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jcrmhscasereports · 1 year

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Giant Cell Tumor of the Infrapatellar Fat Pad of the Knee: A Case Report by Ahmad Jiblawi in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Giant Cell Tumor is a rare benign soft tissue tumor occurring in two forms: localized and diffuse. The two subtypes differ in their location at presentation, shape, recurrence after treatment and prognosis. MRI is still essential in the diagnosis, however pathology remains the gold standard for the final diagnosis. In this article, we report a case of Giant Cell Tumor involving a very rare location with very few reports in the literature; the infrapatellar (Hoffa’s) fat pad of the knee. We discuss its keen clinical and radiological features. The tumor was managed with arthroscopic resection. Confirmation of the diagnosis was done by pathology. Our case is the first to be reported in Lebanon.

Keywords: GCT; Hoffa’s fat pad; STIR

INTRODUCTION

First described by Chassaignac in 1852, Giant Cell Tumor (GCT) is a benign soft tissue tumor [1]. It is a rare disease, associated with synovial inflammation due to hemosiderin deposition. GCT occurs in two forms: localized GCT and diffuse formerly known as pigmented villonodular synovitis. The former typically consists of small well circumscribed, nodule or pedunculated mass that might be intra- or extra-articular, most commonly (85%) in the small joints (ex: hands and feet) while the latter is typically intra-articular with an infiltrative growth pattern commonly occurring in large joints (ex: ankles and knees) [2–4]. Both share similar histologic features; however they have different biological behavior, treatment outcome and prognosis. Thus the importance of differentiating between the two entities [5,6].

MRI is considered essential for the diagnosis, staging, preoperative planning and clinical follow-up of GCT. The mass appears of iso/low signal intensity on T1 and T2 weighted images. In addition to joint effusion and synovial proliferation. Some “blooming” artifact of low signal might be noted on echo-gradient because of the magnetic susceptibility from hemosiderin deposition [1,2].

In this article, we report the first case in Lebanon (to our best knowledge) of a rare, localized Giant Cell Tumor originating in the infrapatellar (Hoffa’s) fat pad, emphasizing on its radiologic manifestation.

CASE REPORT

We report a case of a 35-year-old gentleman, previously healthy, complaining of a 4-month history of recurrent and painful left knee locking. The patient denies any trauma, any recent surgery, no accompanying systemic symptoms as of fever, rash, diffuse arthralgia, or myopathy. His presentation was mimicking that of a meniscal tear injury.

An MRI of the left knee was performed using 1.5 Tesla Philips Ingenia Unit, manufactured in the Netherlands. The following planes and sequences: A sagittal T1 weighted (T1W), proton density (PD) and STIR image, a coronal STIR and an axial STIR image (Figure 1 A-E). Result showed the presence of a soft tissue-like lesion arising directly anterior to the anterior cruciate ligament in between both femoral condyles estimated to be 3 cm in its transverse diameter, 2.7 cm in its antero-posterior diameter and 1.2 cm in its supero-inferior diameter. The lesion showed iso-intensity to the cartilage on T1W as well as on PD but showed an increase signal intensity on STIR weighted images. The lesion relaxes directly on the ACL posteriorly which is of adequate continuity and signal. Minimal associated excess of joint fluid filling the supra-patellar bursa. Both menisci, anterior cruciate ligament, posterior cruciate ligament and medial and lateral collateral were normal. No capsule-meniscal separation is seen. The overall radiologic impression was for a Cyclops lesion or a soft tissue tumor such as Giant Cell Tumor.

The patient underwent an arthroscopic excision of the soft tissue tumor. Procedure went uneventful. The tissue was sent to pathology. Microscopic examination showed fragments of fibrous tissue involved by sheets of fibro-elastic to epithelioid cells with band nuclei and moderately abundant cytoplasm. They are intermixed with osteoclast-like giant cells and foamy histiocytes. There was no evidence of malignancy. Findings suggestive of Giant Cell Tumor of the Tendon Sheath. Unfortunately, the patient was lost to follow up, thus recurrence could not be reassessed.

Figure 1: AT1 weighted image, sagittal plane: showing a soft tissue-like lesion iso-intense to the cartilage measuring 2.7 cm in its antero-posterior diameter relaxing directly on the anterior cruciate ligament posteriorly which is of adequate continuity and signal B: Proton density weighted image, sagittal plane: showing a soft tissue-like lesion iso-intense to the cartilage measuring 2.7 cm in its antero-posterior diameter relaxing directly on the anterior cruciate ligament posteriorly which is of adequate continuity and signal.

C: Short T1-Inversion Recovery weighted image, sagittal plane: showing a hyperintense soft tissue-like lesion measuring 2.7 cm in its antero-posterior diameter. D: Short T1-Inversion Recovery weighted image, coronal plane: showing a hyperintense soft tissue-like lesion measuring 1.2 cm in its supero-inferior diameter. E: Short T1-Inversion Recovery weighted image, transverse plane: showing a hyperintense soft tissue-like lesion measuring 3 cm in its transverse plane.

DISCUSSION

Giant Cell Tumor is a rare benign soft tissue tumor arising from the synovial tissue of the joints, tendon sheath, mucosal bursas, and fibrous tissues adjacent to tendons. Multiple terms are found in the literature to describe this entity; pigmented nodular tenosynovitis, fibrous xanthoma of synovium, benign synovioma, xanthogranuloma and tenosynovial giant cell tumor [1]. Etiology and histiogenesis of which is not completely understood, but many risk factors were mentioned in the literature such as trauma, infection, vascular abnormalities, lipid metabolism disorders, osteoclastic proliferation, and immune system disorders. It can present in two forms: localized and diffuse [3,7]. Localized GCT presents mainly in small joints (85 % observed in fingers while 12% is observed in large joints, GCT in the knee is rare) [4], either intra-articular or extra-articular. Diffuse form occurs mainly in the extra-articular space [8]. However, extra synovial soft tissue forms of localized GCT are very rare and mainly concern the knee joint. Around 50% of patients with a localized GCT arising primarily within the infrapatellar fat pad have a history of trauma but the exact etiology is still unknown [9]. The onset age of localized GCT is older than that of the diffuse type (i.e. localized type usually occurs above 40 years of age)[10]. When affected, patient presents clinically with mechanical derangements, progressively worsening over time. Meniscal symptoms and locking are often present within the knee joint. The main symptoms are swelling (86%), pain (82%), stiffness (73%), limited range of motion (64%) and joint instability (64%) [7,10].

MRI is an effective and highly sensitive diagnostic tool; however pathology is still the gold standard of final diagnosis. On T1 and T2 weighted images, dense collagen and hemosiderin presents with homogenous low or intermediate signal. The most typical feature of a localized GCT is a well circumscribed, nodular mass with low signal intensity on T1, T2 and proton weighted images and high signal intensity on STIR images [4,6,9,10]. Microscopically, GCT is characterized by multinucleated giant cell, lipid-laden macrophages, hemosiderin deposition and fibroblast proliferation [5].

Various pathological conditions should be considered in the differential diagnosis, for example: Synovial Chondromatosis, Cyclops lesion, Rhabdomyosarcoma, Fibroma of tendon sheath, Synovial Sarcoma, Amyloid Arthropathy, Haemophilic Arthropathy, Lipoma Arborescens and Rheumatoid Arthritis [6,9].

The ability to differentiate between the diffuse and localized forms of GCT is paramount to give patients a realistic outlook on future prognosis, chance of recurrence and optimal treatment course [5]. Several treatment options are present: surgery, radiotherapy, pharmacology or a combined solution of the listed methods. Important to note, local recurrence after treatment was reported in 18-46% of cases. However, this might be linked to incomplete resection of satellite nodules in the area of initial change. Other risk factors for recurrence are the location of the disease (more common in the knee), history of previous surgeries and positive surgical margins.

CONCLUSION

To the best of our knowledge, our case is the first to be reported in Lebanon. It is very rare to have a localized GCT in the extra-synovial infrapatellar (Hoffa’s) fat pad of the knee. The rarity of the presented case suggests that GCT should be considered in the differential diagnosis of a painful knee locking in a young patient. Accurate diagnosis will lead to successful treatment associated with low recurrence rate resulting in a better patient outcome.

Conflict of Interest:

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article

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#GCT #Hoffa’s fat pad #STIR #Giant Cell Tumor #MRI #histiocytes #hyperintense #Rhabdomyosarcoma #Arthropathy #Arborescens #Ahmad Jiblawi #jcrmhs

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butch-reidentified · 1 year

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One of my best friends is a gender critical, intensely radfem-aligned, mtf transsexual. I've talked about this friend several times before on here, but I think it's time I devote a stand-alone post. As with most of my posts, it will be long in signature JC fashion, but I think the topic warrants it: my friend is a wonderful person first and foremost, but is a truly fascinating and unique example of transsexuality as well.

First, a note: I've said this before, but for anyone new to my discussions of my gc mtf friend, she has never and would never expect or ask me to use she pronouns, but it's just how my brain perceives her despite rationally knowing she's male. I have no interest in forcing myself to use sex-accurate pronouns when it doesn't come naturally, because I don't believe it really matters in this context. It matters when it comes to things like news media reporting violent crime by transwomen as committed by women, but interpersonally or in a tumblr post, I don't feel a need to firmly stick to sex-accurate pronouns when my brain naturally goes to cross-sex ones for someone.

Here's a slightly amended quote from one of my early posts about her:

These are the same type of people who drove the transwomen I love from their own spaces by shaming them for having actual sex dysphoria and not "embracing the girl dick" or whatever. Literally what happened to my best friend, and she doesn't deserve that. She's so deeply passionate about women's liberation, believes firmly in female only spaces and sports, in honoring all of women's boundaries, in the definition of homosexuality, regularly argues with our other friends that eliminating all males would objectively result in a better world (with sources lol), calls herself a transwoman only - specifically as one word, for which she has a particular definition predicated on being male - not a woman, and most interestingly, comes across as very much female socialized. And not in a remotely intentional or performative way: it negatively impacts her the same way it does me or any actual woman I know. It's wild.

This is something I'd be interested in proper research on, because according to all her lifelong friends and neighbors, she's always been this way (and has been on an anti-porn crusade since the THIRD fuckin grade). She never internalized male socialization, like at all, and somehow seems to have internalized at least the majority of female socialization. Interacting with her feels exactly like interacting with any woman, no matter the context. I've known her for 6 years or so now and that's been consistently very true. I would NEVER have guessed she wasn't raised female. She completely "passes" but doesn't wear makeup or remove body hair, wears normal clothes like just pants and a shirt, etc. She seems like such a regular woman in every way, but she's not a woman (and she won't call herself one or demand you use she pronouns... I just do because nothing else feels right tbh). Several times, friends have straight up not believed she's transsexual at first.

When I talk about her seeming female-socialized in ways that are negatively impactful, I mean things like struggling to feel like you can say no, being prone to imposter syndrome, feeling like everyone else's needs come before your own, not feeling allowed to take up space, devoting endless emotional labor to those around you even when it's 3am on a work night before a crucial 9am meeting, giving of yourself well beyond what you should... those types of things (which are only a few examples of course) are her to a T, and are things she is working to unlearn for her own wellbeing alongside other women in our friend group.

She experiences sex dysphoria the same way I've described in myself - as a seemingly neurological, very physical sensation (in the same way pain or itchiness are physical sensations), somewhat akin to Phantom Limb. I've described her "social transition" before as "an incidental byproduct of medical transition," which I still think is accurate. She transitioned medically as a last resort measure to treat physical/neurological sex dysphoria, and ended up being perceived as female. It eventually just made logistical sense to assimilate socially. She couldn't care less how others perceive her "gender" or what pronouns they use or any of that, and shares the radfem view on the definition of gender and on gender ideology.

She's in the camp of "transactivism behaves like a cult and is explicitly a men's rights movement." I remember once a couple friends asked her why she was so passionate and outraged about female erasure and lesbian erasure, and she said very simply that "the trans cult has already erased, redefined, rewritten actual transsexual people," so she understands to a small degree the feeling of it, and sees them doing the same to women and homosexuals and can't tolerate it.

Her childhood friends (nearly all female) have said they have pretty much always innately interacted with her like they would with a female friend, and never understood why. I've never had to explain anything about the female experience to her, nor known of anyone else doing so. More often, my other friends and I find ourselves explaining to her that other males absolutely don't know the things she does (regarding both the biological and social aspects) or have the awareness she does, all these things she observed as a little kid, many of which upset her deeply on behalf of her female peers.

She did go through CSA, domestic violence, a trafficking attempt, and other major traumas throughout her childhood and into young adulthood, but the people who've known her her entire life say she was already the way she is in terms of all this stuff before that.

The adults she talks about looking up to as a kid, the ones she latched onto as mentors and who shaped her, are all badass, gnc, and/or feminist women. Her number one role model as a kid was her female karate instructor who had won major competitions all over the country and was very gnc both physically and personality-wise. The memories involving these mentors that she talks about most and remembers most vividly are almost all regarding misogyny and the injustices and cruelty women and girls face.

One other interesting fact is that she's XXY and had gynecomastia and slightly more feminine than normal features such as fat distribution before transition, and her body feminized more from HRT (she only had genital surgery due to extreme intractable dysphoria; she is opposed to any other surgeries like FFS or BA since they're entirely cosmetic to her) than any transwoman I've ever met or even seen pictures of. Most TW I've known barely fit a training bra - she's a D cup. It's so odd to me that she has the seemingly-neurological sex dysphoria AND the weird femsoc thing AND her body responded much more dramatically to estradiol than any other transwoman. I'm at a loss. It drives my little scientist brain crazy.

I have my theories, but ultimately I really don't know how to explain her. I've known a whole lot of trans people, and a whole lot of transwomen in particular, and while I have certainly met a few that don't come across like Gamestop Maam/average AGP vibes, they typically seem more like gay men rather than female-socialized. Even with those who do show some femsoc-like traits, it's not remotely to the degree I see in my friend, and oftentimes it's something they clearly trained themselves into to blend in.

I know there are other gender critical transsexuals out there, but idk if there is anyone else like her. I want to know, tbh, I am really super curious about it and about how/why she is the way she is (as is she lol).

I wanted to share this more concisely since I've mentioned her in multiple reblogs and posts and answers to asks over the years, but haven't really made a post specifically about her. Feel free to ask questions! She's given me full permission to discuss her experiences and whatnot here.

#One of our friends is still convinced it's a big prank and she's not trans at all 💀#mine #gender critical transsexual #gc transsexual #gc trans #gcts #femsoc #ntsd #neurological type sex dysphoria #sex dysphoria

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