Purpose: Diffuse-type tenosynovial giant cell tumor (D-TSGCT) is an aggressive proliferation of synovial-like mononuclear cells with inflammatory infiltrates. Despite the COL6A3-CSF1 gene fusion discovered in benign lesions, molecular aberrations of malignant D-TSGCTs remain unidentified. Experimental Design: We used fluorescent in situ hybridization and in situ hybridization to evaluate CSF1 translocation and mRNA expression in six malignant D-TSGCTs, which were further immunohistochemically compared with 24 benign cases for cell cycle regulators involving G 1 phase and G 1 -S transition. Comparative genomic hybridization, real-time reverse transcription-PCR, and a combination of laser microdissection and sequencing were adopted to assess chromosomal imbalances, cyclin A expression, and TP53 gene, respectively. Results: Five of six malignant D-TSGCTs displayed CSF1 mRNA expression by in situ hybridization, despite only one having CSF1translocation. Cyclin A (P = 0.008) and P53 (P < 0.001) could distinguish malignant from benign lesions without overlaps in labeling indices. Cyclin A transcripts were more abundant in malignant D-TSGCTs (P < 0.001). All malignant cases revealed a wild-type TP53 gene, which was validated by an antibody specifically against wild-type P53 protein.Chromosomal imbalances were only detected in malignant D-TSGCTs, with DNA losses predominating over gains. Notably, -15q was recurrently identified in five malignant D-TSGCTs, four of which showed a minimal overlapping deletion at 15q22-24. Conclusions: Deregulated CFS1 overexpression is frequent in malignant D-TSGCTs. The sarcomatous transformation involves aberrations of cyclin A, P53, and chromosome arm 15q. Cyclin A mRNA is up-regulated in malignant D-TSGCTs. Non^random losses at 15q22-24 suggest candidate tumor suppressor gene(s) in this region. However, P53 overexpression is likely caused by alternative mechanisms rather than mutations in hotspot exons.Tenosynovial giant cell tumors (TSGCT) are unique mesenchymal lesions that arise from the synovial lining of articular spaces, bursal sacs, and tendon sheaths (1, 2). The neoplastic property of TSGCTs has been supported by the identification of DNA aneuploidy and clonal karyotypic aberrations in these tumors, such as trisomies 7 and 5 and/or translocations involving chromosomal regions 1p11-13, 2q35-37, or 16q22-24 (2 -6). Given the difference in clinical behavior, TSGCTs are further divided by growth patterns into localized and diffuse types and by the predominant location of occurrence into extra-articular and intra-articular forms (1 -4). Histologically, diffuse-type TSGCT (D-TSGCT), i.e., pigmented villonodular synovitis if located intra-articularly, is an infiltrative proliferation of synovial-like mononuclear cells accompanied by heterogeneous inflammatory infiltrates among varying degrees of collagenous stroma (1, 2, 7). It frequently develops multiple local recurrences that are sometimes difficult to control by surgical excision and can severely compromise joint function...