Tumours of the hand Flashcards by Sally-Anne Phillips

What is this?

Ganglion cyst

A Mucin filled synovial cyst.

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What is a ganglion’s aetiology

Trauma

Mucoid degeneration

Synovial herniation

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What is the epidemiology of ganglion cysts?

Most common hand mass 60-70%

Dorsal (70%) orginate over SL ligament

Volar carpal (20%)- Radiocarpal or STT joint

Volar retinacular- dorsal DIPJ- MUCOID cyst assoc with Heberden’s nodes

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What are the signs and symptoms of a ganglion?

Symptoms= Painless lump

Signs= Firm

Well circumscribed

Often fixed to deep tissue but not to overlying skin

Translucent with illumination

Allen’s test to ensure radial/ ulna artery

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What investigations are useful in identifying a ganglion?

XRays normal

Mri - not normally indicated but show a well cicrumscibed homogenous fluid signal intensity

Increased signal intensity on T2-weighted MRI images

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What is the treatment for a ganglion?

Observation- first line in adults

79% in children resolve in a year.

Aspiration- 2nd line in adult, avoid on volar aspect of wrist due to radial artery

50% chance of reoccurrance cf surgical resection but less risks

Biopsy would show mucin-filled synovial cell lined sac

Surgery if severe symptoms or neurovascular manifestations

adequate exposure to ensure entire resection of cyst including stalk and adjacent capsule.

Volar ganglions higher rate of reoccurrance cf dorsal post surgery (15-20%)

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What is this?

Epidermal inclusion cyst

this is Benign, slow growing soft tissue tumour

DD: Tophus gout

Foreign body granuloma

Sebaceous cyst

GCT

Ganglioncyst

Enchondroma

Glomus tumour

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What is the incidence and epidemiology of epidermal inclusion cyst?

Occurs months to years post trauma

Third most common hand tumour

Men > females

3rd to 4th decade

Distal phalanx most common location

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What is the Pathophysiology of epidermal inclusion cysts?

Results from penetrating trauma that drives Keratinised epithelial into subcutaneous tissue

Cells grow slowly to -> epithelial lined cyst filled with keratin

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What is the prognosis of epidermal inclusion cyst?

Marginal Excision is curative, low reocurrance rates

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What are the symptoms and signs of epithelial inclusion cyst?

Symptoms:

Painless swelling frequently occuring in the fingertip

Well circumscribed slightly mobile lesion with white/yellow/flesh coloured in appearance

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What investigations can be useful in epithelial inclusion cyst?

Xrays- ap, lateral and oblique

soft tissue swelling may be evident

A lytic erosion in distal phalanx

Biopsy- to confirm not infection/ neoplasm

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What is the histology of the epidermal inclusion cyst?

Cysts containing keratin lined with epithelial cells

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What is the Tx of epidermal inclusion cyst?

Non operative- not recommended

Operative- Marginal Excision

Careful to remove Entire capsule

**Currettage and bone graft if **bone erosion/ lesions

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What are the complications of epidermal inclusion cysts?

Wound complications

Infection

Digital neuropraxia

Recurrance

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What is the differential diagnosis on this mass?

Giant cell tumour of tendon sheath ( Pigmented villonodular tumour of tendon sheath)

Ganglion cyst

Desmoid tumour

Fibroma/Fibrosarcoma

Pigmented villonodular synovitis- involves larger joints

What is the epidemiology of giant cell tumour of tendon sheath?

3rd-5th decade

2nd most common tumour of hand after ganglion

most common on PALMAR surface of RADIAL 3 digits near the DIPJ

No reports of mets in literature

What are the signs and symptoms a patient with a giant cell tumour of tendon sheath complains of?

Enlarging swelling

Pain worse on activity

O/E:

Firm nodular mass that does not transilluminate

What investigations would be helpful for diagnosisng GCT of tendon sheath?

Xray- pressure type bony erosions ( see picture)

USS- homogenously hypoechoic

MRI-decreased signal on T1 and T2 images

What do you see on histology with GCT of the tendon sheath?

Proliferating histiocytes, moderately cellular (sheets of rounded or polygonal cells)

Multinucleated giant cells are common

What is the Tx of GCT of tendon sheath?

Operative: marginal excision

Recurrence rate of **5-55% **

More common reocurrance if tumour extends volar plate and into joint

Local reocurrance tx with repeated excision

What is this ?

Glomus tumour

A Rare benign tumor of the glomus body, often occurring in the subungual region

What is the epidemiology of Glomus tumour?

Patients 20-30

Location:75% occur in hand ( other palm, wrist, forearm,foot)

50% subungual

50% have erosions of the distal phalanx

What is a glomus body?

The glomus body is a perivascular temperature regulating structure frequently located at the tip of a digit or beneath the nail

What are the signs and symptoms of a glomus tumour?

_Symptoms_**=** **Paroxysmal Pain** **Cold intolerance** **Exquisite tenderness to touch** _Signs=_ **Small Bluish colour nodule- subungual region** **Nail ridging or discolouration**

What investigations can be used to diagnose a glomus tumour?

Xray- pressure erosions-\> deformity of bone cortex MRI - helpful= T1 low, T2 high signal

What is seen on histology of glomus tumour?

**Well-defined lesion lacking cellular atypia** or **mitotic activity** ## Footnote **small round cells with dark nuclei** **Associated small vessels in a hyaline/myxoid stroma**

How is Glomus tumour tx?

Operative- **Marginal Excision** if symptoms affecting quality of life Surgery is **curative** **Low reocurrance rates** ( benign nature of lesion)

What is this?

**Melanoma of the hand** specifically- **acral lentiginous melanoma** DDX could also be trauma subungual hematoma onychomycosis for a nevus seborrheic keratosis basal cell carcinoma

What is the epidemiology of melanoma of the hand?

Effects **Men 1.2 :1 Females** Age **50-70** yrs location **thumb**\>great toe\> index finger **Sun exposed areas**

What are the risk factors of melanoma of the hand?

Sun exposure- uv supress skin immunity , induce myelocyte cell divison-\> free radicals-\> damage melanocyte DNA Increase use in suncreen users- as out in sun Intermittent burning episodes Fhx Blue eyes, fair hair , freckle complexion xeroderma pigmentosa familial atypical mole or melanoma syndrome (FAMM) multiple benign or dysplastic naevi \* = precursor Immunosupression

What is the pathology of melanoma?

Melanocyte DNA damaged by UV and so benign naevus-\> dysplastic naevus-\>radical growth phase-\> vertical growth phase-\> malignant melanoma

What is the prognosis of melanoma? Name the poor prognostic factors?

**DEPTH** of naevus **most important prognostic factor** **\< 0.7mm survical is 94%** **\> 4.0mm survival is 46%** _Poor prognostic factors_ Deep lesion Male Lesion on scalp or neck Positive lymph nodes and metastasis Ulceration **Subungual melanoma** has poor prognosis overall with **5yr survival 40-60%**

Can you name any classifciations of melanoma?

**Breslow thickness** ## Footnote thickness =\< 0.75mm- survival 96% thickness 0.76 - 1.5mm thickness 1.51 - 4mm thickness \>4mm survival **46% **

What are the signs and symptoms of melanoma?

_Symptoms:_ Recent **change in size or shape** **itchy** or **bleeding** _Signs:_ Brown-black pigmented lesion, may ulcerate **Hutchinson sign**= Extension of brown-black pigment of the nail bed or nail plate to the cuticle and nail folds( see pic) Note (ABCDE)- **Asymmetry** **Border irregularity** **Colour variation** **Diameter** (\<6mm benign) **Elevation** **Enlargement**

What investigations would you preform in a pt with melanoma?

CXR- first site of mets Uss-diagnose lymph node enlargement CT - detect mets Bloods- LFTs - liver mets histology = melanocytes with marked atypia, invasion into the dermis, hyperchromatic nuclei with prominant nucleoli

What tx is available for melanoma of the hand?

If Lesion **\<1MM**= local excision with **1mm resection margins** If lesion is **\>1mm**= l**ocal resection with sentenial node biopsy**, if positive = radial lymph node dissection **Mets**= **local excision,lymph noce dissection** and **chemo** **Subungual melanoma**= **Distal amputation** with sufficient **resection margins**- similar reocurrance cf prox amputation _Prevention_ With sunscreen and avoiding sun exposure