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Upper Extremity > Hand Tumors > Flashcards

Hand Tumors Flashcards

1
Q

List your differential of a painful hand tumor

A

LONG BEAN

  • Leiomyoma
  • OSTEOID OSTEOMA
  • NEUROFIBROMA
  • GLOMUS TUMOUR
  • Blue rubber bleb nevus
  • Eccrine spiradenoma
  • Angiolipoma
  • NEUROMA
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2
Q

List your differential of a hand tumor that varies in size

A
  • Vascular lesion
  • Ganglion
  • Mucous cyst
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3
Q

What soft tissue hand tumors causes cystic changes in adjacent bone?

A
  • glomus tumor
  • epidermal cyst
  • GCT*****
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4
Q

What hand tumors cause calcifications in soft tissues

A
  • Hemangioma
  • Lipoma
  • Scleroderma
  • Heterotopic ossification
  • Fibroma (juvenile aponeurotic)
  • calcinosis circumscripta
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5
Q

Where in the bone are GCT, enchondroma and osteochondroma located?

A
  • GCT: epiphysis
  • Octeochondroma: metaphysis (PP)
  • Enchondroma: diaphysis (PP, DP)
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6
Q

What is your DDX for hand mass in the skin/appendages or subcutaneous tissue/fat

A

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
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7
Q

What is your DDX for hand mass in the Fascia or tendon?

A

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
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8
Q

What is your DDX for hand mass in the muscle?

A

BENIGN

  • Leiomyoma
  • Rhabdomyoma

MALIGNANT

  • leiomyosarcoma
  • rhabdomyosarcoma

PSEUDO TUMOR

  • Anomalous muscle (EDB, PL)
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9
Q

What is your DDX for hand mass of neural origin

A

BENIGN

  • schwanomma
  • neurofibroma
  • neurofibrolipoma
  • neuroma

MALIGNANT

  • MPNST
  • Merkel cell carcinoma
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10
Q

What is your DDX for hand mass in the Joint or bone/cartilage

A

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
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11
Q

What is your DDX for hand mass of vascular origin?

A

BENIGN

  • hemangioma
  • glomus tumor
  • pygenic granuloma
  • vascular malformation
  • aneurysm
  • aberrant radial artery

MALIGNANT

  • hemangiosarcoma
  • kaposi sarcoma
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12
Q

Ganglion Cyst

Epidemiology

Classification

Pathology

Pertinent features on History and Physical

Treatment options

A

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
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13
Q

Epidermal Inclusion Cyst

Epidemiology

Pathology

Pertinent features on History and Physical, Xray

Treatment options

A

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
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14
Q

Lipoma

Epidemiology

Classification

Pathology

Pertinent features on History and Physical

Treatment options

A

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
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15
Q

GCT of tendon sheath

Synonyms

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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
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16
Q

Glomus Tumor

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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%
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17
Q

Nodular Fasciitis

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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
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18
Q

Enchondroma

Epidemiology

Associated diseases w multiple enchondromatosis

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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
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19
Q

Osteochondroma

Definition

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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
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20
Q

GCT of bone

Definition

Epidemiology

Pathology

Pertinent features on History and Physical and imaging

Treatment options

A

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
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21
Q

What are 1’ tumors w bone metastases to the hand

A
  • A-renal
  • Breast
  • Colon
  • Lung
  • Multiple myeloma
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22
Q

What is the most common location for bone mets to the hand

A

Distal phalanx

least common carpal bone

Presents as query infection

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23
Q

What is your managment of patient presenting w bony met to hand of unknown primary

A
  • 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
24
Q

Which sarcoas are known to metastasize via lymphatics

A
  • 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)
25
Q

What is the most common st and bone sarcoma to occur in the hand

A
  • 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
26
Q

List the top 5 locations for a ganglion cyst

A
  • Dorsal wrist (~ SL interval)
  • Volar wrist (~ radioscaphoid interval)
  • Volar retinacular / ganglion of flexor sheath
  • Mucous cyst / dorsal DIPJ
  • 2nd or 3rd CMC boss
27
Q

what are the contents of a ganglion cyst

A
  • “mucin filled”
  • glucosamine, globulin, albumin, hyaluronic acid
  • Wall is compressed collagen fibres
28
Q

what does pathologic specimen say after excision of epidermal inclusion cyst from finger pulp

A
  • 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
29
Q

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?

A
  • wide reported recurrence from 5 - 50%
  • could consider post-operative radiotherapy (described by anastakis)
30
Q

what does pathology show after excision of GCT flexor sheath?

A
  • gross: yellow/brown hemosiderin ladel multi-nodular mass
  • micro: see spindle cells, foam cells
31
Q

what are imaging findings with glomus tumour?

A
  • radiolucent on XR
  • scalloping over DP on lateral XR (bone remodelling, not always present)
  • doppler US shows flow
  • MRI visible T1, bright T2
32
Q

what does pathology say for glomus tumour?

A
  • encapsulated structure
  • polyhedral cells
  • fibrous stroma
  • endotherlial pericytes
  • numerous non-myelinated nerve fibres
33
Q

what is classic triad for glomus tumour?

what are 2 eponymous findings on physical exam?

A
  • triad: paroxysmal pain, pinpoint tenderness, cold hypersensitivity
  • Love test: exquisite pain w tip of pencil
  • Hildreth sign: resolution of pain w/ application of tourniequet
34
Q

compare schwannoma and neurofibroma

A

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

35
Q

what are syndromes associated w enchondroma?

A
  • 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
36
Q

what features suggest malignant transformation of enchondroma?

A
  • rapid change in size
  • pain
  • irregular surface
  • extension of tumour into soft tissue
  • cortical erosion
37
Q

what are xr findings of enchondroma

A
  • lesion of metaphysis/diaphysis
  • demonstrating cortical thinning and expansion
  • pathologic fracture
  • flecks of calcification / stipling
38
Q

what are treatment principles of enchondroma

A
  • 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
39
Q

define osteochondroma; contrast to definition for enchondroma

A
  • 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
40
Q

what is the radiologic features of osteochroma?

A
  • solitary or multiple exostoses
  • projection of cortex is continuous w normal cortex
  • hallmark is medullary continuity
41
Q

pathologic finding in osteochrondroma

A
  • normal bone cortex, lesion has a hyaline cartilage cap
42
Q

list 2 characteristic features of osteoid osteoma

A
  • on history, pain is relieved by NSAID or ASA
  • on imaging, there is a dense, reactive, eccentric cortical sclerosis surrounding a radiolucent nidus
43
Q

what is an osteoid osteoma?

A

painful bone forming tumour, rare in upper extremity, small

44
Q

how does GCT of bone differ from GCT tendon sheath

A
  • 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)
45
Q

what are radiologic features of GCT bone?

A
  • # 3 site is distal radius, also metaphyseal lesion of metacarpal / phalanges
  • see metaphyseal lesion w expansion into epiphysis, lytic , no matrix, indistinct borders, pseudotrabeculation
46
Q

what are treatment principles of GCT bone?

A
  • 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
47
Q

what is most common malignancy of hand?

What is most common malignancy of nailbed?

A

scc for both

48
Q

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?

A
  • Lung (40%) > kidney (14%) > breast (10%) > colon (5%); also thyroid, prostate, multiple myeloma, melanoma
  • distal phalanx
49
Q

which soft tissue sarcoma metastasize via lymphatics (and therefore a SLNB) may be indicated

A
  • SCARE
  • synovial sarcoma
  • clear cell sarcoma
  • angiosarcoma
  • rhabdomyosarcoma
  • epithelioid sarcoma
50
Q

what is the most common soft tissue sarcoma of upper extremity? how does it present?

A
  • epithelioid carcinoma
  • slow growing mass / nodule(s) in volar aspect digits, hand, forearm
  • often painless, can ulcerate & drain
51
Q

what is the second most common soft tissue sarcoma, and how does it present

A
  • synovial sarcoma
  • slow growing solid mass x mos-year, adjacent to bursa or joints (for u/e, most commonly adjacent to carpus)
52
Q

what is the most common bone malignancy of hand? How does it present?

A
  • chrondrosarcoma
  • slow growing, firm, painful mass proximal phalanx or metacarpal
53
Q

what are xray features of chrondrosarcoma?

A
  • tumour matrix w stippled calcifications
  • lysis
  • poorly defined margins
  • extreme cortical expansion
  • perforation of cortical margin
  • extension to surrounding
54
Q

what type of special canal is the abnormality of the AV shunt in Glomus Tumour

A

Suquet-Hoyer canal

55
Q
A

Upper Extremity (27 decks)

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