What is this?
A Mucin filled synovial cyst.
What is a ganglion's aetiology
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
What are the signs and symptoms of a ganglion?
Symptoms= Painless lump
Often fixed to deep tissue but not to overlying skin
Translucent with illumination
Allen's test to ensure radial/ ulna artery
What investigations are useful in identifying a ganglion?
Mri - not normally indicated but show a well cicrumscibed homogenous fluid signal intensity
Increased signal intensity on T2-weighted MRI images
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%)
What is this?
Epidermal inclusion cyst
this is Benign, slow growing soft tissue tumour
DD: Tophus gout
Foreign body granuloma
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
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
What is the prognosis of epidermal inclusion cyst?
Marginal Excision is curative, low reocurrance rates
What are the symptoms and signs of epithelial inclusion cyst?
Painless swelling frequently occuring in the fingertip
Well circumscribed slightly mobile lesion with white/yellow/flesh coloured in appearance
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
What is the histology of the epidermal inclusion cyst?
Cysts containing keratin lined with epithelial cells
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
What are the complications of epidermal inclusion cysts?
What is the differential diagnosis on this mass?
Giant cell tumour of tendon sheath ( Pigmented villonodular tumour of tendon sheath)
Pigmented villonodular synovitis- involves larger joints
What is the epidemiology of giant cell tumour of tendon sheath?
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
What are the signs and symptoms a patient with a giant cell tumour of tendon sheath complains of?
Pain worse on activity
Firm nodular mass that does not transilluminate
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
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
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
What is this ?
A Rare benign tumor of the glomus body, often occurring in the subungual region
What is the epidemiology of Glomus tumour?
Location:75% occur in hand ( other palm, wrist, forearm,foot)
50% have erosions of the distal phalanx
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
What are the signs and symptoms of a glomus tumour?
Exquisite tenderness to touch
Small Bluish colour nodule- subungual region
Nail ridging or discolouration
What investigations can be used to diagnose a glomus tumour?
Xray- pressure erosions-> deformity of bone cortex
MRI - helpful= T1 low, T2 high signal
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
How is Glomus tumour tx?
Operative- Marginal Excision if symptoms affecting quality of life
Surgery is curative
Low reocurrance rates ( benign nature of lesion)
What is this?
Melanoma of the hand
specifically- acral lentiginous melanoma
DDX could also be
for a nevus
basal cell carcinoma
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
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
Blue eyes, fair hair , freckle complexion
familial atypical mole or melanoma syndrome (FAMM)
multiple benign or dysplastic naevi * = precursor
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
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
Lesion on scalp or neck
Positive lymph nodes and metastasis
Subungual melanoma has poor prognosis overall with 5yr survival 40-60%
Can you name any classifciations of melanoma?
thickness =< 0.75mm- survival 96%
thickness 0.76 - 1.5mm
thickness 1.51 - 4mm
thickness >4mm survival 46%
What are the signs and symptoms of melanoma?
Recent change in size or shape
itchy or bleeding
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
Diameter (<6mm benign)
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
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
With sunscreen and avoiding sun exposure