Hand Tumors Flashcards by M A

Epidermal inclusion cysts in the fingertip can mimic infective or malignant conditions

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Most ganglions can be managed conservatively.

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majority oftumors that arise in the hand and wrist are benign,

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Tumors arising from the hand and wrist usually present as a painless mass

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Transillumination is an
invaluableclinical sign when assessing forganglions.

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Tumors that arise from tendons or tendon sheaths are usually mobile
sideways

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For lesions
involving the nail complex, abnormal nail pigmentation and deformity
(e.g., ridging, loss ofadherence) should be looked for.

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The main modality
for evaluating hand tumors

plain radiographs

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CT scans, which provide better resolution and
three-dimensional bone anatomy, are frequently needed to augment
X-rays to properly assess bony changes

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Ultrasound is a low-cost and readily available modality that can
help to assess the nature of the mass (solid versus cystic), the vascularity, and the relative location of the mass.

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it is difficult to differentiate between benign and
malignant masses on ultrasound alone

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the main modality for imaging complex soft tissues
masses

MRI

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Benefit of MRI in evaluating soft tissue ,mass

characterization of tumor activity(heterogeneouscontrast enhancement as well as perilesional edema suggesting a locally aggressive tumor).
assess response to adjuvant therapy
look for local recurrence in a surgical bed
MRI can also delineate soft tissue compartments and relationship of the mass to neurovascular structures

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Nuclear medicine scans are not specific and cannot differentiate between infection, trauma, and neoplasms

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When nuclear medicine scans are coupled with
anatomical imaging such as CT and MRI scans, their utility is further
enhanced

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18-FDG positron emission tomographyscans can also help
to monitor the response to neoadjuvant treatment such as chemotherapy, and can be used as a tool to help prognosticate patients

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myxoid liposarcomas can be evaluated with 18-FDG scan

F tumors, such as myxoid liposarcomas, may not be metabolic and have low 18-FDG uptake, which will limit the utility of these scans

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size should not be the only criterion to rule out malignancy

Because a majority (77%) of patients with soft tissue sarcomas present with tumors less than 5 cm in greatest dimension

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majority of malignant tumors in the hand are detected when they are small

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The standard for diagnosis is biopsy

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Marginal excision is sufficient for almost all benign soft tissue tumors.

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. Wide excision, which involves excision
of the tumor through a margin of normal tissue, may be required for
some benign but locally aggressive tumors such as desmoid tumors.

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For locally aggressive bone tumors such as
giant cell tumors, local adjuvant treatment using techniques such
as cryosurgery or phenol are added to reduce local recurrence rates.

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Safety margin for sarcoma excision?

For sarcomas, there is no universally agreed margin, but in
general, 1 cm of soft tissue, or an appropriate anatomic layer such as fascia, is accepted

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In the hand, the margins are invariably narrow due to the closeness of critical structures.

What is the down side of neoadjuvant treatment

there is a risk of tumor progression during neoadjuvant treatment, and higher wound infection rates are seen in patients that have undergone preoperative radiotherapy

Postoperative radiotherapy indication ?

should be considered for patients following resections with close margins or microscopically positive margins

Postoperative chemotherapy can also be considered

for selected patients with large, high-grade tumors.

The biopsy track should be excised en bloc together with the main tumor during the definitive resection.

Dissection should be done through normal tissue that is not contaminated by tumor

Critical vessels and nerves that are not grossly involved by the tumor can be preserved by dissecting through the adventitia or epineurium

Most patients with soft tissue sarcoma loss their hand

F Hand preservation is possible for most patients with soft tissue sarcomas of the hand, even those with relatively large tumors.

well-performed ray amputation can result in a more functional hand thana reconstructed digit that is painful, poorly padded, and stiff

Functional reconstruction can be delayed until all other treatment has been completed

most common soft tissue tumors seen in the hand

Ganglions are the most common soft tissue tumors seen in the handthey are mucin-filled cysts and are not true neoplasms

At wich age ganglion can occur?

Ganglions can occur at any age, though they are more commonly seen between the second to fourth decade

They can arise from.........

any joint within the hand and wrist, as well as from tendon sheaths

Most common site of ganglion

The most commonly encountered are dorsal wrist ganglions (~70%), followed by volar wrist ganglions (~20%), then ganglions arising from the flexor tendon sheaths and mucous cysts arising from the distal interphalangeal joints

the main constituents of the ganglion fluid

hyaluronic acid, glucosamine, albumin, and globulin

The diagnosis of a ganglion can be established on careful clinical evaluation-a cystic, occasionally multilobulated, mass that transilluminate

X-rays are helpful in evaluating underlying joint changes

MRis can confirm the diagnosis, as well as identify occult ganglions that may be symptomatic but not clinically detectable

The most common treatment for ganglion

observation should be considered because up to 50% resolve without treatment

the rate of spontaneous resolution even higher in children

substances such as steroids" or hyaluronidase26 have been injected following aspiration of the ganglion in an attempt to reduce the recurrence rate,

Injection of sclerosants should be avoided due to the risk of articular cartilage damage

Excision of ganglions can be done using open or arthroscopic techniques

Recurrence rates

between 0.6% and 40% have been reported following open surgery.

Arthroscopic resection, advantage

though technically more difficult, has the advantage of better visualization of the joint and a better surgical scar, with similar recurrence rates to open surgery

pigmented villonodular synovitis (PVNS), fibrous xanthoma, and localized nodular synovitis. They are the second most common soft tissue tumors were seen in the hand after ganglions

Giant cell tumour always arise from the tendons sheath

Despite the name, these tumors do not always arise from the tendon sheath or contain giant cells

The tumors are firm and nodular, and tender

F The tumors are firm and nodular, and generally are nontender

actual bone invasion.occure with this tumour

F They can cause pressure erosions ofthe underlying bone or rarely, actual bone invasion

Marginal excision is the treatment of choice, with recurrence rates of9% to 27%

Factors associated with local recurrence

presence of degenerative joint disease involvement of the distal interphalangeal joint radiographic evidence of bone pressure erosion involvement of the flexor or extensor tendons, or joint capsule satellite nodules that are not completely excised during surgery

Malignant transformation of giant cell tumors of tendon sheath has not been reported

epidermal cysts traumatic implantation ofepithelial cells into the soft tissue, or even into bone

Epidermal cysts are frequently seen over the fingertips and at times even in the stumps of amputated fingers

Patients most frequently present with a painless mass that has been growing slowly over months to years

Occasionally, the mass may be painful and erythematous

cysts in the soft tissue will be firm, well circumscribed, and slightly mobile

Those that involve the bone will be fixed; and they may have a lytic appearance on X-ray

patients with lytic lesions involving the distal phalanx should undergo biopsy to confirm the diagnosis

Treatment

Epidermal inclusion cysts can be treated with a marginal excision with a minimal risk of local recurrence.

Schwannomas are commonly seen in the upper extremity

It is painful mass

Patients often present with a painless mass, though they can occasionally present with radiating pain that occurs when the lesion is traumatized, or even neurological deficits

Most usefull investigation for shwanoma

MRI is the most useful investigation in delineating the lesion, and to identifying the nerve of origin

often difficult to differentiate a schwannoma from other nerve tumors such as neurofibromas, or even malignant peripheral nerve sheath tumors on MRI alone

Postoperative loss of function has been reported in 2.5% to 30% of patients

Local recurrence following tumor excision is common

F Local recurrence following tumor excision is rare

there have been cases of malignant transformation reported

It has been described that schwannomas can be easily dissected and shelled out from the nerve fibers

Enchondromas are the most common primary bone tumor seen in the hand.

They are thought to develop from residual nests ofcartilage originally arising from physis

Incidental lesions can be observed

Most common site of enchondroma

In the hand, enchondromas are most frequently seen in the proximal phalanges, followed by metacarpals and middle phalanges.

The small finger ray is the most commonly involved, whereas carpal involvement is rare

They are usually solitary, and are found in the diaphysis of the bone, though larger lesions can occupy almost the entire bone

Multiple enchondromas where can occures

Multiple enchondromas can be seen in patients with Oilier disease and Maffucci syndrome

Patients are often asymptomatic, and present with pain and swelling due to a pathological fracture

Digital deformity can be seen in patients with multiple enchondromatosis

The diagnosis

be made with plain radiographs

Finding in plain radiograph

which will show a lytic diaphyseal lesion, with lobulated margins and endosteal scalloping; the matrix is clear with a chondroid calcification pattern

Increased pain and swelling may be a sign of malignant change,

malignant change, frequently seen in patients with Oilier disease (25%) and Maffucci syndrome (100%)

Features suggestive of malignant change in xray

cortical destruction, loss of matrix mineralization, periosteal reaction, and a soft tissue mass.

techniques for reconstruction of the bone defect that have been described include leaving it alone, cement, bone substitute, allograft, and autograft

For patients who present following pathological fractures, there is the option ofearly definitive treatment with intralesional curettage, bone grafting and internal fixation, staged treatment with closed treatment ofthe fracture followed by delayed surgery once fracture union has occurred

Sarcomas originate from the embryonic mesodermal layer

Soft tissue sarcomas of the hand were initially thought to have a poorer prognosis than tumors arising elsewhere in the extremities

Continuing improvements in imaging techniques such as MRI allow better imaging and delineation of the tumor,