Hand Tumors Flashcards

1
Q

What is the role of computed tomography in assessing upper extremity tumors?

A

Used to evaluate extent of bone destruction as well as calcified lesions.

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2
Q

What is the role of magnetic resonance imaging in assessing upper extremity tumors?

A

Used for evaluation of lesions involving bone and soft tissue.

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3
Q

How is clonality used to differentiate between neoplasms and benign tissue growths (ie, Dupuytren disease)?

A

Benign and inflammatory conditions are typically polyclonal, whereas neoplasms are monoclonal.

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4
Q

In which direction should the incision be oriented when obtaining a biopsy of an upper extremity mass?

A

Longitudinal (rather than transverse or zigzag) so as to incorporate the biopsy site within the definitive excision or
amputation.

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5
Q

When performing a biopsy on a lesion, should one dissect around muscle planes or split the muscle sharply?

A

Split sharply (to avoid seeding other muscle compartments).

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6
Q

When performing an open biopsy, should drains be placed?

A

No, drains can seed tumor cells along their tracts. Simply obtain hemostasis.

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7
Q

Should a tourniquet be used when operating on a neoplasm of the upper extremity?

A

Yes, but exsanguination of the arm should be done through elevation, not Esmarch bandage.

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8
Q

What is the staging system for musculoskeletal tumors?

A

Stage Grade
IA Low (G1)
IB Low
IIA High (G2)
IIB High
Site
Intracompartmental Extracompartmental Intracompartmental Extracompartmental

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9
Q

What is the usual etiology of epidermal inclusion cysts?

A

Trauma that causes epidermal cells to become embedded in the dermis.

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10
Q

Where do epidermal inclusion cysts usually occur?

A

In the glabrous, non–hair-bearing skin of the palms and fingertips (especially perionychium).

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11
Q

What is the treatment of epidermal inclusion cysts?

A

Complete excision along with the skin puncture wound (or punctum, if present

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12
Q

What are the clinical findings seen with a subungual glomus tumor?

A

Severe pain, cold sensitivity, tenderness, nail deformity, or discoloration.

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13
Q

What is the treatment of a subungual glomus tumor?

A

Removal of nail, excision of tumor.

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14
Q

What is the likely diagnosis of a patient with a subcutaneous elevation just proximal to the eponychial fold and nail grooving?

A

A mucous cyst, or fluid-filled ganglion of the distal interphalangeal joint associated with bony spurs and nail grooving.

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15
Q

What is the treatment of mucous cysts?

A

Cyst excision and removal of bone spurs.

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16
Q

What is the name of a rapidly growing vascular, friable nodule frequently seen on fingertips in young adults, more common after pregnancy?

A

Pyogenic granuloma.

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17
Q

What is the name of the lesion that is commonly found on the dorsal hand that is round, elevated, and usually has a central crater? This lesion usually resolves spontaneously, and only occasionally progresses to squamous cell carcinoma.

A

Keratoacanthoma.

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18
Q

What is the natural history of keratoacanthomas?

A

They undergo three phases:
1. proliferation
2. maturation
3. involution
The clinical story will usually include the rapid growth of a preexisting lesion that then gradually gets smaller as the
central crater expels a keratin plug.

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19
Q

What is the recommended treatment for keratoacanthomas?

A

Surgical excision or intralesional injection with 5-fluorouracil (5-FU) or methotrexate.

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20
Q

What are the first and second most common tumors or masses of the hand?

A

Ganglions and giant cell tumors (GCTs), respectively.

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21
Q

What is the predominant cell type in GCTs (aka localized nodular synovitis)?

A

Histiocytes.

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22
Q

What is the usual site of origin of GCTs?

A

Flexor tendon sheath.

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23
Q

What is the treatment of GCTs?

A

Excision along with stalk (if present).

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24
Q

What is the difference between a neurofibroma and a neurilemmoma?

A

Neurofibroma: in the substance of the nerve. Neurilemmoma (also known as schwannoma): on the nerve surface.

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25
Q

How does this difference impact treatment?

A

Neurilemmoma can be “shelled out” easily, while neurofibroma requires transection at the proximal and distal
fascicles.

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26
Q

Are these common tumors?

A

Neurilemmomas are the most common benign nerve tumors in the upper extremity.

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27
Q

A patient presents with multiple neurofibromas of the upper extremity and cutaneous cafe ́-au-lait spots. What is your diagnosis?

A

Von Recklinghausen disease or neurofibromatosis type 1.

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28
Q

A patient presents with bilateral acoustic schwannomas. What is the likely diagnosis?

A

Neurofibromatosis type 2. Note that these patients rarely have neurofibromas.

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29
Q

What diagnostic studies can be used to differentiate between neurofibroma and neurilemmoma?

A

Magnetic resonance (MR) and nerve conduction studies.

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30
Q

What is the treatment of fibromatosis and juvenile aponeurotic fibromas?

A

Wide excision with skin grafting or free tissue transfer, which still has a high potential for recurrence

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31
Q

What is the chief problem seen with desmoid tumors?

A

High rate of recurrence (especially in female patients).

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32
Q

In general, what is the treatment of upper extremity arteriovenous malformations?

A

Ligation of feeding vessels, complete excision.

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33
Q

Are vascular malformations really neoplasms?

A

No, they are simply an abnormal collection of blood vessels.

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34
Q

What is the most common benign bone tumor?

A

Enchondroma.

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35
Q

What are the common locations of enchondromas?

A

Metacarpals (most common) and phalanges. Carpal bones are rarely involved.

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36
Q

What is Ollier disease?

A

Multiple enchondromatosis.

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37
Q

What is Maffucci syndrome?

A

Multiple enchondromas and hemangiomas.

38
Q

What is the lifetime chance of a solitary enchondroma undergoing malignant transformation?

A

10%.

39
Q

What do enchondromas degenerate into?

A

Chondrosarcomas.

40
Q

How do enchondromas frequently present?

A

Pathologic fracture.

41
Q

What is the treatment of enchondromas?

A

Curettage and bone grafting. In cases of pathologic fracture, it is optimal to allow fracture healing prior to definitive resection

42
Q

What benign cartilaginous tumor is similar to enchondromas and most commonly found at the metaphyseal–diaphyseal junction of the phalanges?

A

Periosteal chondroma.

43
Q

What is the peak age range of unicameral bone cysts (UBCs)?

A

5 to 10 years. In fact, it is seen almost exclusively in children.

44
Q

What is the typical presentation of UBC?

A

An incidental finding on X-ray or a pathologic fracture through the cyst.

45
Q

What nonsurgical treatment is used for UBCs?

A

Intralesional steroid injection.

46
Q

What is the name of a blood-filled cyst that typically occurs in the metaphysis of a metacarpal and then grows toward the physis?

A

Aneurysmal bone cyst (ABC).

47
Q

What is the peak age range of ABC?

A

Second decade of life.

48
Q

What is the typical presentation of ABC?

A

Swelling and pain, often following an injury.

49
Q

What is the treatment of ABCs?

A

Curettage and bone grafting. This is an erosive, although benign, lesion that has to be removed.

50
Q

What is the usual structure of an osteochondroma?

A

Bone stalk and cartilaginous cap growing from the metaphysis in skeletally immature patients.

51
Q

Is excision necessary for osteochondromas?

A

No, unless they are symptomatic. They rarely undergo malignant degeneration.

52
Q

What are the symptoms of an osteoid osteoma?

A

Pain at night relieved by nonsteroidal anti-inflammatory drugs.

53
Q

How do osteoid osteomas present on imaging studies?

A

Sclerotic nidus with a lucent halo, less than 1.0 cm in diameter (by definition).

54
Q

What is the histology of osteoid osteomas?

A

Very vascular nidus of osteoblasts with surrounding cortical reactive bone formation.

55
Q

What is the treatment of osteoid osteomas?

A

Curettage and bone grafting.

56
Q

What is an osteoblastoma?

A

Same as an osteoid osteoma, but greater than 1 cm in diameter. They have unlimited growth potential and all
should be resected.

57
Q

What is the clinical presentation of a giant cell tumor (GCT) of bone ?

A

Gradual swelling, pain, sometimes with pathologic fracture, most often in the distal radius.

58
Q

Why do some classify GCTs as low-grade malignancies?

A

They can metastasize and cause death.

59
Q

Where do GCTs of bone typically metastasize?

A

The lungs (2%).

60
Q

How do GCTs look on radiographs?

A

Lytic lesion; no new bone formation; encroaches on, but does not penetrate joint surface.

61
Q

What is the surgical treatment of GCTs?

A

Wide excision, joint reconstruction if necessary.

62
Q

What is the pathophysiology of fibrous dysplasia?

A

Bone marrow of involved bone(s) filled with noncalcified collagen.

63
Q

What is the X-ray appearance of fibrous dysplasia?

A

Ground-glass opacity.

64
Q

Is treatment of fibrous dysplasia of the hands required?

A

Not usually. Surgical treatment is usually performed for pathologic fractures, or “impending” fractures.

65
Q

What are some other common soft tissue masses in the upper extremity?

A

Ganglia, lipomas, foreign body granulomas, retinacular cysts, palmar fibromatosis, or nodules (Dupuytren).

66
Q

What is the most common malignant tumor of the hand?

A

Squamous cell carcinoma.

67
Q

What is the most common type of melanoma among African Americans and Asians?

A

Acral lentiginous melanoma, usually presenting on hands and feet.

68
Q

When treating melanoma of the hand, how is the amputation level determined?

A

Amputate proximal to the nearest joint (ie, for a subungual melanoma, amputation would be through the middle
phalanx).

69
Q

What role does sentinel node biopsy play in the treatment of subungual melanoma, and why?

A

Sentinel node biopsy is useful with subungual melanoma because depth of the tumor is difficult to determine in the
nail bed.

70
Q

What is the name of a lesion arising in the dermis that presents as a purple-red plaque or nodule?

A

Dermatofibrosarcoma protuberans (DFSP).

71
Q

Has Mohs surgery been shown to be effective for DFSP?

A

Yes.

72
Q

What is a strong risk factor for malignant peripheral nerve sheath tumor?

A

Neurofibromatosis (Von Recklinghausen disease).

73
Q

What is a synovial cell sarcoma?

A

High-grade sarcoma that grows in proximity to (but not in) joints. Size of the lesion is proportional to the mortality.

74
Q

What is the treatment of synovial cell sarcoma?

A

Wide excision, lymph node sampling (and dissection if nodes involved), and consideration of adjuvant radiation
therapy.

75
Q

What other sarcoma is similar to synovial cell sarcoma and usually arises from muscle?

A

Epithelioid sarcoma.

76
Q

What about the spread of epithelioid sarcoma makes it dangerous?

A

It moves proximally along fascial planes, tendons, and lymphatics.

77
Q

Where is malignant fibrohistiocytoma usually found in upper extremities?

A

Deep muscle mass of adductor pollicis or within muscles of the flexors.

78
Q

What is the most common malignant primary bone tumor of the hand seen in children and teens?

A

Osteogenic sarcoma.

79
Q

How does osteogenic sarcoma look on plain radiograph?

A

Bone growth outside normal skeletal boundaries with hazy “cloud-like” bone formation into soft tissues.

80
Q

Is there a role for external beam radiation in treatment of osteogenic sarcoma?

A

No, but chemotherapy has greatly improved survival and limb salvage.

81
Q

What is the most common malignant primary bone tumor of the hand in adults?

A

Chondrosarcoma.

82
Q

Is chondrosarcoma sensitive to chemotherapy or radiation?

A

No.

83
Q

What is the benign predecessor that can rarely degenerate into a chondrosarcoma?

A

Enchondroma.

84
Q

What is a rare bone tumor of the metacarpals and phalanges that consists of abnormal endothelial cells?

A

Angiosarcoma.

85
Q

What is a typical presentation of a Ewing sarcoma of the hand?

A

Pain, swelling, soft tissue mass; can also have fever, elevated WBC and/or ESR.

86
Q

What is the radiographic presentation of Ewing sarcoma?

A

Large lytic lesion of bone with a soft tissue component.

87
Q

What is the periosteal reaction on radiographs called in Ewing sarcoma?

A

“Onion skin” appearance or “sunburst” pattern.

88
Q

What are the common sites of Ewing sarcoma of the hand?

A

Metacarpals, phalanges.

89
Q

What is the treatment of Ewing sarcoma?

A

Surgical excision, systemic chemotherapy and/or external beam radiation.

90
Q

What percentage of patients with primary cancers in other parts of the body will develop a metastasis to the hands or feet?

A

0.3%.

91
Q

What is the most common primary carcinoma that metastasizes to the hand?

A

Bronchogenic carcinoma (followed by breast and kidney).

92
Q

When primary carcinoma metastasizes to the hand, where does it go?

A

The distal phalanx.