy groups. A total of 41 patients with diffuse PVNS were included (20 in open surgery group and 21 in multi-directional arthroscopy group). There was no significant difference in the baseline characteristics between the two groups. Operation time, postoperative bleeding, and length of hospital stay were all significantly lower in the arthroscopy group than in the open surgery group (all, P < 0.05). There were four recurrences in the open surgery group and one in arthroscopy group. All five recurrences received a second surgery without any subsequent recurrences. At both 1- and 3-year postoperatively, IKDC and Lysholm scores were significantly greater in the arthroscopy group than the open surgery group (all P < 0.001). The multi-directional arthroscopic technique was associated with significantly shorter operation time and hospital stay, less blood loss, and better postoperative IKDC and Lysholm scores than open surgery. Retrospective study with controls, Level III.

Pigmented Villonodular Synovitis for Combined Therapy

Pigmented villonodular synovitis (PVNS), inflammatory proliferative disease resulting from synovial cells, has progressive course similar neoplastic local expansion. We followed up a case with effective combined therapy for diffuse PVNS despite incomplete response to its components and reviewed therapies based on MedLine for PVNS. Due to US data residue synovitis after open radical synovectomy, we made decision about external beam radiotherapy. Photon radiation with linear accelerator energy of 6 MV was applied for two fields: anterior and posterior. The total dose was 20 Gy, delivered in 2 Gy a day, five times a week. Due to postoperative pain and the rest of synovial tissue on US study, pharmacologic therapy with salazopyrine and celecoxib was added. For several weeks, the knee pain became episodic and further disappeared. Six months later, the patient feels healthy and continues to take salazopyrine permanently and celecoxib as needed. We conclude high rate response analyzing literature data and our case to combined therapy: arthroscopic or open surgery followed by RT along with complimentary pharmacotherapy. J Med Cases. 2014;5(3):147-151 doi: http://dx.doi.org/10.14740/jmc1656e

A Low Recurrence Rate is Possible With a Combination of Surgery and Radiosynovectomy for Diffuse Pigmented Villonodular Synovitis of the Knee

Diffuse pigmented villonodular synovitis (DPVNS) is an uncommon proliferative disease. After only surgery, recurrence rates are high. This study presents the efficacy of combined surgical and adjuvant radiosynovectomy (RS) in the treatment of DPVNS. Between September 2006 and September 2012, 15 knee joints of 15 patients (10 female and 5 male) with histopathological DPVNS diagnosis with mean age 27 ± 12 years underwent surgery. At mean 14.4 ± 18 weeks postoperatively, RS was applied using 5 mCi (90)Y citrate colloid. Three-phase bone scintigraphy and contrast-enhanced MRI were used to evaluate residual and recurrent tumorous tissues in the joint. Mean follow-up was 48 ± 22 months. Blood flow and blood pool images showed that 2 patients had marked, 4 had moderate, 6 had mild, and 3 had no uptake. Late static images showed 5 had marked, 10 had moderate (99m)Tc-HDP uptake in the related joint. MRI examination indicated that there was no progression in any of the patients. The disease was determined to be stable in 2, regressed in 9, and totally cured in 4 cases. Bremsstrahlung imaging indicated an even distribution of radionuclide in all the knee joints. There was no evidence of leakage of radioactivity in the total body scans. There was significant improvement in Lysholm knee scores after treatment. Adjuvant yttrium-90 radiosynovectomy after surgical excision in the treatment of DPVNS is a reliable and efficient treatment method with successful clinical results. RS treatment can be considered for cases with DPVNS.

Arthroscopic synovectomy in pigmented villonodular synovitis of the knee: clinical series and outcome

The aim of this study was to evaluate the long-term results of arthroscopic excision of pigmented villonodular synovitis (PVNS) of the knee joint. We retrospectively assessed the results of arthroscopic excision of PVNS done in 40 patients from 1987 to 2012 by the senior author (JVS). No radiotherapy was given to any patient. All patients were followed for a mean of seven years. At follow-up functional assessment was done using the Lysholm score. Recurrence-free survival and recurrence-free survival probability were calculated. No recurrence was noted in the localised variety. In the diffuse variety the five year recurrence-free survival probability was 57%. Twelve patients developed recurrences between three months and two years. No recurrence was noted after two years. The mean recurrence interval was 6.25 months. We concluded from this series that arthroscopic excision is an effective treatment for localised as well as diffuse PVNS. Recurrences can also be successfully dealt with by arthroscopic excision with excellent functional outcome.

Diffuse pigmented villonodular synovitis (diffuse-type giant cell tumour) of the foot and ankle

Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle.

Diffuse pigmented villonodular synovitis in a child – what is the best management?

Case A 5 year old boy presented to orthopaedics in 2004 with a 3-4 month history of intermittent left knee pain. As examination was normal he required no specific treatment. In 2007, he attended A&E with a spontaneous left knee effusion with a CRP of 9 mg/l, ESR 9 mm/h, raised platelet count of 559 (10/l) and mild neutrophilia of 9.23 (10/l). Knee x-ray was normal. 20 mls of haemorrhagic fluid was aspirated (cultures negative). 2 months later, he was seen by rheumatologists due to fluctuant swelling, initially responding to oral non-steroidals but later requiring an intra-articular injection (20 mg triamcinolone). MRI imaging suggested PVNS. Synovial biopsy or synovectomy was avoided due to risk of post-op stiffness. JIA was considered after 2 left knee flares following upper respiratory tract infections and transient right knee swelling. However, imaging (2007, 2009, 2012) and aspirate appearances were typical of PVNS. Screening over 5 years revealed no evidence of uveitis. He was ANA negative and there was no history of psoriasis. In 2009, a further intra-articular injection (20 mg triamcinolone) was required. The patient remained well and active with ibuprofen and physiotherapy until a preholiday flare in May 2012. His GP injected the knee, after aspirating blood, with 40 mg triamcinolone with no response. He was referred to our service for review. Repeat MRI (Figure 1) showed progressive changes. As the differential diagnosis includes recurrent haemarthrosis, synovial biopsy has been advised.

Pigmented Villonodular Synovitis Causing Osteonecrosis of the Femoral Head: A Case Report

We report a case of a 27-year-old man with pigmented villonodular synovitis of the hip joint with coincident osteonecrosis of the femoral head. According to our review of the English-language literature, no detailed report of osteonecrosis of the femoral head complicated with pigmented villonodular synovitis has been published. Preoperative X-ray images showed joint narrowing and severe multiple bone erosions at the acetabulum and femoral neck. Magnetic resonance imaging revealed a low-intensity band attributable to osteonecrosis of the femoral head and massive diffuse pigmented villonodular synovitis lesions. Comparison of a three-dimensional computed tomographic image of this patient with an angiographic image of a normal individual demonstrated proximity of the pigmented villonodular synovitis-induced bone erosions to the medial and lateral femoral circumflex arteries and retinacular arteries, suggesting likely the compromise of the latter by the former. We propose that the massive pigmented villonodular synovitis may have contributed to the pathogenesis of osteonecrosis of the femoral head in this patient. We performed open synovectomy and total hip arthroplasty. No operative complications occurred, and no recurrence of the pigmented villonodular synovitis was detected for 3 years after the operation.

Does Combined Open and Arthroscopic Synovectomy for Diffuse PVNS of the Knee Improve Recurrence Rates?

Diffuse-type pigmented villonodular synovitis (PVNS) has a high local recurrence rate and as such can lead to erosive destruction of the involved joint. Multiple surgical modalities exist, but it is unknown which technique best minimizes local recurrence and surgical morbidity. We compared recurrence rates, arthritis progression, and complications between arthroscopic and open modalities for diffuse PVNS of the knee. We retrospectively identified 103 patients with PVNS treated between 1993 and 2011. Of these, 48 had diffuse-type PVNS of the knee treated by all-arthroscopic, open posterior with arthroscopic anterior, or open anterior and open posterior synovectomy. We recorded patient demographics, treatment profiles, recurrence rates, and arthritic progression. Minimum followup was 3 months (median, 40 months; range, 3-187 months). Recurrence rates were lower in the open/arthroscopic group compared with the arthroscopic or open/open groups: 9% versus 62% versus 64%, respectively. Arthritic progression occurred in 17% of the total study group with 8% going onto total knee arthroplasty within the followup period. We detected no difference between groups with regard to arthritic progression or progression to arthroplasty. The most common complication was hemarthrosis, which we drained in three patients (6% of the total study group), but there were no detectable differences between groups. Open posterior with arthroscopic anterior synovectomy is a viable, comprehensive approach to diffuse PVNS of the knee and provides both low recurrence rates and a low postoperative complication profile. Greater numbers of recurrences may be partially explained in the arthroscopic group by technical challenges associated with posterior arthroscopic synovectomy and in the open/open group by selection bias toward more aggressive disease. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A COMBINATION OF PIGMENTED VILLONODULAR SYNOVITIS AND SYNOVIAL CHONDROMATOSIS PRESENTING AS A LARGE LOOSE BODY IN KNEE

AbstractIntra-articular calcific lesions of knee usually manifest as loose bodies with symptoms of recurring episodes of locking and restriction of movement. These loose bodies are a consequence of trauma or degeneration of structures in the joint and occasionally may be of inflammatory or neoplastic condition of the synovium.Here we present our case as a rare form of presentation where in our patient had a large loose body in the knee with chronic pain and swelling and restriction of the movements of knee. Arthrotomy, loose body excision and total synovectomy of the knee confirmed coexistence of a dual lesion of synovial chondromatosis of the Hoffa's fat pad with diffuse pigmented villonodular synovitis of the knee joint. The patient made an uneventful recovery and full range of knee movement was restored by end 3 months. These benign conditions have inherent risk of recurrence, and in our case, till the last follow up at 14 months after surgery, he has remained asymptomatic with no clinico radiological evidence of any recurrence.

Pigmented villo-nodular synovitis of joints and tendon sheaths

Abstract Pigmented villo-nodular synovitis (PVNS) is a rare, benign and aggressive disorder of synovial joints and tendon sheaths which is capable of eroding articular structures and bone. It represents a spectrum of pathological disorders ranging from the most common giant-cell tumour of tendon sheath to localized or diffuse intra-articular PVNS lesions and may be associated with joint erosions. It is best treated surgically but recurs if inadequately excised. Adjunctive therapies include injection of intra-articular radio-isotopic materials and external beam radiotherapy.

Application of rhenium-186 radiosynovectomy in elbow diffuse pigmented villonodular synovitis. - a case report with multiple joint involvement.

After surgical therapy of diffuse pigmented villonodular synovitis (DPVNS), recurrence is seen in almost half of the patients. The effectiveness of radiosynovectomy (RSV) in preventing recurrence and complaints of DPVNS is well known. Elbow involvement in DPVNS is a very rare condition; therefore, RSV in elbow hasn't been experienced widely. The aim of this case report is to show the effectiveness of RSV with rhenium-186 (Re-186) sulfide colloid. We applied Re-186 sulfide colloid to the elbow joint of DPVNS patients six weeks after arthroscopic synovectomy. As a result, the patient did not have any complaints, and our findings are compatible with residue or recurrence on magnetic resonance imaging (MRI) in sixth and twentieth month controls after administration. We concluded that Re-186 is an effective adjuvant therapy for the prevention of recurrence and complaints.

Bilateral Diffuse Pigmented Villonodular Synovitis of the Knee

Pigmented villonodular synovitis (PVNS) is a proliferative disease of synovial tissue characterized by lipid-laden macrophages, multinucleated giant cells, and hemosiderin deposits. PVNS presents either in a localized form with minimal rates of recurrence after surgical resection or in a diffuse form with an expansive growth pattern showing formation of osseous erosions and extra-articular manifestation. In the diffuse form high recurrence rates occur as a result of the challenge of achievement of total synovectomy. Typically only one single joint, being the knee in 80% of cases, is involved with diffuse PVNS. Reports of bi- or multiarticular manifestation are at best rare. Here, a case of a 16-year-old girl with bilateral diffuse PVNS of the knee allows discussion of diagnostic and treatment considerations.

Long-Term Success in the Treatment of Diffuse Pigmented Villonodular Synovitis of the Knee With Subtotal Synovectomy and Radiotherapy

The objective of this study was to evaluate the effectiveness and long-term outcome of the treatment of patients with diffuse pigmented villonodular synovitis (PVNS) of the knee with subtotal arthroscopic and open synovectomy and subsequent external-beam radiotherapy. Eight patients diagnosed with diffuse PVNS by clinical and magnetic resonance imaging were treated surgically with subtotal arthroscopic synovectomy and an additional posterior incision for extra-articular lesions, followed by local adjuvant radiotherapy. These patients were followed up for a mean of 8.6 years to monitor remaining lesions and to detect new occurrences of the condition. None of the patients presented with major postoperative complications or have had radiotherapeutic late effects. In no case was radiographic arthritis progression detected. Three patients exhibited late minor complications (peripatellar pain, articular effusion, and persistent quadricipital muscle atrophy). Only 1 patient (12.5%) presented with recurrence of the disease during the follow-up period. On the basis of our limited study, subtotal arthroscopic and open synovectomy with subsequent local external-beam radiotherapy had a recurrence rate of 12.5% at 8.6 years of follow-up for the treatment of diffuse PVNS of the knee joint. Level IV, therapeutic case series.

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee

Background and purpose Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder involving synovial membranes, and patients with PVNS have a variable prognosis. We retrospectively analyzed clinical outcomes after synovectomy plus low-dose external beam radiotherapy for diffuse PVNS of the knee.Methods We reviewed the medical records of 23 patients who underwent postoperative radiotherapy between 1998 and 2007. 19 patients had primary disease and 4 had recurrent disease with an average of 2.5 prior surgeries. After synovectomy (17 arthroscopic surgeries; 6 open), all 23 patients received 4-MV or 6-MV external beam radiotherapy with a median dose of 20 (12–34) Gy in 10 fractions.Results At a median follow-up of 9 (0.8–12) years, 4 patients had recurrent disease, with a median disease-free interval of 5 years. Of these 4 patients, 3 received salvage synovectomy and regained local control. Univariate analysis showed that age, sex, history of trauma, and total dose of radiation were not predictive of local control. 22 patients reported excellent or good joint function, and 1 who refused salvage synovectomy had poor joint function. None of the patients experienced grade 3 or higher radiation-related toxicity or radiation-induced secondary malignancies.Interpretation Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).

Simultaneous Anterior and Posterior Synovectomies for Treating Diffuse Pigmented Villonodular Synovitis

The current treatment methods for diffuse intraarticular or extraarticular type pigmented villonodular synovitis (PVNS) include arthroscopic synovectomy or staged anterior and posterior open synovectomies. However, it is unclear whether simultaneous anterior and posterior synovectomies achieve local control and recovery of function. We therefore determined the recurrence rate and function in patients with diffuse PVNS treated with anterior and posterior synovectomies and adjuvant radiotherapy. We retrospectively reviewed all 19 patients with diffuse PVNS involving the knee treated with anterior and posterior synovectomies and adjuvant radiotherapy between January 2001 and November 2007. From the records, we determined local recurrence and Tegner-Lysholm scores. The minimum followup was 42months (median, 98months; range, 42-143months). Postoperative MRI revealed residual tumor in five of the 19 patients, although three had no disease progression during followup and had knee scores of 86 to 90. Two patients had recurrences at 6 and 9months with knee scores of 88 at 42months and 90 at 68months. The mean Tegner-Lysholm knee score improved from 59 to 93 points. Mean maximum extension and flexion angles improved from 11° to 2° and from 76° to 127°, respectively. Compared with the literature, simultaneous anterior and posterior synovectomies associated with postoperative radiotherapy provided rates of residual or recurrent tumor and knee function recovery comparable to that with staged synovectomies reported in the literature. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.