Chapter 31- Hand Tumors Flashcards
What is the role of CT in assessing upper extremity tumors?
CT is used to evaluate the extent of the bone destruction as well as calcified lesions.
What is the role of MRI in assessing upper extremity tumors?
Evaluation of lesions involving bone and soft tissue
How is clonality used to differentiate between neoplasms and benign tissue growths (Dupuytren’s)?
Benign and inflammatory conditions are typical polyclonal, whereas neoplasms are monoclonal.
In which direction should the incision be oriented when obtaining a biopsy of an upper extremity mass?
Longitudinal, rather than transverse or zigzag, to incorporate the incision in the final excision/amputation
When performing a biopsy, should one dissect around the muscle plane or split the muscle sharply?
Split the muscle sharply to avoid seeding other compartments
Should drains be placed after performing an open biopsy?
No. Drains can seed tumor cells along tracts. Use diligent hemostasis.
Should a tourniquet be used when operating on a neoplasm of the upper extremity?
Yes, but exsanguinate by gravity (elevation of the arm), do not use an Esmarch bandage.
What is the usual etiology of an epidermal inclusion cyst?
Epidermal cells become embedded in the dermis, which is usually the result of trauma.
Where do epidermal inclusion cysts usually occur and what is the treatment?
In glabrous, non-hair-bearing skin of the palms and fingertips (usually perinychium). Treatment is complete excision including punctum.
What is a glomus tumor?
A benign, hamartomatous neoplasm formed from the thermoregulatory neuromyoarterial apparatus in the stratum reticulare.
What are the clinical findings seen with a subungal glomus tumor? What is the treatment?
Severe pain, cold sensitivity, tenderness, nail deformity, discoloration. Treatment is removal of the nail plate and complete excision of the tumor.
What is the most likely diagnosis in a patient with a subcutaneous elevation just proximal to the eponychial fold and associated nail grooving? Treatment?
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.
What is a pyogenic granuloma? What demographic does it affect most commonly?
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.
What is a keratoacanthoma?
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.
What is the natural history of a keratoacanthoma?
1: Proliferation - rapid growth of a pre-existing lesion
2: Maturation
3: Involution - gradually gets smaller as central crater expels keratin plug
What is the recommended treatment for keratoacanthoma?
Surgical excision or intralesional 5FU or methotrexate
What are the first and second most common tumors or masses of the hand?
1: Ganglions
2: Giant cell tumors
What is the predominant cell type in giant cell tumors (aka localized nodular synovitis)?
Histiocytes
What is the usual site of origin of giant cell tumors?
Flexor tendon sheath
What is the treatment of giant cell tumors?
Complete excision along with the stalk (if present)
What is the difference between a neurofibroma and a neurilemmoma?
Neurofibroma; tumor arising within the nerve fascicles
Neurilemmoma (schwannoma); tumor of schwann cells on the nerve surface
What is the treatment of a neurofibroma and a neurilemmoma?
neurofibroma; requires transection of the proximal and distal fasicles
neurilemmoma; can be shelled out
What are the most common benign NERVE tumors of the upper extremity?
neurilemmoma
A patient presents with multiple neurofibromas of the upper extremity and cutaneous cafe-au-lait spots, what is the diagnosis?
NF1, Von Rechlinghausen disease
A patient presents with bilateral acoustic schwannomas, what is the likely diagnosis?
NF2 (these patients rarely have neurofibromas)
What diagnostic studies can be used to differentiate between neurofibroma and a neurilemmoma?
MRI and nerve conduction studies
What is the treatment of fibromatosis and juvenile aponeurotic fibromas?
Treatment involves wide excision with skin grafting or free tissue transfer. High recurrence.
What is infantile digital fibromatosis?
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.
What are the histologic findings of infantile digital fibromatosis?
Interlacing fibroblasts and intracytoplasmic eosinophilic inclusion bodies. The inclusion bodies distinguish from other fibromatoses.
What is the treatment for infantile digital fibromatosis?
Wide excision of the lesion(s) with full-thickness skin grafting if defect warrants.
What is the chief problem seen with desmoid tumors?
High rate of recurrence (esp in females)
What is the treatment for an upper extremity AVM?
Ligation of feeding vessels, complete excision of the malformation. Preoperative embolization may be performed prior to excision.
What is the most common benign bone tumor?
Enchondroma
What are the common locations for echondroma?
Proximal phalanx, metacarpal, middle phalanx
What is Ollier’s disease?
Non-hereditary disease of multiple enchondromas that usually present unilaterally
What is Maffucci syndrome?
A condition characterized by multiple endochondromas and hemangiomas
What is the lifetime chance of a solitary enchondroma undergoing malignant transformation?
<5%
What to enchondromas degenerate into?
Chondrosarcomas
How do enchondromas typically present?
Often discovered as the cause of a pathologic fracture presenting with pain
What is the treatment for enchondromas?
Curettage and bone grafting. Allow fracture to heal prior to definitive resection if present.
What is a periosteal chondroma?
Benign cartilaginous tumor that is similar to an enchondroma and most commonly found at the metaphyseal-diaphaseal junction of the phalanx.
What is the peak age range of unicameral bone cysts?
5-10 years, seen almost exclusively in children
What is the typical presentation of unicameral bone cysts?
Incidental finding on radiography or pathologic fracture
What is the nonsurgical treatment for unicameral bone cysts?
Intralesional corticosteroid injection
What is the name of the blood-filled cysts that typically occurs in the metaphysis of a metacarpal and then grows towards the physis?
Aneurysmal bone cyst
What is the peak age range and what are the symptoms for aneurysmal bone cyst?
Second decade of life; swelling and pain, often following an injury
What is the treatment for aneurysmal bone cyst?
Curettage and bone grafting is recommended as they are erosive, although benign, they must be removed.
What is the usual structure of an osteochondroma?
Bone stalk and cartilaginous cap growing from the metaphysis in skeletally immature patients
Is excision necessary for osteochondromas?
Excision is not necessary unless they are symptomatic, as they rarely undergo malignant transformation
What are the symptoms of an osteoid osteoma?
Pain at night that is generally resolved be NSAIDs
How do osteoid osteomas present on imaging?
Sclerotic nidus with lucent halo, LESS than 1 cm in diameter
What is the histology of osteoid osteomas?
Hypervascular nidus of osteoblasts with surrounding cortical reactive bone formation
What is the treatment for osteoid osteomas?
Curettage and bone grafting
What is an osteoblastoma, how do they present on imaging?
Hypervascular nidus of osteoblasts with surrounding cortical reactive bone formation; Sclerotic nidus with lucent halo, GREATER than 1 cm in diameter
What is the clinical presentation of a giant cell tumor of bone?
Gradual swelling, pain, sometimes with pathologic fracture, most often in distal radius
Do giant cell tumors have malignant potential?
yes, they are capable of metastasizing (Most commonly to lung)
How do giant cell tumors of bone appear on radiographs?
Lytic lesion without new bone formation; the lesion encroaches on, but does not penetrate the joint surface
What is the surgical treatment of giant cell tumors?
Wide excision and joint reconstruction if necessary
What is the pathophysiology of fibrous dysplasia?
Bone marrow involved bone(s) filled with noncalcified collagen
What is the xray appearance of fibrous dysplasia?
ground-glass opacity
What is the treatment of fibrous dysplasia of the hands?
No treatment required, only if there is a pathologic fracture or “impending” fracture
What is the staging system for malignant musculoskeletal tumors?
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)
What is the most common malignant tumor of the hand?
SCC
What is the most common type of melanoma in African Americans and Asians?
Acral lentiginous, generally presenting on hands and feet
When treating melanoma of the hand, how is the level of amputation determined?
Amputate proximal to the nearest joint
What role does sentinel lymph node biopsy play in the treatment of subungal melanoma?
Helpful because the depth of the tumor is difficult to determine in the nail bed
What is dermatofibrosis protuberans?
Soft tissue neoplasm arising in the dermis that presents as a purple-red plaque or nodule - can be treated with Mohs
What is a strong risk factor associated with malignant peripheral nerve sheath tumor?
NF1
What is synovial cell sarcoma?
High grade sarcoma that grows in proximity to (but not in) joints. Size of the lesion is proportional to the mortality.
What is the treatment for synovial cell sarcoma?
Wide excision with lymph node sampling (and dissection if nodes are positive), consider adjuvant radiation therapy
What other sarcoma is similar to synovial cell sarcoma and usually arises from the muscle?
Epitheloid sarcoma
What pattern of spread does epitheloid sarcoma demonstrate?
Spreads proximally along fascial planes, tendons, and lymphatics
Where is malignant fibrohistiocytoma usually found in the upper extremities?
Deep muscle mass of the adductor pollicis or within the flexor muscles
What is the most common malignant primary bone tumor of the hand seen in children and teens?
Osteogenic sarcoma
How does osteogenic sarcoma look on plain radiograph?
Bone growth outside the normal skeletal boundaries with laze “cloud-like” bone formation into soft tissues
What is the adjuvant treatment regimen for osteogenic sarcoma
Chemotherapy improves limb salvage and survival, no role for external beam radiation
What is the most common malignant primary bone tumor of the hand in adults?
Chondrosarcoma
Is chondrosarcoma sensitive to chemotherapy or radiation?
No
What is the benign predecessor that can rarely degenerate into a chondrosarcoma?
Enchondroma
What is a rare bone tumor of the metacarpals and phalanges that consists of abnormal endothelial cells?
Angiosarcoma
What is the typical presentation of a Ewing sarcoma of the hand?
Pain, swelling, soft-tissue mass; generalized symptoms such as fever, elevated WBCs or ESR
Whats it the radiographic presentation of a Ewing sarcoma?
Lytic lesion of the bone with a soft tissue component
What is the periosteal reaction called in the Ewing sarcoma?
“Onion skin” appearance or “sunburst” pattern
What are the common sites of Ewing sarcoma of the hand?
Metacarpals, phalanges
What is the treatment of Ewing sarcoma?
Surgical excision, chemotherapy, and/or external beam radiation
What percentage of patients with primary cancers in other parts of the body will develop a metastasis to the hands or feet?
0.3%
What is the most common primary carcinoma that metastasizes to hand?
Bronchogenic carcinoma, followed by breast and kidney
When primary carcinoma mestastasizes to the hand what location does it go to?
Distal phalanx
