Pigmented Villonodular Synovitis

The literature is replete with reports of what we believe to be a single lesion of the synovial membrane described under various titles. Among these are giant-cell tumor of the synovia, xanthoma, hemorrhagic villous synovitis, sclerosing hemangioma, xanthogranuloma, pigmented giant-cell xanthosarcoma, benign synovioma, and pigmented villonodular synovitis. This host of terms may be explained to some extent by the varied histologic picture and the greater or less import ascribed to the different cellular components by the individual pathologist. In 1941, Jaffe, Lichtenstein, and Sutro (1), after exploring various stages in the life history of this synovial lesion, suggested the term “pigmented villonodular synovitis.” They described also its anatomical equivalent involving tendon sheaths and bursae. Microscopic findings in both early and late phases of the disease were critically analyzed, and the common origin of the cellular components from primitive connective-tissue cells of the lining synovia was noted. Evidence was presented to show that the previous conception of the lesion as a neoplasm was unsound, and that the evolution, as well as the histologic findings, indicate that the process is entirely inflammatory. With the publication of this significant article, a splendid contribution was made toward the clarification of the disease process. In spite of the report of Jaffe and his associates, one finds that a uniform nomenclature has still to be accepted and that considerable difference of opinion exists among those concerned with the diagnosis and classification of villonodular synovitis. It is surprising, furthermore, to see how few reports have appeared in the radiologic literature. Not only is the nomenclature confusing, but the management of this lesion has also been subject to considerable variation. Kling and Sashin (2) recommended either total synovectomy or partial synovectomy with postoperative roentgen therapy. Galloway et al. (3), dealing with 70 cases, advised conservative surgical treatment and questioned the value of irradiation on the basis of a small number of cases so treated. De Santo and Wilson (4), analyzing 41 cases, found recurrence in 7 of the 32 patients followed. They concluded: “The proper treatment is radical extirpation. It is possible that postoperative radiation may be of some value in preventing local recurrence, but its use in large doses as the primary method of treatment would almost certainly result in loss of joint function and would offer little hope of causing disappearance of the tumor.” The first report on roentgen therapy as the treatment of choice in the management of this lesion was that of Friedman and Ginzler (5), appearing in 1940. Under the title “Xanthogranuloma of the Knee Joint,” the authors presented 2 histologically confirmed cases which were treated with fractionated high-voltage x-ray therapy in moderate dosage.