35 - Soft Tissue Masses Flashcards
(47 cards)
1
Q
Goals of tumor management
A
- Identify lesion
- Rule out malignancy
- Relieve pain
- Prevent growth or spread (limit local destruction)
- Cosmetic improvement
2
Q
Tumor
A
- General morphologic term for any abnormal mass
- Does not define benign vs. malignant
- “Soft Tissue” does not include epithelial tissue however there is such a great overlap in evaluation and management in this presentation epithelial factors and conditions will be included
- Tumor just means a growth – to a patient, a tumor means cancer, so be careful
- Both are just skin tags (acral cordon) – all others except bottom left
- Bottom left is an amelanotic melanoma
3
Q
Overview of soft tissue tumors
A
- Over 80 distinct soft tissue tumor types
- 100:1 ratio of benign to malignant STM
- Most Common = Ganglion and fibroma (Benign) and Synovial sarcoma (Malignant)
- Higher frequency of malignancy in the hind-foot
- Early recognition common in the foot because of local prominence
- There is clinical feature overlap between STM, dermatologic conditions and ulcerations
4
Q
Classification system of soft tissue mass (STM)
A
Histologic type
o Cell type
o Germ layer
Biologic behavior
o Benign
o Malignant
Anatomic site
o Localized
o Widespread
5
Q
Benign tumor staging
A
- Stage 1 = latent, not growing
- Stage 2 = active, enlarging but not invading, pushing tissues out of the way, entwining within them
- Stage 3 = aggressive, invade other structures
6
Q
Cellular changes
A
- Hyperplasia (just more cells)
- Metaplasia (one cell turns into different cell)
- Dysplasia (disordered growth)
- Neoplasia (new growth)
7
Q
Factors influencing cell activity
A
- Mechanical
- Inflammatory
- Infectious
- Metabolic
- Genetic
8
Q
Morton’s neuroma
A
- Example: 3rd interspace, deep transverse intermetatarsal ligament
- Example: Ankle fracture where they partially nicked the nerve – scar tissue formation – NOT NEW GROWTH, just a neuroma
9
Q
Benign neoplasm
A
o Named by adding “- oma” to the parenchymal cell type
o Both for cells of epithelial or mesenchymal origin
o Most are single cell origin
10
Q
Malignant neoplasm
A
o “Carcinoma” if epithelial in origin
o “Sarcoma” if mesenchymal in origin
11
Q
Diagnosis of a soft tissue mass
A
- History
- Clinical Characteristics
- Imaging
- Biopsy
- CANNOT make a diagnosis by imaging – THE ONLY WAY TO DIAGNOSE IS BY BIOPSY***
12
Q
Clinical features of a soft tissue mass to look for
A
- Size
- Shape
- Texture
- Location
- Mobility
- Color
- Pain
- Temperature
- Pulse / Bruit
- Parathesia
13
Q
Diagnostic imaging modalities for soft tissue masses
A
- X-ray
- CT
- Bone scan
- MRI
14
Q
Use of X-ray to assess soft tissue mass
A
o Calcification
o Bone Tumor simulating STM
o Bone invasion
15
Q
Use of CT to assess soft tissue mass
A
o Location, Size, Bone invasion
16
Q
Use of MRI to assess soft tissue mass
A
o Anatomic localization
o Relative tissue type
o Does not provide a definitive diagnosis
17
Q
Biopsy
A
- Most important method of identification for tumors
- Provides vital information for prognosis and treatment
- Excisional biopsy may provide “cure”
- ***MOST IMPORTANT THING IS BIOPSY – need to know what you are looking for
18
Q
Biopsy types
*THIS IS IMPORTANT
A
- Closed biopsy
- Incisional biopsy
- Excisional biopsy
19
Q
Closed biopsy
A
o Needle aspiration
o Core Biopsy
20
Q
Incisional biopsy
A
o Wedge
o Punch
o Shave
21
Q
Excisional biopsy
A
o Marginal
o Wide local
o Radical (TAKE OUT ENTIRE COMPARTMENT***)
22
Q
Lesions that should be biopsied
A
- Fast growing
- Inflamed or ulcerated
- Large masses
- Painful, pruritic and otherwise symptomatic
- Ulcerations present for greater than 4 weeks
- Non responsive to treatment
- Pigmented Lesions
- If there is no other reason for it to be ulcerated, ALWAYS BIOPSY IT
23
Q
Incision location
A
- Direct access to the tumor
- Do not cross compartments
- Consider the local anatomy
- Consider subsequent care
24
Q
Clinical considerations for biopsy
A
- When determining incision location, consider access to mass, how to protect local anatomy, and plan for future excision if necessary
- When dissecting tissue, determine normal or abnormal
- Remove tissue so that we may achieve accuracy of pathology
- Consider tissue planes and possible spread of tumor cells
25
Tissue removal
- Representative sample
- Adequate amount
- Avoid frankly necrotic tissue
- Advancing edge?
- If possible, excisional biopsy is best
26
Compare incisional vs excisional biopsy
***TEST QUESTION***
Excisional biopsy preferred
o Diagnosis & Cure
o One procedure
Incisional best if
o Complicated anatomy
o Clinical suspicion of malignancy
o Large lesion (can’t do an excisional)
27
Types of excision
***TEST QUESTION***
- Intra-capsular Excision
- Marginal Excision
- Wide Local Excision
- Radical Resection
28
Intra-capsular Excision
o Excision within tumor capsule or margins
o De-bulking
o You’re not even taking the whole tumor, just “de-bulking it”
29
Marginal Excision
o Excision of entire tumor and capsule with minimal normal tissue
30
Wide Local Excision
o Excision of tumor and cuff of normal tissue
31
Radical Resection
o Removal of entire anatomic compartment
32
Incision location
- Direct access to the tumor
- Do not cross compartments
- Consider the local anatomy
- Consider subsequent care
33
Neurofibromatosis
- Neurofibromatosis – just wanted to do an intracapsular incision (de-bulk it) in order to prevent the nerve compression and relieve pain
34
Mucocutaneous cyst
- Related to ganglion cyst (mucoid cyst)
- This is a mucocutaneous cyst, which is another type of mucoid cyst
- Would have a thick gel fluid in it, just like in a ganglion cyst
35
Example of plantar tumor
- There is tumor everywhere
- Need incision that allows you to get to everything
- Widely invasive into the tissues – This is an intracapsular incision
- Wide local incision – had to take a lot of tissue to get as much of it as you can so it doesn’t recur
36
Example of tumor on hallux
- Hard to get to both sides of the hallux
- Need to design an incision that allows you to get to all sides of the hallux
- This was putting pressure on the nerves underneath
- INVADES tissue – no capsule, no separation of the vital structures
- Had to take out a lot
- Need to start from where you can see normal tissue
37
Example of BAD approach
- VERY BAD APPROACH – Need a wide marginal incision (this is very small)
- You can’t see any anatomy
- They will have multiple recurrences and an ugly scar already
- Need to open it up to the extent of the lesion
38
Dermafibroma
- Skin is hard to close on the toes because there is not an excess of tissue – this approach saves 60% of tissue
39
Pathology analysis of specimen
- Formalin fixed
- Frozen section
- Culture media
- Aerobic, anerobic, fungal, acid fast
40
Fomalin fixed
o When you take it out, you need to send it to pathology – most tumors will go in formalin
o If you’re trying to get a culture, DO NOT put it in formalin (kills bacteria)
o If you are trying to test for gout, DO NOT put it in formalin (dissolves it)
41
Frozen section
o Identify need for immediate further treatment
| o They may be able to tell you if it is malignant or not
42
Goals of biopsy
- Determine histologic type and grade of tumor
- Determine the anatomic extent of the tumor
- Determine prognosis and establish further treatment
43
Properties of benign tumors
****TEST QUESTION***
```
o Well differentiated
o Normochromatic
o Rare mitoses
o Cells retain normal function
o Encapsulated
o Push local structures aside
```
44
Properties of malignant tumors
****TEST QUESTION****
```
o Anaplastic
o Pleomorphic
o Hyperchromatic
o Mitoses common
o Normal function lost
o Invade local structures
```
45
Staging of malignant tumors
- Grade (G)
- Anatomic site and extent (T)
- Metastasis (M)
- Used to predict prognosis, choose treatment, predict response to treatment and recurrence
Notes:
o Not going to belabor a lot of this, but these factors are used to predict prognosis
o We will always work with an oncologist or a surgeon that is experienced with melanoma and they usually do the staging, we will just do the local treatment of it
o You do need to understand what goes into the prognosis
46
Lesions NOT to miss
- Pigmented Lesions
- High index of suspicion for malignancy
o Large and/or fast growing
o Associated with ulceration
o Painful
- Biopsy, Biopsy, Biopsy
- If there is NO OTHER REASON for the patient to have an ulcer, you NEED TO BIOPSY it
47
REVIEW
- Biopsy is the only definitive way to diagnose a STM
- Excisional biopsy is preferred if possible
- Carefully consider approach to excision to avoid unnecessary damage or spread
- Must have a low threshold for biopsy of suspicious lesions
