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PVNS Diagnosis — SCE Rheumatology MCQ

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HardSoft Tissue RheumatologyPVNS DiagnosisSCE Rheumatology

A 30-year-old woman has an 18-month history of recurrent atraumatic swelling and intermittent locking of one knee. Repeated aspirations have yielded blood-stained fluid despite a normal coagulation screen. CRP is normal and rheumatoid factor and anti-CCP antibodies are negative. MRI demonstrates diffuse multinodular synovial thickening involving the anterior and posterior joint compartments. The lesions contain low-to-intermediate signal foci on T1- and T2-weighted images with marked blooming on gradient-echo sequences. There are no mineralised loose bodies or fat-signal synovial fronds. What is the most likely diagnosis?

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Correct answer: D — Diffuse-type tenosynovial giant cell tumour

The diagnosis is diffuse-type tenosynovial giant cell tumour, formerly termed pigmented villonodular synovitis. The discriminating features are recurrent atraumatic haemarthrosis, diffuse multinodular synovial involvement and susceptibility blooming caused by haemosiderin. Low-to-intermediate signal is commonly seen on both T1- and T2-weighted imaging. Rheumatoid synovitis can produce pannus and effusion but is not characterised by this marked haemosiderin blooming pattern. Synovial chondromatosis produces multiple cartilaginous nodules or loose bodies, often with mineralisation. Lipoma arborescens has frond-like synovial fat that follows fat signal and suppresses on fat-saturated sequences. Synovial sarcoma is usually a juxta-articular soft-tissue mass rather than a diffuse intra-articular synovial proliferation.

Reference: Spierenburg G et al. MRI of diffuse-type tenosynovial giant cell tumour in the knee: a guide for diagnosis and treatment response assessment. Insights into Imaging. 2023;14:22. https://pubmed.ncbi.nlm.nih.gov/36725759/