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Flashcards in Tumours of the hand Deck (37):
1

What is this?

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Ganglion cyst

A Mucin filled synovial cyst.

2

What is a ganglion's aetiology

Trauma

Mucoid degeneration

Synovial herniation

 

3

What is the epidemiology of ganglion cysts?

Most common hand mass 60-70%

Dorsal (70%) orginate over SL ligament

Volar carpal (20%)- Radiocarpal or STT joint

Volar retinacular- dorsal DIPJ- MUCOID cyst assoc with Heberden's nodes

 

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4

What are the signs and symptoms of a ganglion?

Symptoms= Painless lump

Signs= Firm 

Well circumscribed

Often fixed to deep tissue but not to overlying skin

Translucent with illumination

Allen's test to ensure radial/ ulna artery

 

5

What investigations are useful in identifying a ganglion?

XRays normal 

Mri - not normally indicated but show a well cicrumscibed homogenous fluid signal intensity

Increased signal intensity on T2-weighted MRI images

6

What is the treatment for a ganglion?

Observation- first line in adults

79% in children resolve in a year.

Aspiration- 2nd line in adult, avoid on volar aspect of wrist due to radial artery

50% chance of reoccurrance cf surgical resection but less risks

Biopsy would show mucin-filled synovial cell lined sac

Surgery if severe symptoms or neurovascular manifestations

adequate exposure to ensure entire resection of cyst including stalk and adjacent capsule.

Volar ganglions higher rate of reoccurrance cf dorsal post surgery (15-20%)

 

 

7

What is this?

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Epidermal inclusion cyst

this is Benign, slow growing soft tissue tumour

DD: Tophus gout

Foreign body granuloma

Sebaceous cyst

GCT

Ganglioncyst

Enchondroma

Glomus tumour

8

What is the incidence and epidemiology of epidermal inclusion cyst?

Occurs months to years post trauma

Third most common hand tumour

Men > females

3rd to 4th decade

Distal phalanx most common location

 

9

What is the Pathophysiology of epidermal inclusion cysts?

Results from penetrating trauma that drives Keratinised epithelial into subcutaneous tissue

Cells grow slowly to -> epithelial lined cyst filled with keratin

10

What is the prognosis of epidermal inclusion cyst?

Marginal Excision is curative, low reocurrance rates

11

What are the symptoms and signs of epithelial inclusion cyst?

Symptoms:

Painless swelling frequently occuring in the fingertip

Well circumscribed slightly mobile lesion with white/yellow/flesh coloured in appearance

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12

What investigations can be useful in epithelial inclusion cyst?

Xrays- ap, lateral and oblique

soft tissue swelling may be evident

A lytic erosion in distal phalanx

Biopsy- to confirm not infection/ neoplasm

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13

What is the histology of the epidermal inclusion cyst?

Cysts containing keratin lined with epithelial cells

14

What is the Tx of epidermal inclusion cyst?

Non operative- not recommended

Operative- Marginal Excision

Careful to remove Entire capsule

Currettage and bone graft if bone erosion/ lesions

15

What are the complications of epidermal inclusion cysts?

Wound complications

Infection

Digital neuropraxia

Recurrance

16

What is the differential diagnosis on this mass?

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Giant cell tumour of tendon sheath ( Pigmented villonodular tumour of tendon sheath)

Ganglion cyst

Desmoid tumour

Fibroma/Fibrosarcoma

Pigmented villonodular synovitis- involves larger joints

17

What is the epidemiology of giant cell tumour of tendon sheath?

3rd-5th decade

2nd most common tumour of hand after ganglion

most common on PALMAR surface of RADIAL 3 digits near the DIPJ

No reports of mets in literature

 

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18

What are the signs and symptoms a patient with a giant cell tumour of tendon sheath complains of?

Enlarging swelling

Pain worse on activity

O/E:

Firm nodular mass that does not transilluminate

 

19

What investigations would be helpful for diagnosisng GCT of tendon sheath?

Xray- pressure type bony erosions ( see picture)

USS- homogenously hypoechoic   

MRI-decreased signal on T1 and T2 images

 

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20

What do you see on histology with GCT of the tendon sheath?

Proliferating histiocytes, moderately cellular (sheets of rounded or polygonal cells)


Multinucleated giant cells are common
 

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21

What is the Tx of GCT of tendon sheath?

Operative: marginal excision

Recurrence rate of 5-55% 

More common reocurrance if tumour extends volar plate and into joint

Local reocurrance tx with repeated excision

22

What is this ?

Q image thumb

Glomus tumour

A Rare benign tumor of the glomus body, often occurring in the subungual region

23

What is the epidemiology of Glomus tumour?

Patients 20-30 

Location:75% occur in hand ( other palm, wrist, forearm,foot)

50% subungual

50% have erosions of the distal phalanx

24

What is a glomus body?


The glomus body is a perivascular temperature regulating structure frequently located at the tip of a digit or beneath the nail
 

25

What are the signs and symptoms of a glomus tumour?

Symptoms=

Paroxysmal Pain

Cold intolerance

Exquisite tenderness to touch

 

Signs=

Small Bluish colour nodule- subungual region

Nail ridging or discolouration

26

What investigations can be used to diagnose a glomus tumour?

Xray- pressure erosions-> deformity of bone cortex

MRI - helpful= T1 low, T2 high signal 

 

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27

What is seen on histology of glomus tumour?

Well-defined lesion lacking cellular atypia or mitotic activity

small round cells with dark nuclei


Associated small vessels in a hyaline/myxoid stroma



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28

How is Glomus tumour tx?

Operative- Marginal Excision if symptoms affecting quality of life

Surgery is curative

Low reocurrance rates ( benign nature of lesion)

29

What is this?

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Melanoma of the hand

specifically- acral lentiginous melanoma

DDX could also be


trauma 




subungual hematoma 






onychomycosis 







for a nevus 




seborrheic keratosis 






basal cell carcinoma
 

30

What is the epidemiology of melanoma of the hand?

Effects Men 1.2 :1 Females

Age 50-70 yrs

location thumb>great toe> index finger 

Sun exposed areas

31

What are the risk factors of melanoma of the hand?

Sun exposure- uv supress skin immunity , induce myelocyte cell divison-> free radicals-> damage melanocyte DNA

Increase use in suncreen users- as out in sun

Intermittent burning episodes

Fhx

Blue eyes, fair hair , freckle complexion


xeroderma pigmentosa 



familial atypical mole or melanoma syndrome (FAMM) 

multiple benign or dysplastic naevi * = precursor

Immunosupression

 

32

What is the pathology of melanoma?

Melanocyte DNA damaged by UV and so

benign naevus-> dysplastic naevus->radical growth phase-> vertical growth phase-> malignant melanoma

33

What is the prognosis of melanoma?

Name the poor prognostic factors?

DEPTH of naevus most important prognostic factor

< 0.7mm survical is 94%

> 4.0mm survival is 46%

Poor prognostic factors

Deep lesion

Male

Lesion on scalp or neck

Positive lymph nodes and metastasis

Ulceration


Subungual melanoma has poor prognosis overall with 5yr survival 40-60%
 

 

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34

Can you name any classifciations of melanoma?

Breslow thickness


thickness =< 0.75mm- survival 96% 




thickness 0.76 - 1.5mm 






thickness 1.51 - 4mm 








thickness >4mm survival 46% 
 

35

What are the signs and symptoms of melanoma?

Symptoms:

Recent change in size or shape

itchy or bleeding

Signs:


Brown-black pigmented lesion, may ulcerate 

Hutchinson sign= Extension of brown-black pigment of the nail bed or nail plate to the cuticle and nail folds( see pic)

Note (ABCDE)- Asymmetry 

           Border irregularity

            Colour variation

Diameter (<6mm benign)

Elevation

Enlargement

 

 



 

 

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36

What investigations would you preform in a pt with melanoma?

CXR- first site of mets

Uss-diagnose lymph node enlargement

CT - detect mets

Bloods- LFTs - liver mets

histology = melanocytes with marked atypia, invasion into the dermis, hyperchromatic nuclei with prominant nucleoli



 

37

What tx is available for melanoma of the hand?

If Lesion <1MM= local excision with 1mm resection margins

If lesion is >1mm= local resection with sentenial node biopsy, if positive = radial lymph node dissection

Mets= local excision,lymph noce dissection and chemo

Subungual melanoma= Distal amputation with sufficient resection margins- similar reocurrance cf prox amputation

 

 

Prevention

With sunscreen and avoiding sun exposure