Transcript
Announcer:
Welcome to CE on ReachMD. This activity is provided by AGILE and is part of our MinuteCE curriculum.
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Dr. Gelderblom:
This is CE on ReachMD, and I'm Dr. Hans Gelderblom.
Dr. Cole:
And I'm Dr. Chelsea Cole.
And we're going to start with a case. So I had a patient, a 39-year-old male, come into my clinic a couple weeks ago with some swelling on their lateral part of their wrist that had been there for a couple of years and was getting more painful.
And because I do a lot of ultrasound in my clinic, and because one of the more common diagnoses I see with this kind of presentation is a ganglion cyst, I put an ultrasound on the area. And with extension, there was 2 fairly large, 1- to 2-cm circular cystic-type lesions on either side of the extensor tendons in that fourth dorsal compartment. But they didn’t look black. They had mixed echotexture in the middle, and that suggests to me that there’s something else going on that’s not just a ganglion cyst.
And so I talked to the patient and sent them to get an MRI to further clarify what this was and whether it was something we could actually drain in clinic or not. And they came back in to do an MRI review, and the MRI read came back as pigmented villonodular synovitis vs synovial chondromatosis. And so I explained the diagnosis and referred them on to our orthopedic oncologist for next steps.
Dr. Gelderblom:
Well, thank you, Dr. Cole. This really illustrates how difficult it is to make the primary diagnosis when you have so many other diagnoses in your clinic. So it was really good of you that you made this diagnosis and you helped the patient with that.
And so typically these patients usually are referred in our center to our orthopedic surgeon first, so they look at options; they discuss the options. And of course, a wrist is a very difficult place.
Dr. Cole:
But I think one of things that can be very helpful with this—for at least me, when I’ve diagnosed or seen these patients before—is ultrasound, because I look at these patients with ultrasound all the time, and I can do it in my clinic. And so anytime I see something that looks kind of abnormal or unusual about an effusion—because I see effusions from arthritis and other things all the time—and there is a difference in kind of the synovial lining and the thickening and like what that looks like. And so that’s one of the things that I always—anytime something looks a little bit abnormal, I’m going to get further imaging to make sure this isn’t a mass or something else that doesn’t need to just be drained or need to be treated.
Dr. Gelderblom:
And honest question to you—and of course, you are aware of the opportunities with TKIs currently. Would you have referred, like, 5 years ago or 10 years ago, this patient to a different specialist?
Dr. Cole:
So at least where I am right now, anytime I have any sort of MSK or like joint-type concern for any tumor, I have an orthopedic oncologist that I work with that gets people in pretty quickly. And if I need to send them to medical oncology, I can. And so that’s usually kind of the first stop for me, and if it’s anything concerning, I’ll usually call and kind of discuss the case with them.
Dr. Gelderblom:
Okay. That’s great you have that service. And well, how we go further—and Dr. van de Sande and I discussed about that—so we see the patient in a joint clinic. We discuss options for surgery and the drawbacks of that with long recovery. Usually not complete surgery, but patients can choose for that if they just want to be up and running and take a risk of a recurrence. Or a patient would say, okay, I have that high risk of recurrence and not complete surgery; let’s try a TKI for a while.
And of course, there are several options now in the US and probably in Europe soon as well. So it’s a matter of choosing. It’s just a personal choice and see how it goes and see what dose you end up and how long you treat. And this is something that we really will have to learn in the future.
So, well, thanks. For me, it was very interesting to hear where these patients come from, and thanks for your explanation of the case. And with that, our time is up, and we hope you found this quick case review helpful, and thanks for listening.
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Global Learning Collaborative (GLC) designates this activity for 1.0 contact hour(s)/0.1 CEUs of pharmacy contact hour(s). 
Global Learning Collaborative (GLC) has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit(s) for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credit(s). Approval is valid until 12/15/26. PAs should claim only the credit commensurate with the extent of their participation in the activity. 
