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Flashcards in Hand Tumors Deck (55)
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1

List your differential of a painful hand tumor

 

LONG BEAN

 

  • Leiomyoma
  • OSTEOID OSTEOMA
  • NEUROFIBROMA
  • GLOMUS TUMOUR
  • Blue rubber bleb nevus
  • Eccrine spiradenoma
  • Angiolipoma
  • NEUROMA

2

List your differential of a hand tumor that varies in size

  • Vascular lesion
  • Ganglion
  • Mucous cyst

3

What soft tissue hand tumors causes cystic changes in adjacent bone?

  • glomus tumor
  • epidermal cyst
  • GCT*****

4

What hand tumors cause calcifications in soft tissues

  • Hemangioma
  • Lipoma
  • Scleroderma
  • Heterotopic ossification
  • Fibroma (juvenile aponeurotic)
  • calcinosis circumscripta

5

Where in the bone are GCT, enchondroma and osteochondroma located?

  • GCT: epiphysis
  • Octeochondroma: metaphysis (PP)
  • Enchondroma: diaphysis (PP, DP)

6

What is your DDX for hand mass in the skin/appendages or subcutaneous tissue/fat

Skin /Appendage

BENIGN

  • keratoses (Seborrheic, actinic)
  • dermatofibroma (? fibrous tissue)
  • benign sweat gland tumor (pilomatrixoma, tricholemmoma, trichoepithelioma, sebaceous adenoma)

MALINGNANT

  • BCC, SCC, KA, melanoma
  • DFSP (?fibrous tissue / sarcomatous)
  • Malignant sweat gland tumors (sebaceous carcinoma, clear cell/pappillaryeccrine adenocarcinoma)

PSEUDOtumors

  • Xanthoma
  • Epidermal inclusion cyst, sebaceous cyst
  • Verruca vulgaris
  • Pyogenic granuloma (? vascular?)

 

Subcutaneous/FAT

BENIGN

  • Lipoma
  • Lipofibroma
  • Angiolipoma

Malingnant

  • Liposarcoma

PSEUDO tumor

  • Gouty tophi
  • FB granuloma

7

What is your DDX for hand mass in the Fascia or tendon?

Fascia

BENIGN

  • Dupuytren nodule
  • Fibroma
  • Nodular fasciitis
  • Juvenile aponeurotic fibroma

MALIGNANT

  • Fibrosarcoma
  • epithelioid carcinoma
  • Malignant fibrous histiocytoma

 

Tendon

BENIGN

  • GCT of tendon sheath
  • Xanthoma
  • Volar retinagular ganglion (ganglion of tendon sheath)
  • Stenosing tenosynovitis (pseudo-tumour)

MALIGNANT

  • Malignant GCT of tendon sheath

 

8

What is your DDX for hand mass in the muscle?

BENIGN

  • Leiomyoma
  • Rhabdomyoma

MALIGNANT

  • leiomyosarcoma
  • rhabdomyosarcoma

PSEUDO TUMOR

  • Anomalous muscle (EDB, PL)

9

What is your DDX for hand mass of neural origin

BENIGN

  • schwanomma
  • neurofibroma
  • neurofibrolipoma
  • neuroma

MALIGNANT

  • MPNST
  • Merkel cell carcinoma

10

What is your DDX for hand mass in the Joint or bone/cartilage

BENIGN

  • osteoid osteoma
  • osteochondroma
  • enchondroma
  • aneurysmal bone cyst
  • IOhemangioma
  • GCT
  • GCT of joint synovium
  • Carpo-metacarpal  boss
  • ganglion

MALIGNANT

  • osteosarcoma
  • chondrosarcoma
  • Ewings sarcoma
  • Seondary metastases
  • GCT of bone
  • synovial sarcoma

 

11

What is your DDX for hand mass of vascular origin?

BENIGN

  • hemangioma
  • glomus tumor
  • pygenic granuloma
  • vascular malformation
  • aneurysm
  • aberrant radial artery

MALIGNANT

  • hemangiosarcoma
  • kaposi sarcoma

12

Ganglion Cyst

Epidemiology

Classification

Pathology

Pertinent features on History and Physical

Treatment options

Epidemiology

  • F>M, 20-40s, most common hand tumor

Classification

  • By location 
    • Dorsal wrist 70% => S-L ligament
    • Volar wrist 20% => radiocarpal S-Trapezial jt
    • Volar retinaculum 10% =>A1/A2 pulley
    • Tendon => extensor zone 6
    • Digital mucous cyst =>DIP jt
    • Intraosseous =>carpal bone

Pathology

  • capsule= condensed collagen
  • mucoid degeneration (mucin + glucosamine+HA)

Pertinent features on History and Physical

  • Hx: size variation, increase w activity
  • PE: transilluminates, location

Treatment options

  • Non-op:
    • Rest, splint, NSAIDS
    • Aspiration +/- steroid
      • minimal morbidity, only 30% cure
  • Operative - Excision w portion of jt capsule + bone irritant
    • scar, neuroma, infection, stiffness, pain
      • Dorsal wrist 
        • b/w 3/4
      • Volar wrist
        • b/w FCR APL
        • careful of radial art, Hx oof asp and pseudoaneurysm
      • Volar retinaculum
        • excise A1/2 pulley segment w cyst
      • Mucous cyst
        • excise osteophyte, cyst

13

Epidermal Inclusion Cyst

Epidemiology

Pathology

Pertinent features on History and Physical, Xray

Treatment options

Epidemiology

  • M>F, teens-middle age, 3rd most common tumor, located on distal pulps/dorsum of digits

Pathology

  • dermal cyst lined with keratinized squamous epithelium, filled with keratin and giant cells

Pertinent features on History and Physical, Xray

  • Hx: trauma, slow growth painless
  • PE: firm, punctum, no transillumination, possible nail bed/bone deformity
  • Xray - secondary bone erosion

Treatment options

  • complete excision

14

Lipoma

Epidemiology

Classification

Pathology

Pertinent features on History and Physical

Treatment options

Epidemiology

  • F>M, 30-60s, 3% of hand tumors

Classification

  • lipoma, angiolipoma, angiolipofibroma (latter 2 are painful)

Pathology

  • hypertrophy and hyerplasia of adipose tissue with pseudocapsule

Pertinent features on History and Physical and Imaging

  • Hx: slow growing, may cause nerve compression symptoms (CTS)
  • PE: likely in thenar, PP, soft, well demarcated
  • MRI- T1 =>bright well circumscribed

Treatment options

  • observe vs complete excision for diagnosis/symptoms

15

GCT of tendon sheath

Synonyms

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Synonyms

  • Pigmented Villonodulat tenosynovitis
  • fibroxanthoma
  • tendon xanthoma

Epidemiology

  • M>F, 40-60s, 2nd most common hand tumor
  • assocaited with joint/tendon

Pathology

  • reactive lesion
  • multilobular, deep brown due to hemosiderin pigmentation
  • spindle cells, foam cells

Pertinent features on History and Physical and imaging

  • slow growing, non tender
  • PE: PALMAR surface of hand, digits, radial three digits most common, also at DIP, firm
  • Xray - may show bone erosion adjacent

Treatment options

  • Excision
  • Guarded prognosis 5-50% recurrence

16

Glomus Tumor

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Epidemiology

  • F>M, 30-60, 4% of hand tumors

Pathology

  • specialized AV shunt
  • encapsulated Polyhedal and pericyte cells with stroma, small vessels and nerve endings

Pertinent features on History and Physical and imaging

  • Hx: TRIAD - paroxysmal pain, pin point tenderness, cold hypersensitivity
  • PE: on finger tip/nail bed,  blue discoloraiton of nail bed +/- ridging, love sign (pinpoint pain), HIldreth sign (pain relieved w tourniquet)
  • Xray - radioluscent, erosion of DP
  • MRI - T1 - well circumscribed, T2 - BRIGHT

Treatment options

  • Excision
    • remove nail plante, careful w steriel matrix, look for multiple
    • recurrence 20%

 

17

Nodular Fasciitis

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Epidemiology

  • 30-40, locaed in forearm, may have rapid growth, rare but important to distinguish from sarcoma

Pathology

  • immature fibroblats, mitotic activity

Pertinent features on History and Physical and imaging

  • Hx: rapidly growing, causing pain /compression
  • PE: firm fixed mass
  • Xray - may calcify

Treatment options

  • Need biopsy for diagnosis
  • marginal excision, good prognosis

18

Enchondroma

Epidemiology

Associated diseases w multiple enchondromatosis

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Epidemiology

  • 10-40s, M=F, most common 1' bone tumor of the hand
  • most likely in PP/MC rarely carpus, diaphysis of bone

Associated diseases w multiple enchondromatosis

  • Ollier's: multi enchondroma, 30% risk of osteosarc/chondrosarc
  • Maffucci: ass. w VM, 30%risk of chondrosarc

Pathology

  • benign cartilage

Pertinent features on History and Physical and imaging

  • Hx: patholgoic fracture
  • PE: enlarged bone
  • Xray - lytic lesion w cortical expansion, thinned cortex, stippling of matrix
  • CT - chondroid matrix mineralization

Treatment options

  • Observe if asx, q1y f/u
  • open biopsy
  • curettage and BG w small cortical window
  • if pathologic fracture - allow to heal and wait at least 6mths prior to curettage and BG
  • low recurrence

19

Osteochondroma

Definition

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Definition

  • benign bone & cartilaginous tumor characterized by aberrant seondary bone formation via endochondral ossification (abnormal chrondoblast activity @ metaphysis/physis)
  • in metaphysis, PP, MC
  • <5% malignant degeneration

Epidemiology

  • 20s-30s, , rare in hands unless multiple exostoses

Pathology

  • benign bone cortex with hyaline cartilaginous cap

Pertinent features on History and Physical and imaging

  • Hx: multiple exostoses, may cause angulation
  • PE: non tender bony prominence
  • Imaging: **medullary continuity with overrgowth of bone cortex

Treatment options

  • excision at bone maturity - sooner if deforming

20

GCT of bone

Definition

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

Definition

  • benign based on patho but locally aggresive, may metastasize
  • distal radius 3rd most comon location, RARE in hand

Pertinent features on History and Physical and imaging

  •  pain/swelling
  • Xray- lytic lesion of epiphysis/cortex
  • MRI - to delineate tumor and ST extension

Treatment options

  • Staging
  • risk of mets 10%
  • treat as sarcoma

21

What are 1' tumors w  bone metastases to the hand

  • A-renal
  • Breast
  • Colon
  • Lung 
  • Multiple myeloma

22

What is the most common location for bone mets to the hand

Distal phalanx

least common carpal bone

 

Presents as query infection

23

What is your managment of patient presenting w bony met to hand of unknown primary

  • Hx, PE
  • Bld work - CBC ESR, ALP
  • Imaging 
    • CT for bony extent
    • MRI for ST invasion
    • Bone scan - to detect skip lesions
    • CXR - look for other mets
  • Tissue biopsy 
    • FNA, bone needle bx, open bx

24

Which sarcoas are known to metastasize via lymphatics

  • Jay Wonder says "SCARE"
  • Synovial sarcoma (second most common hand/wrist)
  • Clear cell sarcoma
  • Angiosarcoma
  • Rhabdomyosarc
  • Epithelioid sarcoma (most common in hand/wrist)
  • (seminar also says MFH/UPS, third most common, hand/wrist)

 

 

25

What is the most common st and bone sarcoma to occur in the hand

  • ST: epithelioid sarcoma
  • Bone :Chondrosarcoma
    • may arise from osteochondroma, enchondroma or de novo
    • Xray -stippled calcification, lysis, poorly defined, cortical expansion, perforation
    • Tx: wide exc/ray amp

 

26

List the top 5 locations for a ganglion cyst

  • Dorsal wrist (~ SL interval)
  • Volar wrist (~ radioscaphoid interval)
  • Volar retinacular / ganglion of flexor sheath
  • Mucous cyst / dorsal DIPJ
  • 2nd or 3rd CMC boss

27

what are the contents of a ganglion cyst

  • "mucin filled"
  • glucosamine, globulin, albumin, hyaluronic acid
  • Wall is compressed collagen fibres

28

what does pathologic specimen say after excision of epidermal inclusion cyst from finger pulp

  • cyst cavity lined w compressed stratified squamous epithelium (no stratum corneum)
  • contents are loosely packed keratin, inflammatory infiltrate including foreign body giant cells & lipid-rich debris

29

what do you tell your patient about risk of recurrence after GCT tendon sheath, volar radial D2? What is an alternative therapy to consider in recurrent/incompletely excised tumours?

  • wide reported recurrence from 5 - 50%
  • could consider post-operative radiotherapy (described by anastakis)

30

what does pathology show after excision of GCT flexor sheath?

  • gross: yellow/brown hemosiderin ladel multi-nodular mass
  • micro: see spindle cells, foam cells