Tumors of the hand Flashcards
Cartilage Tumor: benign
Enchondroma
Definition:
most common bone tumor of the hand (90%), comprised hyaline cartilage islands seperated from the growth plate, slowly growing after the growth plate closed
no sex predilection
most commonly diagnosis in the 2nd or 3rd decade
most common:
proximal phalanx - metacarpus - middle phalanx with most common from ulnar to radial
carpus ralely involved
Presentation:
no growth, clinical symptoms by pathologic fracture, when growth maybe transformation into chondrosarcoma, less than 1% per year of observation
Imaging:
lucent lesion intramedullary, maybe matrix calcification - chondroid calcification, endosteal erosion with thinning the surrounding cortex
(cave: cortical remodelling and endosteal erosion can be the possibility of an low-grade chondrosarcoma)
Differential Diagnosis:
giant cell tumor
giant cell reparative granuloma
aneurysmal bone cyste (ABC)
intraosseous ganglion cyste
chondrosarcoma (cotical destruction and soft tissue mass)
Associated Conditions (Ollier/Maffucci):
M. ollier (mutiple enchondromas of one body half)
often eccentric cartilage lesions of the phalangeal bones, mostly first decade, 30% malignant transformation, hand 80-90% involved,
Maffucci Syndrome: enchondromatosis with deef cavernic haemangioma non osseus, 80-90% of the hand (100% maligne transformationj - higher than ollier disease)
Treatment:
curettage, bone filling oder PMMA, more stability, when pathologic fracture there is a better outcome, when first treated the fracture und delay curettage of the bone
maybe Phenol for the cavity to avoid recurrence
Complications/Recurrence:
Recurrence 5 - 14%, oberservation 2 - 5 years
transformation to chondrosarcoma is very rare
Cartilage Tumor: benign
Osteochondroma
very rare, 3-7% of the tumors of this area, only 4% of all osteochondromas, arise from a defect in the perichondral ring, allowing cartilage from the physis to protrude through, than calcify with cortical and trabecular bone and an associates cartilage cap with cortical and medullary continuity with the host bone, most presentation during the first 2 decades, predilection for the proximal phalanx
Presentation:
painless mass with symptoms resulting from affecting mechanical irritation to the surrounding soft tissue, growth away from the joint, when physis is open, ceasing at skeletal maturity
when found - evaluation for multiple hereditary exostosis
Imaging:
continuity between the cortex and medullary canal and the lesion
MRT ist necessary, bursa above the lesion or thick cartilage cap, maybe malignant transformation with mass of the soft tissue, irregularity of the cortical margin and heterogenous mineralization
growing cartilage cap (normal only a few milimeters) maybe sign for malignant transformation into a chondrosarcoma
Associated conditions:
multiple hereditary osteochondromas, autosomal dominant disorder, mutation in EXT of genes 1 and 2, first decade of life, limb-length discrepancies and deformities, 79% involving the hand, malignant transformation in 5-25%
Treatment:
if necessary waiting for skeletal maturity, malignant transformation maybe needs wide excision of the mass, amputation
Cartilage Tumor: benign
Chondroblastoma
benign cartilage tumors, epiphysis of long bones, associated with the growth plate, derive from this structure, mostly young male patients, 90% of chondroblastomas between 5-25years, in hand rare
mononuclear and giant cells, cartilage matrix may calcify in a “lice-lake” or “chicken-wire” pattern
Presentation:
mostly pain!!!! longstanding pain, swelling 10%, joint effusion, ROM limitation, when lesion at the joint line
Imaging:
eccentric lesions, epiphysis of the long bones, may cross the physis and involve the metaphysis, thin rim of sclerosis, may expand the overlying host bone cortex
exuberant surrounding bone marrow
soft-tissue swelling
joint effusion
Hand: not epiphyseal region - tendency to involve the diaphysis or metaphysis of the involved bone
Differential:
epiphyseal predilection: GCT, intraosseus Ganglion cyst, infection (Brodie abscess)
Carpus: ganglion cyst, osteoid osteoma, osteoblastoma, infection (Brodie abscess)
Treatment:
curettage, maybe secondary development of ABC, filling with autologous bone from the iliacal crest, Phenol application possible, maybe PMMA for the defect to see recurrence early
Complications:
when secondary ABC 100% Chondroblastoma recurrence
38% recurrence of all chondroblastoma
Cartilage Tumor: benign
Chondromas
periosteal Chondroma
rare benign lesions, from periosteoum or the connective tissue
second or third decade
lobulated fibrocarilaginous matrix with hyaline cartilage
25% involve bones of the hand, mostly proximal and middle phalanx in the diaphysis or metaphysis
Presentation:
painless enlarging mass, mechanical symptoms near to a joint, restricted ROM, snapping of tendons
Imaging:
associated with the surface of the bone with chronig extrinsic scalloping of the underlying bone, rim of sclerosis between the lesion and the medullary cavity, thin cortical shell of bone along the peripheral margin of the soft-tissue component of the mass, intralesional calcification in 50%
Differential Diagnosis
intracortical chondroma
surface ABC
osteoblastoma
periosteal chondrosarcoma
periosteal osteosarcoma
Treatment:
lokal excision with resection of the underlying cortex
Complications:
15% recurrence
Chondromas
soft-tissue Chondroma
uncommon benign tumor of the hand and feet, mostly 96%, 80% fingers - palmar aspect, inimately associated with tendons and arise from the surrounding synovial tissue
age from 30 to 60, not attached to the periosteum, histologically hyaline cartilage with chondrozyte maturation and associated with intrasubstance calcification, arranged in lobules and classically well-encapsulated
Cartilage Tumor: benign
Bizarre Parosteal Osteochondromatous Proliferation (BPOP)
“Nora’s Lesion”
on phalangeals, metacarpals and metatarsals, no sex predilection, third and fourth decade of life
most related to an injury (30%), trauma causes subperiosteal hemorrhage, than periostitis, etiology not clearly defined, histologically cartilage bone with spindle cells, cartilage cap overlying the lesion, irregular bone trabeculae, no communcation with the underlying host bone
Presentation:
painless slow-growing mass, nearly a joint maybe restricted range of motion
Imaging:
surface lesion, present a nodular, densely mineralized masses on the bone surface, (likely osteochondroma), no medullary continuity, arise directly from the periosteum, no disruption of the unterlying cortical bone
heavily mineralized masses, comes from the surface, no continuity to the cortex or the medullary bone
Differential diagnosis:
osteochondroma, subungual exostosis, paraosteal osteosarcoma, heterotopic ossification, periostitis, myositis ossificans
Treatment:
Excision, aggressive resection because of 54% recurrence with marginal resection, includes the fibrous cap and the underlying periosteum
Complication/Recurrence:
50% recurrence, no metastatic spread
Cartilage Tumor: benign
Synovial Chondromatosis
proliferate synovial process comprised of multiple cartalaginous nodules, larger joints including hip, knee, elbow, shoulder and ankle
intra- and extraarticular, metaplasia of the synovial tissure surrounding a joint or tendon, male predominance 3th to 5th decade, over the age of 50 involvement of the hand of both sexes
nodules histologically hyline cartilage with atypical appearing chondrocytes, calcification
Presentation:
pain and swelling, decrease range of motion, any joint about the wrist, progress over an extended time, delay in diagnosis is common, patient with extraarticular chondromatosis have no pain in compare to intraarticular chondromatosis, maybe similar to a trigger finger with chondromatosis in the flexor tendons
Imaging:
detection in x-ray depends on calcification, 75% calcification, MRI in T2 low signal with high signal of joint fluid surround the tumor
Differential diagnosis:
joint included: pigmented villonodular synovitis, crystal deposition desease, rheumatoid arthritis with rice bodies, chronic proliferative synovitis
soft-tissue: soft-tissue chondroma, tumoral calcinosis, rarely soft-tissure chondrosarcoma, maybe degenerative joint disease
Associated conditions:
Wagner-stickler-Syndrome - multifocal synovial chondromatosis
Treatment:
stage 1 (early disease): active synovial desease without intraarticular loose bodies
stage 2 (transitional stage: both active synovial disease, as well as intra-articular loose bodies
stage 3 (late disease): intra-articular loose bodies without active synovial disease
Excision, maybe with arthrodesis when degenerative disease, wide synovialectomy
Complications/Recurrence:
from rare to 60%, malignant transformation very rare to a synovial chondrosarcoma, if left untreated can causes advanced or recalctrant synovial chondromatosis may occur with secondary degenerative arthritis
Cartilage Tumors
malignant
Chondrosarcoma
clinical presentation:
mostly pain and swelling, can go over years, 25% pathological fracture, regional or distant lymph node involvement is rare,
clinical features of secondary chondrosarcoma
M. ollier
Maffucci Syndrom
solitary osteochondroma (average 50-55y)
multiple osteochondromas (25-30y)
- increasing mass
- development of pain or tenderness after skeletal maturity
Diagnostic Imaging:
Low-grade chondrosarcoma
endosteal erosion, cortical destruction, indistinct margins, greater than 5cm, occasionally soft-tissue extension, mostly metaphysis, not over the joint but possible (extremely rare)
High-grade chondrosarcoma
larger than 5cm , pathological fracture, mature and immature periosteal reaction, cortical thickening
threshold of 2cm cartilage cap, increased cap thickness maybe conversion to a low grade chondrosarcoma,
Histopathology
grade I:
low degree of cellularity, sparse multinucleated cells with minimal cytologic atypia, no mitotic figures
grade II:
degeneration of cartiaginous matrix, increased cellularity, moderate atypia, few mitotic figures
grade III:
predominantly myxoid matrix, high degree of cellularity, nuclear pleomorphism, numerous mitotic figures
Treatment:
nonsurgical treatment - rarlely - maybe splinting in poor prognosis, - cave: resistant against radiation and chemotherapeutics
operative Treatment:
biopsy necessary for staging purposes
low-grade: intraleasional with cryotherapy, maybe wide resection
high-grade: wide en bloc resection
chondrosarcomas are treated with limb-sparing surgery
Oncologic outcome
depends on the grade of the tumor and the resection strategy - 11 - 50%, survival is less than 25% at 5y
Follow up:
low grade: ct scan 6-12 month for 2y
high grade: ct scan 3-6 month for 5y - then annualy up to 10y
primary Chondrosarcomas are rare - 1,5-3,2%, 85% are primary chondrosarcomas, 15% are malignant transformations, mostly the proximal humerus
chondrosarcomas are the most common malignant bone tumor of the hand, incidence less than 1%, mostly the proximal phalanx, small finger, 40-60y, slow growing, rist of metastasis is low, mostly the lung, other viscera or cutaneous involvement has been reported
Bone tumors
benign
major occur in the phalanges 70%
metacarpales 25%
carpal bones 5%
- enchondroma
- epidermoid inclusion cyst
- osteoid osteoma
- osteochondroma
- giant cell tumor (GCT)
- aneurysmal bone cyst (ABC)
- bizarre parosteal osteochondromatous proliferation (BPOP - Nora’s lesion)
- osteoblastoma
bone tumors
benign
enchondroma
most common tumor of the hand, 60% found in the hand, 50% in proximal phalanges - 20-40y, soft tissue involvement can be a sign of a low-grade chondrosarcoma
Histology:
enchondroma:
hypocellular matrix with bland-appearing hyaling cartilage and endochondral ossification surrounding cartilage with lamellar bone
chondrosarcoma:
hypercellular cartilage with binucleate cells and giant cells with clumps of chromatin
bone tumor
benign
osteoid osteoma
second most common osseous hand tumor, 10% of all hand tumors in the hand, 20-30y, classic presentation is a localized sharp pain worse at night, improves with NSAR, result from nerve fibers within the blood vessels associated with the the nidus
metacarpales, proximal phalanges and carpal bones, mostly in the scaphoid
radiographic nidus with a slerotic border, when the nidus is greater than 1,5cm the diagnosis is osteoblastoma
ct or mri with a hyperintense signal on T2 sequence
Treatment:
excision or radio-frequency ablation, for surgical marking administration of tetracycline is helpful to use a Woods UV lamp to localize the tumor with its nidus
bone tumor
benign
epidermoid bone cyst
third most common bone tumor of the hand, caused by trauma - forces keratinizing epthelium into the subcutanenous tissue or bone, over time the cells grow und produce an epithelial cell-lined cyst filled with keratin, mostly at the distal phalanx, more men, 30-40y,
recurrence is rare, curettage and bone filling, DD osteomyelitis or malignant process
bone tumor
benign
giant cell tumor (GCT)
lytic tumor, local aggressive and destructive, 20% of all benign bone tumors, rarely seen in the small bones of the hand (1-5%), distal radius is the third most common location overall, women > men, 30-50y,
metaphyseal and epiphyseal regions, GCT cann metastases into the lung, hand GCT have a higher incidence of local recurrence and pulmonary metastases after interlesional treatment,
bright on T2 mri, histology disorganized trabecular bone with multiple multinucleatesd giant cells, recurrence 50%, radiation is contraindicates with GCT because of radiation induced sarcoma
bone tumor
benign
aneurysmal bone cyst (ABC)
5% of all benign bone tumors, hand involvement is very rare with 3-5%, metacarpal > phalangeal, filled with multiple blood-filled cavaties, locally destructive, occurs with patient of 20y,
associated with other bone tumors
GCT, chondroblastoma, fibrous dysplasia, chondromyxoid fibroma, nonossifiying fibroma
primary (gen defect) and secondary
pain and swelling, pathologic fractures, imaging shows a metaphyseal, expansile, eccentric and lytic lesion with bony septae
bone tumor
benign
osteoblastoma
benign but aggressive tumor characterized by osteoid and woven bone production, nidus larger than 1,5cm, mostly posterior aspect of the spine, 5% of all benign tumors of the hand, involvement of the carpus scaphoid, capitate and hamate has been reported, 2x men than women, 10-30y
DD
osteoid osteom, ABC, osteosarcoma, osteomyelitis
bone tumor
benign
Osteochondroma
osseus growth with a hyline cap - orginated from the physis or tendon insertion site, most common benign bone tumor of the human body, only 4% at the hand
painless, slow-growing mass in the metaphysis of long bones, hand distal aspects of the metacarpal and proximal phalanx, massive growing results in joint limitations or tendon snapping, contact to the medullary canal
recurrence extremely rare, no risk of malignant transformation
bone tumor
benign
benign parosteal osteochondromatous proliferation (BPOP)
Nora’s lesion
hand and feet, hand typical proximal and middle phalanx, as well as the metacarpals
localized swelling and discomfort in the volar aspect of the hand, do not appear in the distal phalanx
DD:
osteochondroma, parosteal osteosarcoma, peripheral chondrosarcoma, healing stress fracture callus, turret exostosis, ossified hematoma, periostitis and myositis ossificans
calcified pedunculated lesion that ist located directly off the corex but is seperated from the intermedullary canal or medullary cavitiy
chondrocytes are so called “bizarre” because of bony trabeculae with irregular endochondral ossification
wide excision, 50% local recurrence
bone tumor
malignant
painful mass, swelling, deformity or pathologic fracture, malignant primary bone tumors of the hand and upper extremity are rare
mostly:
- chondrosarcoma
- osteosarcoma
- Ewing’s sarcoma
- metastatic disease
bone tumor
malignant
osteosarcoma
mostly children and young adults - 10y - 30y, bimodal distribution with another peak at the age of 60y, typically associated with radiation or Paget’s disease (ostitis deformans - higher activity of osteoclasts)
osteosarcoma starts in the medullary cavity and often breaches the cortex and expands into the soft tissues, aggressive periosteal reaction with “sunburst” or “Codman triangle”, tumor produces a matrix of osteoid or chondroid
imaging: T2 hyperintense signal with fat suppression
Subtypes:
classical (80%)
chondroblastic
fibroblastic
Juxtacortical (surface) (parosteal, low grade - well differentiated, periosteal, more aggressive - higher grade, high grade
low-grade intramedullary
small cell (rare)
telangiectatic (25% with pathologic fracture, often with ABC)
secondary (radiation induced, Paget’s associated)
pathogenesis:
malignant primary bone tumor that arises from primitive mesenchymal cells
10% humerus
0,18% hand
metastatic into the lung and the bone
riskfactors:
inactivation of the retinoblastoma gene
Paget’s disease
Li-Fraumeni Syndrome
Rothmund-Thomson syndrome
mostly sporadically, 70% with chromosomal abnormality, radiation in older ages
Treatment:
neoadjuvant (2 month) - surgical - adjuvant
Adriamycin, methotrexate, cisplatin, ifosfamide
bone tumor
malignant
Ewing’s sarcoma
most common in males, peak incidence between 10y and 20y of age, often bone pain, maybe present with systemic symptoms such as fever, anemia, leukocytosis and an increase of lactate dehydrogenase and/or erythrocyte sedimentation rate
Imaging:
poorly marginated, aggressive appearing lytic lesion with permeative appearance and laminated onion skin periosteal reaction, sclerosis of codman triangle or sunburst patterns of the periosteum
Pathogenesis:
rare malignant tumor occurs from the bone or soft-tissue
small-blue-round-cell tumor characteristic from the hematoxylin-eosin staining
10% humerus
3% forearm, wrist and hand
Treatment:
neoadjuvant (2 month) - surgical - adjuvant
vincristine, doxorubicin, cyclophosphamid, (ifosfamine and etoposide)
bone tumor
malignant
metastatic disease
acrometastases exceedingly rare, present with pain or pathologic fracture, 40y or older, 33% of hand metastases are from a previously undiagnosed primary cancer, distal phalanx is the most common location, poor prognosis, life expectancy is less than 6 month
mostly:
thyroid, breast and prostata
treatment:
mostly non-surgical, when risk for pathologic fracture stabilization is needed
Mirel’s scoring System
Score 1 - 2 - 3
site, pain, lesion, size
over 8 points!!! stabilization is needed
Nerve tumors
benign
are uncommon, only 2-5% of all tumors,
Differential diagnosis:
- schwannoma
- neurofibroma
- lipofribromatous hamartoma
- granular cell tumor
- perineurioma
- neurothekeoma
- intraneural ganglion/cyst
- traumatic neuroma
- lipoma
- malignant peripheral nerve sheath tumor
etioloy largely unknown, abnormalities of chromosomes 17 und 22 associated with multiple neurofibromas
difficult diagnosis, (invasion into surrounding tissue, rapid increase in size, constitutional symptoms, large size >5cm, persence of night pain - malignancy)
histologic analysis is the reference standard
mostly painless mass, paresthesias and/or motor weakness, (rapid growth into the nerve fascicles)
mostly the forearm and the volar hand, less than 2cm, in the Hand positive Tinel sign
nerve tumor
benign
Schwannoma
most common benign periphal nerve sheath tumor, solitary and involves large major nerves
asymptomatic and painless, maybe parasthesias, 30-50y, eccentric position to the nerve, tinel sign positive,
MRI bright on T2, hypointense capsule, “tail” on mri,
Pathogenesis:
Tumor arises from the Schwann cells, histologic two areas, Hypercellular (Antoni A) areas with palisading nuclei and Verocay bodies, Hypocellular (Antoni B) areas are less cellular, mostly extracellular matrix
Treatment:
mostly encapsulet, making complete exzision possible, if there is adherence to the soft-tissue around, sign for malignancy, carefully seperation from all nerve fascicles from the tumor, if nerve fascicles enters the tumor maybe a sign for malignancy
nerve tumor
benign
neurofibromas
benign peripheral nerve sheath tumors arising from the schwann cells, fibroblasts and perineural cells, in association with von Recklinghausen disease, 85% cases are solitary in nature
solitary neurofibromas have a low risk of malignant transformation, (von Recklinghausen 4% malignant transformation)
3 main types:
dermal neurofibromas:
affect cutaneus nerves and penetrate into the subcutaneous tissue - “plaque-like swellings”
plexiform neurofibromas:
found along larger nerves and form tortuous masses
localized neurofibromas:
most common with 85% of upper extremity cases
Clinic:
similar to schwannoma, typical not painful, remain small less than 2cm, pain and greater size is a sign for malignancy, associated with the fascicles and not encapsulated, often the fascicles are in the tumor,
Imaging:
“Target sign” in MRI in T2 (lipomas have a hypertense signal on T1)
Pathogenesis:
interlacing bundles or spindle cells with nerve fibers throughout the lesion
Treatment:
surgical excision is difficult because of the contact to the nerv fascicles, 18-44% worsening pain, 15-50% increased weakness
nerve tumor
benign
lipofibromatous harmatoma
benign fibroadipose tumor slowly growing in the volar forearm, mostly like a cts because the median nerve is often involved
one third have a macrodactyly, typical slow growing small tumor, but maybe can reach sizable proportions
Imaging:
MRI - enlarged nerve with “pathognomonic coaxial cables” correspond to 2 / 3mm diameter bundles of axons encased in epineural fibrous tissue, nerve conduction and electromyography is pathologic
pathogenesis:
distinguish from Schwannoma and Neurofibroma from the mass of fat in the tumor, histologic individual nerv bundles with fibroadipose tissue and expansion of the epineurium
treatment:
controversial, Epineurotomy with intraneuronal debulking has been attempted, permanent sensory or motor loss may occur, may occur in the plexus brachialis - than only debulking due pain or disfigurement
nerve tumor
benign
granular cell tumor
from Schwann cell origin, smaller than 3cm, may or may not associated with a major nerve 20% in the upper extremity,
histologic:
large, granular-appearing eosinophilic cells, granular cell tumor stain is positiv for PAS and S-100
difficult to differentiate from schwannoma or neurofibroma without histology, malignant versions exists, treatment with wide excision,
nerve tumor
benign
perineurioma
solitary tumors composed of perineurial cells,
2 main categories:
soft tissue and intraneural
monosomy of Chromosome 22
soft tissue perineurioma are slow growing, painless nodules that occur in young adults, no clear association to a nerve, dermis or subcutaneous fat
intraneural perineuriomas arise within the nerve - commonly with loss of sensory or motor, mostly in the pediatric population, 70% less than 30y, mostly the median nerve is involved
histologic:
perineural cells arranged in whorls and interweaving fascicles - positive for EMA and negative for S-100 perineural cells forming “onion bulbs”
treatment:
controversial, no malignant transformation, maybe tumor resection with nerve autograft,
nerve tumor
benign
neurothekeoma
arise from the Schwann cells or perineural cells, small dermal lesions of the face or upper extremity usually in young adults, less than 20y and more likely to female
histologic:
demonstrates nests and cords of cells with a mucinous matrix, located around small nerves
treatment:
no malignant transformation, oberservation!!!, when neurologic symptoms or diagnosis is unclear, biopsy is performes, mostly encapsulated so they can remove without harming the nerve
nerve tumor
benign
intraneural ganglion / intraneural cyst
uncommon, benign peripheral nerve tumors, peripheral nerve mucoid degeneration, cystic nerve tumor, and neural mucoid pseudocyst
firm mass with motor and or sensory findings due to nerve compression, ulnar nerve within the Guyon’s canal is the most commonly affected nerve in the upper extremity
MRI: hyperintense T2
Pathogenesis:
mucoid containing nonepithelialized cells consistent with a typical ganglion cyst, arises from a stalk from a tendon sheath or joint capsule
treatment:
excision, 30% of patients have persistent symptoms and neurologic dysfunction after excision
Nerve tumor
malignant
MPNST - malignant peripheral nerve sheath tumors
MPNST - malignant peripheral nerve sheath tumor
arise from peripheral nerves or pre-existing benign nerve sheath tumor
development idiopathic, 10% prior radiation, metastize via hematogeneous spread but also local extension and lymphatic spread
origin neuroectodermal and derived from one of the cellular components of the nerve sheath
in contrast to benign tumors this tumor has contact to the axon!!!
very rare - 0,001% incedence in the general population, 20-30% in the upper extremity, 50% of the MPNSTs are from patients with von Recklinghausen disease (neurofibroamatosis Type I) - autosomal dominant condition, loss of the function of the NF1 tumor suppressor gene, which encodes neurofibromin on chromosome 17q11.2
symptoms: 2 or more
- relative first degree
- cafe-au-lait spots
- neurofibromas
- axillary and inguinal freckling
- optic glioma
- Lisch nodules (hyperpigmented iris hamartomas)
- distinctive osseous lesion (sphenoid dysplasia or congenital pseudarthrosis of the tibia)
malignant transformation 10-15%
clinical presentation and diagnosis
pain, enlarging mass and associated neurologic symptoms, diagnosis delayed because of delayed symptoms, malignant transformation - rapid growth over a short time after a long time of slow growth
50y, (neurofibromatosis 30-40y),
Imaging:
“target sign” , MRI can not really differentiate between Neurofibromatosis and MPNSTs, better positronen emissions tomography, CT and x-ray to rule out metastases of the lung and the bone, maybe magnet resonance angiography for surgical planning
MRI: T1 equivalent between tumor and muscle, T2 surrounding edema
amputation and nerve sacrifice is often required
adjuvant radiation maybe helpful for outcome
recurrence is guarded, recurrence 40%, metastasis 67% mostly in lung and bone,
poor prognostic:
proximal tumor
large tumor greater than 5cm
neurofibromatosis
subtotal resection
5y survival rate 40 to 60%, 10y survival rate 23 to 45%
soft tissue tumor
benign
ganglions
most common wrist mass - develop gradually as a swelling on the dorsum of the wrist
20-50y, maybe asymptomatic, maybe pain, cosmetic concern or malignancy concern,
stalk without epithel, not a true herniation, maybe proliferation of benign synovial cells
mostly dorsal scapholunate ligament (SLL), volar - space of Poirier (between the radioscaphocapitate and long radiolunate ligaments), secondary maybe from the scaphotrapeziotrapezoid joint. adults not common from tendon sheaths, children more tendon sheats,
DD: mucous cysts, volar retinacular cysts
soft tissue tumor
benign
dorsal wrist ganglion
treatment:
oberservation, NSAIDs, splinting, aspiration or closed rupture with recurrence rates from 64 - 83%, ASK resection is better because the SLL can be seen and sometimes there are other intraarticular pathologies (42-100%), postoperative splinting for 7-10d, normal function after 4 weeks
recurrence 4-10%, stalk excision recurrence about 1%, incomplete resection recurrence 40%, recurrence open and arthroscopic excision is comparable (0-11%)
