Fibroma of Tendon Sheath

Fibroma of the tendon sheath is a distinct clinicopathologic entity rarely occurring on the foot. It is a benign tumor derived from the fibroblast that clinically appears as a slow-growing painless mass. Complete surgical excision is curative. Recurrence occurs in 24% of the cases, usually due to inadequate excision. This report describes a 36-year-old man with such a tumor of the foot.

Deba P. Sarma, M.D.1 Gault H. Townsend, M.D.2 Fred H. Rodriguez, Jr., M.D.3
ibroma of the tendon sheath is an uncommon but distinct entity, first described in detail by Chung and Enzinger ( I) in 1979. Although clinically it resembles giant cell tumor of tendon sheath, histologically and ultrastructurally (2) the fibroma of tendon sheath is a distinct tumor. Most of the fibromas of tendon sheath have been described to occur in the upper extremities
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(I).

This report describes the clinical and pathologic features and ultrastructural observations of a case of fibroma of tendon sheath occurring on the foot.
Case Report

A 36-year-old black man presented with the complaint of a right foot mass having been present for approximately I year. There was no history of trauma to the site of the lesion. The patient denied any pain or tenderness in the lesion. He had noticed a gradual increase in the size of the mass that now prevented him from wearing shoes. Physical examination revealed a 4 x 5-cm. firm, nonmobile subcutaneous mass over the extensor tendon of the right great toe. The remainder of the physical examination was unremarkable. Radiographs of the right foot revealed a soft tissue mass (Fig. I) immediately superior to the metatarsals. There was no lesion in the adjacent bones. Under general anesthesia, the mass was explored in the subcutaneous tissue of the foot. With blunt and sharp dissection, the entire 4-cm. size lobulated mass
From the Department of Pathology. Veterans Administration Medical Center and Louisiana State University Medical School. New Orleans. Louisiana. ' Associate Professor of Pathology and Dermatology; Address correspondence to: Veterans Administration Medical Center. 1601 Perdido Street. New Orleans. La. 70146. 2 Submitted while resident. 3 Associate Professor. 0449/2544/87/0265-0422S02.00/0 Copyright 1987 by The American College of Foot Surgeons

was manipulated and excised. It appeared to have arisen from the tendon sheath of the extensor hallucis longus tendon. There was an uneventful postoperative recovery. The excised lesion was a lobular, white, firm, and rubbery mass measuring 4 x 4 x 2.5 cm. (Fig. 2). Cut surfaces were white, firm, and almost cartilaginous. Microscopically (Fig. 2), the lesion was hypocellular, containing large amounts of collagenous tissue with spindle-shaped fibroblasts and a few blood vessels. There was no nuclear atypism or mitosis in the fibroblastic cells. There were no giant cells or xanthoma cells. Ultrastructurally (Fig. 3), isolated spindle and stellate-shaped cells were identified within interlacing bundles of interstitial-type banded collagen. The cells were typical fibroblasts with fusiform nuclei and a cytoplasm dominated by irregular arrays of rough endoplasmic reticulum whose cisterns contained amorphous material. The cells lacked a basal lamina and showed no specific membrane junctions with adjacent cells. There was isolated cytoplasmic accumulation of intermediate filament material, but no specific granules or histiocytic or myogenic differentiation was noted. The pathologic diagnosis of the mass was a fibroma of the tendon sheath. During the follow-up period of 2 years, the patient has been free of any recurrence.
Discussion

Since the first detailed description (I) of fibroma of tendon sheath, only a few reports (2-4) of this tumor have appeared in the English literature. Fibroma of tendon sheath is a benign neoplasm with distinct clinical and histologic features. It is a slow-growing fibrous mass firmly attached to tendon sheath and it occurs most commonly in the extremities. Although it clinically resembles a giant cell tumor of tendon sheath, histologically it is a hypocellular, collagenous, fibroblastic lesion free of giant cells and xanthoma cells.

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origin of the lesion may be present in less than 10% of the cases. Generally, x-ray studies confirm the soft tissue lesion, but no bone changes are noted. The fibroma is usually attached to a tendon sheath; it is well circumscribed and lobulated. The firm and rubbery tumor on cut section appears pearly white, almost cartilaginous. Most of the tumors are 1 to 2 cm. in size. The largest one measured 5.5 cm. in diameter (1). Typical microscopic features include distinct lobules of spindle fibroblastic cells within a large amount of dense collagenous stroma showing hyalinization, few vessels, and occasional zones revealing transition between a cellular and hypocellular collagenous area. Giant cells and xanthoma cells (abundant in giant cell tumor of tendon sheath) are absent. Ultrastructural features are those of typical fibroblasts. Treatment of the fibroma of tendon sheath is complete excision of the entire tumor. Local recurrence has been reported in 24% of the cases (1). The interval between excision and recurrence may range from months to 5 years. Cause of recurrence does not appear to be the aggressiveness of the tumor, rather an inadequate primary excision leaving minute lobules of tumor

at the site (3). Re-excision of the recurrent lesion is curative (1). Differential diagnosis for a slow-growing painless mass attached to the tendon should include giant cell tumor of tendon sheath, fibroma of tendon sheath, fibrous histiocytoma, and nodular fasciitis. A specific diagnosis can be made only after a thorough pathologic study of the excised lesion.
Acknowledgment

The authors thank Mrs. Roey Holliday for her excellent secretarial assistance.
References

1. Chung, E. B., and Enzinger, F. M. Fib^oia of tendon sheath. Cancer 44:1945-1954, 1979. 2. Sarma, D. P., Weilbaecher. T. G., and Rodriguez. F. H. Fibroma of tendon sheath. J. Surg. Oncol. 32:230-232. 1986. 3. Cooper. P. H. Fibroma of tendon sheath. J. Am. Acad. Dermatol. 11:625-628, 1984. 4. Jablokow, V. R., and Kathuria, S. Fibroma of tendon sheath. J. Surg. Oncol. 19:90-92, 1982. 5. Alguacil-Garcia. A., Unni, K. K., and Goellner. J. R. Giant cell tumor of tendon sheath and pigmented villonodular synovitis: an ultrastructural study. Am. J. Clin. Pathol. 69:6-17, 1978.

Sarma DP, Townsend GH, Rodriguez FH(1987): Fibroma of tendon sheath. J Foot Surg 26:422-424. PMID: 3680870 [PubMed - indexed for MEDLINE]

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