Chapter 31- Hand Tumors

Question 1

What is the role of CT in assessing upper extremity tumors?

Answer 1

CT is used to evaluate the extent of the bone destruction as well as calcified lesions.

Question 2

What is the role of MRI in assessing upper extremity tumors?

Answer 2

Evaluation of lesions involving bone and soft tissue

Question 3

How is clonality used to differentiate between neoplasms and benign tissue growths (Dupuytren’s)?

Answer 3

Benign and inflammatory conditions are typical polyclonal, whereas neoplasms are monoclonal.

Question 4

In which direction should the incision be oriented when obtaining a biopsy of an upper extremity mass?

Answer 4

Longitudinal, rather than transverse or zigzag, to incorporate the incision in the final excision/amputation

Question 5

When performing a biopsy, should one dissect around the muscle plane or split the muscle sharply?

Answer 5

Split the muscle sharply to avoid seeding other compartments

Question 6

Should drains be placed after performing an open biopsy?

Answer 6

No. Drains can seed tumor cells along tracts. Use diligent hemostasis.

Question 7

Should a tourniquet be used when operating on a neoplasm of the upper extremity?

Answer 7

Yes, but exsanguinate by gravity (elevation of the arm), do not use an Esmarch bandage.

Question 8

What is the usual etiology of an epidermal inclusion cyst?

Answer 8

Epidermal cells become embedded in the dermis, which is usually the result of trauma.

Question 9

Where do epidermal inclusion cysts usually occur and what is the treatment?

Answer 9

In glabrous, non-hair-bearing skin of the palms and fingertips (usually perinychium). Treatment is complete excision including punctum.

Question 10

What is a glomus tumor?

Answer 10

A benign, hamartomatous neoplasm formed from the thermoregulatory neuromyoarterial apparatus in the stratum reticulare.

Question 11

What are the clinical findings seen with a subungal glomus tumor? What is the treatment?

Answer 11

Severe pain, cold sensitivity, tenderness, nail deformity, discoloration. Treatment is removal of the nail plate and complete excision of the tumor.

Question 12

What is the most likely diagnosis in a patient with a subcutaneous elevation just proximal to the eponychial fold and associated nail grooving? Treatment?

Answer 12

Mucous cyst. Mucous cysts are fluid-filled ganglia of the distal interphalangeal joint associated with bony spurs and nail grooving. Treatment is cyst excision and removal of bone spurs.

Question 13

What is a pyogenic granuloma? What demographic does it affect most commonly?

Answer 13

Pyogenic granuloma is a rapidly growing vascular, friable nodule. It is frequently seen on the fingertips in young adults, and notably most common after pregnancy.

Question 14

What is a keratoacanthoma?

Answer 14

A lesion found most commonly on the dorsum of the hand (elderly patients), round, elevated, with a central crater. Can spontaneously regress or progress to SCC.

Question 15

What is the natural history of a keratoacanthoma?

Answer 15

1: Proliferation - rapid growth of a pre-existing lesion
2: Maturation
3: Involution - gradually gets smaller as central crater expels keratin plug

Question 16

What is the recommended treatment for keratoacanthoma?

Answer 16

Surgical excision or intralesional 5FU or methotrexate

Question 17

What are the first and second most common tumors or masses of the hand?

Answer 17

1: Ganglions
2: Giant cell tumors

Question 18

What is the predominant cell type in giant cell tumors (aka localized nodular synovitis)?

Answer 18

Histiocytes

Question 19

What is the usual site of origin of giant cell tumors?

Answer 19

Flexor tendon sheath

Question 20

What is the treatment of giant cell tumors?

Answer 20

Complete excision along with the stalk (if present)

Question 21

What is the difference between a neurofibroma and a neurilemmoma?

Answer 21

Neurofibroma; tumor arising within the nerve fascicles

Neurilemmoma (schwannoma); tumor of schwann cells on the nerve surface

Question 22

What is the treatment of a neurofibroma and a neurilemmoma?

Answer 22

neurofibroma; requires transection of the proximal and distal fasicles
neurilemmoma; can be shelled out

Question 23

What are the most common benign NERVE tumors of the upper extremity?

Answer 23

neurilemmoma

Question 24

A patient presents with multiple neurofibromas of the upper extremity and cutaneous cafe-au-lait spots, what is the diagnosis?

Answer 24

NF1, Von Rechlinghausen disease

Question 25

A patient presents with bilateral acoustic schwannomas, what is the likely diagnosis?

Answer 25

NF2 (these patients rarely have neurofibromas)

Question 26

What diagnostic studies can be used to differentiate between neurofibroma and a neurilemmoma?

Answer 26

MRI and nerve conduction studies

Question 27

What is the treatment of fibromatosis and juvenile aponeurotic fibromas?

Answer 27

Treatment involves wide excision with skin grafting or free tissue transfer. High recurrence.

Question 28

What is infantile digital fibromatosis?

Answer 28

Benign condition presenting in children 5mo-6yrs in which a broad-based, firm, non-tender nodule(s) develops on the dorsal or lateral aspects of the fingers.

Question 29

What are the histologic findings of infantile digital fibromatosis?

Answer 29

Interlacing fibroblasts and intracytoplasmic eosinophilic inclusion bodies. The inclusion bodies distinguish from other fibromatoses.

Question 30

What is the treatment for infantile digital fibromatosis?

Answer 30

Wide excision of the lesion(s) with full-thickness skin grafting if defect warrants.

Question 31

What is the chief problem seen with desmoid tumors?

Answer 31

High rate of recurrence (esp in females)

Question 32

What is the treatment for an upper extremity AVM?

Answer 32

Ligation of feeding vessels, complete excision of the malformation. Preoperative embolization may be performed prior to excision.

Question 33

What is the most common benign bone tumor?

Answer 33

Enchondroma

Question 34

What are the common locations for echondroma?

Answer 34

Proximal phalanx, metacarpal, middle phalanx

Question 35

What is Ollier's disease?

Answer 35

Non-hereditary disease of multiple enchondromas that usually present unilaterally

Question 36

What is Maffucci syndrome?

Answer 36

A condition characterized by multiple endochondromas and hemangiomas

Question 37

What is the lifetime chance of a solitary enchondroma undergoing malignant transformation?

Answer 37

<5%

Question 38

What to enchondromas degenerate into?

Answer 38

Chondrosarcomas

Question 39

How do enchondromas typically present?

Answer 39

Often discovered as the cause of a pathologic fracture presenting with pain

Question 40

What is the treatment for enchondromas?

Answer 40

Curettage and bone grafting. Allow fracture to heal prior to definitive resection if present.

Question 41

What is a periosteal chondroma?

Answer 41

Benign cartilaginous tumor that is similar to an enchondroma and most commonly found at the metaphyseal-diaphaseal junction of the phalanx.

Question 42

What is the peak age range of unicameral bone cysts?

Answer 42

5-10 years, seen almost exclusively in children

Question 43

What is the typical presentation of unicameral bone cysts?

Answer 43

Incidental finding on radiography or pathologic fracture

Question 44

What is the nonsurgical treatment for unicameral bone cysts?

Answer 44

Intralesional corticosteroid injection

Question 45

What is the name of the blood-filled cysts that typically occurs in the metaphysis of a metacarpal and then grows towards the physis?

Answer 45

Aneurysmal bone cyst

Question 46

What is the peak age range and what are the symptoms for aneurysmal bone cyst?

Answer 46

Second decade of life; swelling and pain, often following an injury

Question 47

What is the treatment for aneurysmal bone cyst?

Answer 47

Curettage and bone grafting is recommended as they are erosive, although benign, they must be removed.

Question 48

What is the usual structure of an osteochondroma?

Answer 48

Bone stalk and cartilaginous cap growing from the metaphysis in skeletally immature patients

Question 49

Is excision necessary for osteochondromas?

Answer 49

Excision is not necessary unless they are symptomatic, as they rarely undergo malignant transformation

Question 50

What are the symptoms of an osteoid osteoma?

Answer 50

Pain at night that is generally resolved be NSAIDs

Question 51

How do osteoid osteomas present on imaging?

Answer 51

Sclerotic nidus with lucent halo, LESS than 1 cm in diameter

Question 52

What is the histology of osteoid osteomas?

Answer 52

Hypervascular nidus of osteoblasts with surrounding cortical reactive bone formation

Question 53

What is the treatment for osteoid osteomas?

Answer 53

Curettage and bone grafting

Question 54

What is an osteoblastoma, how do they present on imaging?

Answer 54

Hypervascular nidus of osteoblasts with surrounding cortical reactive bone formation; Sclerotic nidus with lucent halo, GREATER than 1 cm in diameter

Question 55

What is the clinical presentation of a giant cell tumor of bone?

Answer 55

Gradual swelling, pain, sometimes with pathologic fracture, most often in distal radius

Question 56

Do giant cell tumors have malignant potential?

Answer 56

yes, they are capable of metastasizing (Most commonly to lung)

Question 57

How do giant cell tumors of bone appear on radiographs?

Answer 57

Lytic lesion without new bone formation; the lesion encroaches on, but does not penetrate the joint surface

Question 58

What is the surgical treatment of giant cell tumors?

Answer 58

Wide excision and joint reconstruction if necessary

Question 59

What is the pathophysiology of fibrous dysplasia?

Answer 59

Bone marrow involved bone(s) filled with noncalcified collagen

Question 60

What is the xray appearance of fibrous dysplasia?

Answer 60

ground-glass opacity

Question 61

What is the treatment of fibrous dysplasia of the hands?

Answer 61

No treatment required, only if there is a pathologic fracture or "impending" fracture

Question 62

What is the staging system for malignant musculoskeletal tumors?

Answer 62

Stage 1A - Low (G1) - Intracompartmental (T1) - M0 Stage 1B - Low (G1) - Extracompartmental (T2) - M0 Stage IIA - High (G2) - Intracompartmental (T1) - M0 Stage IIB - High (G2) - Extracompartmental (T2) - M0 Stage III - Any - Any - M1 (regional or distant)

Question 63

What is the most common malignant tumor of the hand?

Answer 63

SCC

Question 64

What is the most common type of melanoma in African Americans and Asians?

Answer 64

Acral lentiginous, generally presenting on hands and feet

Question 65

When treating melanoma of the hand, how is the level of amputation determined?

Answer 65

Amputate proximal to the nearest joint

Question 66

What role does sentinel lymph node biopsy play in the treatment of subungal melanoma?

Answer 66

Helpful because the depth of the tumor is difficult to determine in the nail bed

Question 67

What is dermatofibrosis protuberans?

Answer 67

Soft tissue neoplasm arising in the dermis that presents as a purple-red plaque or nodule - can be treated with Mohs

Question 68

What is a strong risk factor associated with malignant peripheral nerve sheath tumor?

Answer 68

NF1

Question 69

What is synovial cell sarcoma?

Answer 69

High grade sarcoma that grows in proximity to (but not in) joints. Size of the lesion is proportional to the mortality.

Question 70

What is the treatment for synovial cell sarcoma?

Answer 70

Wide excision with lymph node sampling (and dissection if nodes are positive), consider adjuvant radiation therapy

Question 71

What other sarcoma is similar to synovial cell sarcoma and usually arises from the muscle?

Answer 71

Epitheloid sarcoma

Question 72

What pattern of spread does epitheloid sarcoma demonstrate?

Answer 72

Spreads proximally along fascial planes, tendons, and lymphatics

Question 73

Where is malignant fibrohistiocytoma usually found in the upper extremities?

Answer 73

Deep muscle mass of the adductor pollicis or within the flexor muscles

Question 74

What is the most common malignant primary bone tumor of the hand seen in children and teens?

Answer 74

Osteogenic sarcoma

Question 75

How does osteogenic sarcoma look on plain radiograph?

Answer 75

Bone growth outside the normal skeletal boundaries with laze "cloud-like" bone formation into soft tissues

Question 76

What is the adjuvant treatment regimen for osteogenic sarcoma

Answer 76

Chemotherapy improves limb salvage and survival, no role for external beam radiation

Question 77

What is the most common malignant primary bone tumor of the hand in adults?

Answer 77

Chondrosarcoma

Question 78

Is chondrosarcoma sensitive to chemotherapy or radiation?

Answer 78

No

Question 79

What is the benign predecessor that can rarely degenerate into a chondrosarcoma?

Answer 79

Enchondroma

Question 80

What is a rare bone tumor of the metacarpals and phalanges that consists of abnormal endothelial cells?

Answer 80

Angiosarcoma

Question 81

What is the typical presentation of a Ewing sarcoma of the hand?

Answer 81

Pain, swelling, soft-tissue mass; generalized symptoms such as fever, elevated WBCs or ESR

Question 82

Whats it the radiographic presentation of a Ewing sarcoma?

Answer 82

Lytic lesion of the bone with a soft tissue component

Question 83

What is the periosteal reaction called in the Ewing sarcoma?

Answer 83

"Onion skin" appearance or "sunburst" pattern

Question 84

What are the common sites of Ewing sarcoma of the hand?

Answer 84

Metacarpals, phalanges

Question 85

What is the treatment of Ewing sarcoma?

Answer 85

Surgical excision, chemotherapy, and/or external beam radiation

Question 86

What percentage of patients with primary cancers in other parts of the body will develop a metastasis to the hands or feet?

Answer 86

0.3%

Question 87

What is the most common primary carcinoma that metastasizes to hand?

Answer 87

Bronchogenic carcinoma, followed by breast and kidney

Question 88

When primary carcinoma mestastasizes to the hand what location does it go to?

Answer 88

Distal phalanx