Bone & joints

Other nonneoplastic

Ganglion


Editorial Board Members: Jose G. Mantilla, M.D., Borislav A. Alexiev, M.D.
Serenella Serinelli, M.D., Ph.D.
Gustavo de la Roza, M.D.

Topic Completed: 15 March 2021

Minor changes: 27 May 2021

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PubMed Search: Ganglion [title] joints (y_5[Filter]) AND (ffrft[Filter])

Serenella Serinelli, M.D., Ph.D.
Gustavo de la Roza, M.D.
Page views in 2020: 21,704
Page views in 2021 to date: 27,353
Cite this page: Serinelli S, de la Roza G. Ganglion. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/jointsganglion.html. Accessed October 28th, 2021.
Definition / general
Terminology
ICD coding
  • ICD-10: M67.40 - ganglion, unspecified site
Epidemiology
  • 60 - 70% of the soft tissue masses in the hand and wrist (StatPearls: Ganglion Cyst [Accessed 2 March 2021])
  • F:M = 3:1
  • Can occur at any age
  • Most common: 20 - 50 years
  • Risk factors:
    • Repetitive microinjuries due to overuse of the joint
    • Previous traumas
Sites
  • Dorsal aspect of the wrist, from the scapholunate ligament or scapholunate articulation → 70%
  • Volar aspect of the wrist, from the radiocarpal joint or scaphotrapezial joint → 20%
  • Distal interphalangeal joint, hip, knee, ankle, foot, others → 10%
  • Some studies found the volar location to be more common than the dorsal (J Ultrasound Med 2019;38:2155)
Pathophysiology
  • Cystic fluid analysis: gelatinous material containing mainly hyaluronic acid and lesser amounts of glucosamine, globulins and albumen (Curr Rev Musculoskelet Med 2008;1:205)
  • Since no epithelial lining exists in these structures, they should not be classified as true cysts
Etiology
  • Unclear
  • Numerous theories (Curr Rev Musculoskelet Med 2008;1:205):
    • Displacement of synovial tissue during embryogenesis
    • Herniation of synovial capsule / fluid from joints into the surrounding tissues → reaction between fluid and local tissue results in the creation of the cyst
    • Proliferation of pluripotential mesenchymal cells
    • Myxoid degeneration of connective tissue after trauma: repetitive injury to the capsular and ligamentous structures → production of hyaluronic acid from fibroblasts → accumulation of mucin jelly-like material to form the cyst (most likely)
    • Inflammatory etiology
Clinical features
Clinical images

Images hosted on other servers:

Dorsal wrist ganglion

Ganglion: intraoperative view

Volar wrist ganglion

Diagnosis
  • Clinical presentation is usually adequate for diagnosis
  • Cyst typically transilluminates on the exam
  • Ultrasound is used for a definitive diagnosis
  • MRI is useful to rule out a possible solid tumor or in case of occult dorsal ganglion cyst (which is not clinically observed or palpated but is found on imaging studies or intraoperatively) (J Wrist Surg 2019;8:276)
Radiology description
Radiology images

Images hosted on other servers:

Ultrasound: dorsal wrist ganglion

MRI: volar wrist ganglion

Prognostic factors
  • Benign condition
  • Prognosis for most patients is excellent
  • Ganglion cysts spontaneously recede in more than half of patients (ISRN Orthop 2013;2013:940615)
  • Recurrence rate is approximately 10 - 15% after surgery (Adv Clin Exp Med 2019;28:95)
    • Recurrence after surgery is unpredictable and independent of patient demographic factors or surgical techniques
  • Aspiration has higher rates of recurrence (ISRN Orthop 2013;2013:940615)
Case reports
Treatment
  • Indications for treatment include pain, stiffness, weakness and cosmetic appearance (J Hand Surg Am 2015;40:546)
  • Three general treatment approaches:
    • Observation
    • Aspiration: often combined with some form of injection, electrocautery or multiple puncture
    • Excision: open or arthroscopic
Gross description
Gross images

Images hosted on other servers:

Ganglion

Microscopic (histologic) description
  • Uni or multilocular cystic structure
  • Dense collagenous walls with foci of myxoid changes (Lindberg: Diagnostic Pathology - Soft Tissue Tumors, 2nd Edition, 2015)
  • No true epithelial lining
  • Lumen may contain myxoid fluid
  • There is no nuclear atypia or mitotic activity
  • Inflammation / hemorrhage may be observed if the cyst has previously been ruptured
Microscopic (histologic) images

Contributed by Serenella Serinelli, M.D., Ph.D.
Unilocular ganglion cyst

Unilocular ganglion cyst

Cyst wall and content

Cyst wall and content

Multilocular ganglion cyst

Multilocular ganglion cyst

Myxoid changes

Myxoid changes

Absence of synovial lining

Absence of synovial lining

Virtual slides

Images hosted on other servers:

Ganglion cyst

Cytology description
  • Aspiration of a ganglion can be used as a preoperative diagnostic tool or a therapeutic procedure
  • Paucicellular myxoid material that contains scattered / clustered histiocytes (Am J Clin Pathol 2005;123:858)
  • Myxoid material of the cyst usually forms thick folds on the slide
Cytology images

Images hosted on other servers:
Ganglion cyst mucoid material

Ganglion cyst mucoid material

Histiocytes in ganglion cyst

Histiocytes in ganglion cyst

Electron microscopy description
  • Wall is composed of randomly oriented sheets of collagen arranged in loose layers
  • Rare cells are present in the collagen sheets and appear to be fibroblasts or mesenchymal cells (Curr Rev Musculoskelet Med 2008;1:205)
Videos

Ganglion cyst features

Sample pathology report
  • Soft tissue, left dorsal wrist, excision:
    • Ganglion cyst
Differential diagnosis
  • Myxoma:
    • Lobulated, gelatinous cut surfaces
    • Most commonly occurring within large muscles (thigh, shoulder, upper arm)
  • Low grade myxofibrosarcoma:
    • Multinodular cut surfaces
    • At least focal nuclear atypia
    • Conspicuous, elongated, curvilinear, thin walled blood vessels are characteristic
    • Most common in subjects older than 50
  • Neurofibroma:
    • Absence of cystic spaces
    • S100+
Board review style question #1

40 year old woman presents with a superficial lesion over the dorsal wrist. The lesion is excised and displays a cystic appearance. The histology is shown above. What is one of the main features of this condition?

  1. Cyst shows no true epithelial lining
  2. Invariably consists of a unilocular cyst
  3. Marked cellular atypia is seen
  4. Mitoses are frequent
  5. Rare condition
Board review style answer #1
A. Cyst shows no true epithelial lining

Comment Here

Reference: Ganglion
Board review style question #2
Which of the following statements is true regarding ganglion cysts?

  1. More common among females
  2. More common in the pediatric population
  3. Myxoid changes in the cyst wall are never observed
  4. Nuclear atypia is required for the diagnosis
  5. Rarely found in the hand / wrist area
Board review style answer #2
A. More common among females

Comment Here

Reference: Ganglion
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