A rare case of ganglion cyst of sternoclavicular joint

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There was no history of trauma to that region. On palpation, the swelling was well defined, 0.5 cm in diameter, nonmobile, present over the right sternoclavicular ...
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CASE REPORT

A rare case of ganglion cyst of sternoclavicular joint diagnosed and treated by fine‑needle aspiration cytology Divya Sethi, Sangeeta Lamba, Barkha Gupta, Mitali Swain Department of Pathology, ESI Hospital, New Delhi, India

ABSTRACT

Address for correspondence: Dr. Divya Sethi, C-5/20, Sector-11, Rohini, Delhi - 110 085, India. E‑mail: [email protected]

Ganglion cyst although a common swelling observed near joints of hands and feet, it is extremely rare in the sternoclavicular joint. Diagnosis is usually based on clinical examination, radiological investigations, or fine‑needle aspiration cytology (FNAC). We hereby report a case of an 8‑year‑old girl who presented to the surgical outpatient department with a nontender, nonerythematous swelling over the right sternoclavicular joint for 3 months. Ultrasonography revealed a cystic swelling measuring 0.4 cm × 0.3 cm × 0.3 cm. The diagnosis of ganglion cyst was finally confirmed on FNAC. The aspiration acted both as diagnostic and therapeutic modality thus avoiding surgery. The patient is under follow‑up for the chance of recurrence. Key words: Ganglion cyst, pediatric neck masses, sternoclavicular joint

INTRODUCTION Ganglion cysts are commonly observed in association with joints and tendons. They are lined by connective tissue, contain mucinous fluid, and are attached at the base by a tendon sheath or narrow stalk to the underlying joint capsule. Usually, they are painless because they lack an inflammatory infiltrate. Regardless of age, ganglion cysts are mostly located on the appendicular skeleton specially hand and wrist and are extremely rare in the sternoclavicular joint.[1] The extensive study of literature has revealed only a handful of cases diagnosed as ganglion cyst at this site. We hereby report a case of asymptomatic nontraumatic ganglion cyst of sternoclavicular joint in a pediatric age group diagnosed and treated on fine‑needle aspiration cytology (FNAC).

CASE REPORT

An 8‑year‑old female child presented to the surgery outpatient department with complaints of painless swelling in the neck which was gradually increasing in size over a period of 3 months reaching a pea size at presentation. Access this article online

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DOI: 10.4103/jcls.jcls_57_17

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There was no history of trauma to that region. On palpation, the swelling was well defined, 0.5 cm in diameter, nonmobile, present over the right sternoclavicular joint. It was nontender, nonerythematous not attached to the overlying skin [Figure 1]. Ultrasonography (USG) revealed a cystic swelling measuring 0.4 cm × 0.3 cm × 0.3 cm in the anterosuperior region of the sternoclavicular joint. Thyroid and other neck structures did not show any abnormality. FNAC was done which yielded scant, thick colorless gelatinous material. Microscopically, the smears showed single mononuclear cells with central ovoid nuclei and abundant cytoplasm resembling histiocytes against a background of abundant mucoid/myxoid material [Figures 2 and 3]. The swelling immediately collapsed on aspiration. The procedure of FNAC was both diagnostic as well as therapeutic, and the patient is under follow‑up for any recurrence.

DISCUSSION

Pediatric neck masses are typically divided into congenital and acquired. The congenital masses commonly include This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]

How to cite this article: Sethi D, Lamba S, Gupta B, Swain M. A rare case of ganglion cyst of sternoclavicular joint diagnosed and treated by fine-needle aspiration cytology. J Clin Sci 2017;14:204-6.

© 2017 JOURNAL OF CLINICAL SCIENCES | PUBLISHED BY WOLTERS KLUWER - MEDKNOW

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Sethi, et al.: Ganglion cyst of sternoclavicular joint

cystic lesions such as branchial cleft cyst, lymphatic malformations, and dermoid cyst. The location of the neck mass provides diagnostic clues.[2] Acquired lesions are infectious or inflammatory such as epidermal cysts, trichilemmal cysts, or vascular cysts such as hemangioma and lymphocele. The duration of the lesion clearly differentiates between congenital and acquired categories. Further, the type of aspirate on FNAC gives a diagnostic clue. Thick, greasy, foul smelling material goes in favor of epidermal cyst whereas clear yellowish mucoid material points toward lymphocele. Cytology of all these lesions is different too. Figure 1: A firm nonmobile 0.5 cm swelling on the right sternoclavicular joint

Figure 2: Single mononuclear cells with central ovoid nuclei and abundant cytoplasm against a background of abundant mucoid/myxoid material (MGG, ×100)

Ganglion cysts, in general, are associated with a history of trauma, though the etiology is not clearly elucidated. Mucin accumulates within the cyst through a stalk‑like connection to the joint capsule.[3] In the index case, the history of trauma was lacking.

The diagnosis of ganglion cyst although rare in the sternoclavicular joint there have been very few cases published on it being diagnosed on FNAC. Most of the authors have described it radiologically comparing the sensitivity of diagnosis on USG versus computed tomography scan or magnetic resonance imaging (MRI). In a study by Haber et al., five cases of sternoclavicular ganglion cysts was done, most of which were diagnosed on MRI and confirmed on histopathology.[4] The present case was diagnosed on FNAC, a USG which was done defined the lesion as cystic. A clinical possibility of a parasitic cyst was kept, but neither the type of aspirate nor the morphological findings on fine‑needle aspiration (FNA) smears supported this. Among the treatment methods included injection of sclerosing fluids or steroids.[5]

In consideration of the benign nature of these lesions, observation of the asymptomatic patient is a perfectly reasonable treatment plan. Spontaneous resolution of ganglion cysts occurs in two‑thirds of cases.[6] This patient was treated by FNA alone and is under follow‑up for any chance of recurrence.

CONCLUSION

Figure 3: Single mononuclear cells with central ovoid nuclei and abundant cytoplasm against a background of abundant mucoid/myxoid material (MGG, ×400)

This case report highlights the importance of keeping ganglion cyst in the differential diagnosis of acquired neck swellings, especially over sternoclavicular joint. FNA in such cases is not only diagnostic but is a simple, fast, effective, nontraumatic, inexpensive method of treating asymptomatic ganglion cysts and also avoiding the surgical trauma involved in surgeries to the surrounding tissues. However, this requires further studies for definite correlation.

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JOURNAL OF CLINICAL SCIENCES, VOLUME 14, ISSUE 4, OCTOBER-DECEMBER 2017

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Sethi, et al.: Ganglion cyst of sternoclavicular joint

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Esteban JM, Oertel YC, Mendoza M, Knoll SM. Fine needle aspiration in the treatment of ganglion cysts. South Med J 1986;79:691‑3. 2. Cunningham MJ. The management of congenital neck masses. Am J Otolaryngol 1992;13:78‑92.

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3. Adam SI, Karas DE, Lesnik G. Rare pediatric neck mass: Sternoclavicular joint ganglion cyst. Int J Pediatr Otorhinolaryngol 2011;6:361‑2. 4. Haber LH, Waanders NA, Thompson GH, Petersilge C, Ballock RT. Sternoclavicular joint ganglion cysts in young children. J Pediatr Orthop 2002;22:544‑7. 5. Ramraje SN, Chaturvedi N, Bhatia V, Goel A. Fine needle aspiration: A simple and convenient alternative for diagnosing and treating ganglions. East Cent Afr J Surg 2011;16:135‑8. 6. MacCollum MS. Dorsal wrist ganglions in children. J Hand Surg Am 1977;2:325.

JOURNAL OF CLINICAL SCIENCES, VOLUME 14, ISSUE 4, OCTOBER-DECEMBER 2017