Hand Tumors Flashcards
List your differential of a painful hand tumor
LONG BEAN
- Leiomyoma
- OSTEOID OSTEOMA
- NEUROFIBROMA
- GLOMUS TUMOUR
- Blue rubber bleb nevus
- Eccrine spiradenoma
- Angiolipoma
- NEUROMA
List your differential of a hand tumor that varies in size
- Vascular lesion
- Ganglion
- Mucous cyst
What soft tissue hand tumors causes cystic changes in adjacent bone?
- glomus tumor
- epidermal cyst
- GCT*****
What hand tumors cause calcifications in soft tissues
- Hemangioma
- Lipoma
- Scleroderma
- Heterotopic ossification
- Fibroma (juvenile aponeurotic)
- calcinosis circumscripta
Where in the bone are GCT, enchondroma and osteochondroma located?
- GCT: epiphysis
- Octeochondroma: metaphysis (PP)
- Enchondroma: diaphysis (PP, DP)
What is your DDX for hand mass in the skin/appendages or subcutaneous tissue/fat
Skin /Appendage
BENIGN
- keratoses (Seborrheic, actinic)
- dermatofibroma (? fibrous tissue)
- benign sweat gland tumor (pilomatrixoma, tricholemmoma, trichoepithelioma, sebaceous adenoma)
MALINGNANT
- BCC, SCC, KA, melanoma
- DFSP (?fibrous tissue / sarcomatous)
- Malignant sweat gland tumors (sebaceous carcinoma, clear cell/pappillaryeccrine adenocarcinoma)
PSEUDOtumors
- Xanthoma
- Epidermal inclusion cyst, sebaceous cyst
- Verruca vulgaris
- Pyogenic granuloma (? vascular?)
Subcutaneous/FAT
BENIGN
- Lipoma
- Lipofibroma
- Angiolipoma
Malingnant
- Liposarcoma
PSEUDO tumor
- Gouty tophi
- FB granuloma
What is your DDX for hand mass in the Fascia or tendon?
Fascia
BENIGN
- Dupuytren nodule
- Fibroma
- Nodular fasciitis
- Juvenile aponeurotic fibroma
MALIGNANT
- Fibrosarcoma
- epithelioid carcinoma
- Malignant fibrous histiocytoma
Tendon
BENIGN
- GCT of tendon sheath
- Xanthoma
- Volar retinagular ganglion (ganglion of tendon sheath)
- Stenosing tenosynovitis (pseudo-tumour)
MALIGNANT
- Malignant GCT of tendon sheath
What is your DDX for hand mass in the muscle?
BENIGN
- Leiomyoma
- Rhabdomyoma
MALIGNANT
- leiomyosarcoma
- rhabdomyosarcoma
PSEUDO TUMOR
- Anomalous muscle (EDB, PL)
What is your DDX for hand mass of neural origin
BENIGN
- schwanomma
- neurofibroma
- neurofibrolipoma
- neuroma
MALIGNANT
- MPNST
- Merkel cell carcinoma
What is your DDX for hand mass in the Joint or bone/cartilage
BENIGN
- osteoid osteoma
- osteochondroma
- enchondroma
- aneurysmal bone cyst
- IOhemangioma
- GCT
- GCT of joint synovium
- Carpo-metacarpal boss
- ganglion
MALIGNANT
- osteosarcoma
- chondrosarcoma
- Ewings sarcoma
- Seondary metastases
- GCT of bone
- synovial sarcoma
What is your DDX for hand mass of vascular origin?
BENIGN
- hemangioma
- glomus tumor
- pygenic granuloma
- vascular malformation
- aneurysm
- aberrant radial artery
MALIGNANT
- hemangiosarcoma
- kaposi sarcoma
Ganglion Cyst
Epidemiology
Classification
Pathology
Pertinent features on History and Physical
Treatment options
Epidemiology
- F>M, 20-40s, most common hand tumor
Classification
- By location
- Dorsal wrist 70% => S-L ligament
- Volar wrist 20% => radiocarpal S-Trapezial jt
- Volar retinaculum 10% =>A1/A2 pulley
- Tendon => extensor zone 6
- Digital mucous cyst =>DIP jt
- Intraosseous =>carpal bone
Pathology
- capsule= condensed collagen
- mucoid degeneration (mucin + glucosamine+HA)
Pertinent features on History and Physical
- Hx: size variation, increase w activity
- PE: transilluminates, location
Treatment options
- Non-op:
- Rest, splint, NSAIDS
- Aspiration +/- steroid
- minimal morbidity, only 30% cure
- Operative - Excision w portion of jt capsule + bone irritant
- scar, neuroma, infection, stiffness, pain
- Dorsal wrist
- b/w 3/4
- Volar wrist
- b/w FCR APL
- careful of radial art, Hx oof asp and pseudoaneurysm
- Volar retinaculum
- excise A1/2 pulley segment w cyst
- Mucous cyst
- excise osteophyte, cyst
- Dorsal wrist
- scar, neuroma, infection, stiffness, pain
Epidermal Inclusion Cyst
Epidemiology
Pathology
Pertinent features on History and Physical, Xray
Treatment options
Epidemiology
- M>F, teens-middle age, 3rd most common tumor, located on distal pulps/dorsum of digits
Pathology
- dermal cyst lined with keratinized squamous epithelium, filled with keratin and giant cells
Pertinent features on History and Physical, Xray
- Hx: trauma, slow growth painless
- PE: firm, punctum, no transillumination, possible nail bed/bone deformity
- Xray - secondary bone erosion
Treatment options
- complete excision
Lipoma
Epidemiology
Classification
Pathology
Pertinent features on History and Physical
Treatment options
Epidemiology
- F>M, 30-60s, 3% of hand tumors
Classification
- lipoma, angiolipoma, angiolipofibroma (latter 2 are painful)
Pathology
- hypertrophy and hyerplasia of adipose tissue with pseudocapsule
Pertinent features on History and Physical and Imaging
- Hx: slow growing, may cause nerve compression symptoms (CTS)
- PE: likely in thenar, PP, soft, well demarcated
- MRI- T1 =>bright well circumscribed
Treatment options
- observe vs complete excision for diagnosis/symptoms
GCT of tendon sheath
Synonyms
Epidemiology
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Synonyms
- Pigmented Villonodulat tenosynovitis
- fibroxanthoma
- tendon xanthoma
Epidemiology
- M>F, 40-60s, 2nd most common hand tumor
- assocaited with joint/tendon
Pathology
- reactive lesion
- multilobular, deep brown due to hemosiderin pigmentation
- spindle cells, foam cells
Pertinent features on History and Physical and imaging
- slow growing, non tender
- PE: PALMAR surface of hand, digits, radial three digits most common, also at DIP, firm
- Xray - may show bone erosion adjacent
Treatment options
- Excision
- Guarded prognosis 5-50% recurrence
Glomus Tumor
Epidemiology
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Epidemiology
- F>M, 30-60, 4% of hand tumors
Pathology
- specialized AV shunt
- encapsulated Polyhedal and pericyte cells with stroma, small vessels and nerve endings
Pertinent features on History and Physical and imaging
- Hx: TRIAD - paroxysmal pain, pin point tenderness, cold hypersensitivity
- PE: on finger tip/nail bed, blue discoloraiton of nail bed +/- ridging, love sign (pinpoint pain), HIldreth sign (pain relieved w tourniquet)
- Xray - radioluscent, erosion of DP
- MRI - T1 - well circumscribed, T2 - BRIGHT
Treatment options
- Excision
- remove nail plante, careful w steriel matrix, look for multiple
- recurrence 20%
Nodular Fasciitis
Epidemiology
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Epidemiology
- 30-40, locaed in forearm, may have rapid growth, rare but important to distinguish from sarcoma
Pathology
- immature fibroblats, mitotic activity
Pertinent features on History and Physical and imaging
- Hx: rapidly growing, causing pain /compression
- PE: firm fixed mass
- Xray - may calcify
Treatment options
- Need biopsy for diagnosis
- marginal excision, good prognosis
Enchondroma
Epidemiology
Associated diseases w multiple enchondromatosis
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Epidemiology
- 10-40s, M=F, most common 1’ bone tumor of the hand
- most likely in PP/MC rarely carpus, diaphysis of bone
Associated diseases w multiple enchondromatosis
- Ollier’s: multi enchondroma, 30% risk of osteosarc/chondrosarc
- Maffucci: ass. w VM, 30%risk of chondrosarc
Pathology
- benign cartilage
Pertinent features on History and Physical and imaging
- Hx: patholgoic fracture
- PE: enlarged bone
- Xray - lytic lesion w cortical expansion, thinned cortex, stippling of matrix
- CT - chondroid matrix mineralization
Treatment options
- Observe if asx, q1y f/u
- open biopsy
- curettage and BG w small cortical window
- if pathologic fracture - allow to heal and wait at least 6mths prior to curettage and BG
- low recurrence
Osteochondroma
Definition
Epidemiology
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Definition
- benign bone & cartilaginous tumor characterized by aberrant seondary bone formation via endochondral ossification (abnormal chrondoblast activity @ metaphysis/physis)
- in metaphysis, PP, MC
- <5% malignant degeneration
Epidemiology
- 20s-30s, , rare in hands unless multiple exostoses
Pathology
- benign bone cortex with hyaline cartilaginous cap
Pertinent features on History and Physical and imaging
- Hx: multiple exostoses, may cause angulation
- PE: non tender bony prominence
- Imaging: **medullary continuity with overrgowth of bone cortex
Treatment options
- excision at bone maturity - sooner if deforming
GCT of bone
Definition
Epidemiology
Pathology
Pertinent features on History and Physical and imaging
Treatment options
Definition
- benign based on patho but locally aggresive, may metastasize
- distal radius 3rd most comon location, RARE in hand
Pertinent features on History and Physical and imaging
- pain/swelling
- Xray- lytic lesion of epiphysis/cortex
- MRI - to delineate tumor and ST extension
Treatment options
- Staging
- risk of mets 10%
- treat as sarcoma
What are 1’ tumors w bone metastases to the hand
- A-renal
- Breast
- Colon
- Lung
- Multiple myeloma
What is the most common location for bone mets to the hand
Distal phalanx
least common carpal bone
Presents as query infection
What is your managment of patient presenting w bony met to hand of unknown primary
- Hx, PE
- Bld work - CBC ESR, ALP
- Imaging
- CT for bony extent
- MRI for ST invasion
- Bone scan - to detect skip lesions
- CXR - look for other mets
- Tissue biopsy
- FNA, bone needle bx, open bx
Which sarcoas are known to metastasize via lymphatics
- Jay Wonder says “SCARE”
- Synovial sarcoma (second most common hand/wrist)
- Clear cell sarcoma
- Angiosarcoma
- Rhabdomyosarc
- Epithelioid sarcoma (most common in hand/wrist)
- (seminar also says MFH/UPS, third most common, hand/wrist)
What is the most common st and bone sarcoma to occur in the hand
- ST: epithelioid sarcoma
- Bone :Chondrosarcoma
- may arise from osteochondroma, enchondroma or de novo
- Xray -stippled calcification, lysis, poorly defined, cortical expansion, perforation
- Tx: wide exc/ray amp
List the top 5 locations for a ganglion cyst
- Dorsal wrist (~ SL interval)
- Volar wrist (~ radioscaphoid interval)
- Volar retinacular / ganglion of flexor sheath
- Mucous cyst / dorsal DIPJ
- 2nd or 3rd CMC boss
what are the contents of a ganglion cyst
- “mucin filled”
- glucosamine, globulin, albumin, hyaluronic acid
- Wall is compressed collagen fibres
what does pathologic specimen say after excision of epidermal inclusion cyst from finger pulp
- cyst cavity lined w compressed stratified squamous epithelium (no stratum corneum)
- contents are loosely packed keratin, inflammatory infiltrate including foreign body giant cells & lipid-rich debris
what do you tell your patient about risk of recurrence after GCT tendon sheath, volar radial D2? What is an alternative therapy to consider in recurrent/incompletely excised tumours?
- wide reported recurrence from 5 - 50%
- could consider post-operative radiotherapy (described by anastakis)
what does pathology show after excision of GCT flexor sheath?
- gross: yellow/brown hemosiderin ladel multi-nodular mass
- micro: see spindle cells, foam cells
what are imaging findings with glomus tumour?
- radiolucent on XR
- scalloping over DP on lateral XR (bone remodelling, not always present)
- doppler US shows flow
- MRI visible T1, bright T2
what does pathology say for glomus tumour?
- encapsulated structure
- polyhedral cells
- fibrous stroma
- endotherlial pericytes
- numerous non-myelinated nerve fibres
what is classic triad for glomus tumour?
what are 2 eponymous findings on physical exam?
- triad: paroxysmal pain, pinpoint tenderness, cold hypersensitivity
- Love test: exquisite pain w tip of pencil
- Hildreth sign: resolution of pain w/ application of tourniequet
compare schwannoma and neurofibroma
SCHWANNOMA
NEUROFIBROMA
Definition
Benign PNST arising from Schwann cells and located at periphery of nerve
Benign PNST arising from Schwann cells that involves entire x-section of nerve
History
Slowly growing mobile nodule, rarely associated w pain or motor/sensory findings; can have tinel
Similar to schwannoma; also rarely pain/motor/sensory findings, but plausibly more common than w schwannoma; can have tinel
Investigations (MRI)
Fusiform w tapered ends, low-intermed T1, high T2, target sign (lower in centre), split fat sign (fat splits around tumour)
- eccentric
Fusiform w tapered ends, low-intermed T1, high T2, target sign (lower in centre), split fat sign (fat splits around tumour)
- centric
Treatment
Active surveillance w regular phys exam/MRI
Vs excision (shell out of epineurium)
Active surveillance
Exicision if symptomatic, especially if primary coaptation and distal/non-critical nerve (sens)
Malignant transformation
Rare << 1%
Rare < 1%; w NF1 2-15%
Associations
NF2, (NF3 = “multiple schwannomatosis”)
NF1
what are syndromes associated w enchondroma?
- ollier’s disease
- spontaneous disease of childhood - multiple enchondromatosis of long/short bones of hands/feet/extremities
- 30% malignant transformation rate to chrondrosarcoma
- Mafuccie sydrome
- spontaneous condition of multiple enchondromas and hemangioma’s hands and feet
- also 5-55% spontanteous malignant transformation to chrondrosarcoma, osteosarcoma, soft tissue sarcoma
what features suggest malignant transformation of enchondroma?
- rapid change in size
- pain
- irregular surface
- extension of tumour into soft tissue
- cortical erosion
what are xr findings of enchondroma
- lesion of metaphysis/diaphysis
- demonstrating cortical thinning and expansion
- pathologic fracture
- flecks of calcification / stipling
what are treatment principles of enchondroma
- obtain history/physical to rule out red flags for malignant transformation
- if pathologic fracture - treat closed, allow fracture to unite, then excise
- if symptomatic, or old pathologic fracture, then corticotomy, marginal debridement of all cartilaginous tumour material within the cortex, and pack with cancellous bone graft or alloplast bone substitute
- if asymptomic incidental finding in area not prone to fracture - could consider serial examinations and excision as needed
define osteochondroma; contrast to definition for enchondroma
- osteochondroma is a benign cartilage tumour characterized by 2ary bone formation through endochondral ossification and a hyaline cartilage cap, commonly at bony metaphysis
- enchondroma is a benign cartilage tumour characterized by aberrant cartilage formation at diaphyseal / metaphyseal bone regions
what is the radiologic features of osteochroma?
- solitary or multiple exostoses
- projection of cortex is continuous w normal cortex
- hallmark is medullary continuity
pathologic finding in osteochrondroma
- normal bone cortex, lesion has a hyaline cartilage cap
list 2 characteristic features of osteoid osteoma
- on history, pain is relieved by NSAID or ASA
- on imaging, there is a dense, reactive, eccentric cortical sclerosis surrounding a radiolucent nidus
what is an osteoid osteoma?
painful bone forming tumour, rare in upper extremity, small
how does GCT of bone differ from GCT tendon sheath
- completely different entities w similar name
- GCT bone is technically a benign lesion, but is locally aggressive and has the potential to metastasize (mostly to lungs) and has an associated mortality (therefore in many ways behaves like a malignant tumour)
what are radiologic features of GCT bone?
- # 3 site is distal radius, also metaphyseal lesion of metacarpal / phalanges
- see metaphyseal lesion w expansion into epiphysis, lytic , no matrix, indistinct borders, pseudotrabeculation
what are treatment principles of GCT bone?
- establish diagnosis via open incisional biopsy following appropriate “sarcoma” protocol
- then work up w CT chest +/- bone scan
- then consider curretage and marginal excision for benign lesions (not usually recommended due to recurrence)
- vs. wide excision or (ray) amputation with primary/delayed reconstruction
what is most common malignancy of hand?
What is most common malignancy of nailbed?
scc for both
what is the etiology/primary for metastatic lesions to bones in hand?
what is the most common site in the hand/wrist for a bony met?
- Lung (40%) > kidney (14%) > breast (10%) > colon (5%); also thyroid, prostate, multiple myeloma, melanoma
- distal phalanx
which soft tissue sarcoma metastasize via lymphatics (and therefore a SLNB) may be indicated
- SCARE
- synovial sarcoma
- clear cell sarcoma
- angiosarcoma
- rhabdomyosarcoma
- epithelioid sarcoma
what is the most common soft tissue sarcoma of upper extremity? how does it present?
- epithelioid carcinoma
- slow growing mass / nodule(s) in volar aspect digits, hand, forearm
- often painless, can ulcerate & drain
what is the second most common soft tissue sarcoma, and how does it present
- synovial sarcoma
- slow growing solid mass x mos-year, adjacent to bursa or joints (for u/e, most commonly adjacent to carpus)
what is the most common bone malignancy of hand? How does it present?
- chrondrosarcoma
- slow growing, firm, painful mass proximal phalanx or metacarpal
what are xray features of chrondrosarcoma?
- tumour matrix w stippled calcifications
- lysis
- poorly defined margins
- extreme cortical expansion
- perforation of cortical margin
- extension to surrounding
what type of special canal is the abnormality of the AV shunt in Glomus Tumour
Suquet-Hoyer canal
