Week 1 - G - Benign/Malignant Soft Tissue Tumours - Lipoma/Giant cell/Ganglion & Sebaceous cyst/Bursitis/Abscesses & Sarcomas

Question 1

A soft tissue swelling may present to orthopaedics if situated on an arm or leg. Soft tissue swellings may be diffuse (as in synovitis or oedema) or local. What do local swellings include?

Answer 1

Local swellings include

* Inflammatory swellings - bursitis, rheumatoid nodules

* INfection - abscesses

* Cystic lesions - ganglion cyst, meniscal cyst, Baker’s cyst

* Lipoma

* and Malignant neoplasms

Question 2

What questions do you usually ask for a localised swelling?

Answer 2

How long the lump has been present

Whether the lump is painful

If it is growing or fluctuating in size

Whether it is solitary or multiple

Question 3

Findings to look for on examination of a soft tissue tumour: * Site * Size * Definition – well defined or ill defined * Consistency – cystic, solid, soft, hard * Surface – smooth or irregular * Mobility or Fixity – to skin or deep tissues * Temperature – abscess * Transilluminable – fluid filled * Pulsatility * Overlying skin changes * Local lymphadenopathy

Which findings suggest a benign soft tissue neoplasm?

Answer 3

Features suggestive of a benign soft tissue neoplasm include

• * Smaller size
• * Fluctuation in size (malignant tumours do not regress in size)
• * Cystic lesions
• * Well defined lesions
• * Mobile lesions
• * FLuid filled lesions
• * Soft and fatty lesions

Question 4

Findings to look for on examination of a soft tissue tumour: * Site * Size * Definition – well defined or ill defined * Consistency – cystic, solid, soft, hard * Surface – smooth or irregular * Mobility or Fixity – to skin or deep tissues * Temperature – abscess * Transilluminable – fluid filled * Pulsatility * Overlying skin changes * Local lymphadenopathy

Which findings suggest a malignant soft tissue neoplasm?

Answer 4

Features suggestive of a malignant soft tissue neoplasm include

• * Larger lesions (>5cm), rapid growth in lesion
• * Ill-defined lesions
• * Solid lesion
• * Irregular surface
• * Associated lymphadeopathy and systemic upset

Question 5

What investigations may be necessary for any lesions where the nature of the swelling is unknown?

Answer 5

Any lesions where the nature of the swelling is unknown may need imaging by

* MRI (or ultrasound to confirm a cystic lesion)

* or biopsy for histological diagnosis

Question 6

Benign soft tissue tumours can involve any of the non‐bony connective tissues, nerves or vessels. What is the commonest benign soft tissue tumour? Where does it occur?

Answer 6

The commonest benign soft tissue tumour is a lipoma - a neoplastic proliferation of fat

Lipomas usually occur in the subcutaneous fat but can occur in muscle

Question 7

How would you describe a lipoma on examination?

Answer 7

Lipoma’s have smooth, imprecise margins and are not fixed to skin or deeper structures

Question 8

What is the giant cell tumour of tendon sheath? Why can it also be known as giant cell synovium?

Answer 8

Giant cell tumour of the tendon sheath is a rare benign tumour which can develop on the tendon sheaths around the body

A tendon sheath is a layer of membrane around a tendon known as synovium hence the name giant cell synovium

Question 9

What does the giant cell tumour of the tendon sheath feel like and which tendon sheath is normally affected?

Answer 9

Giant cell tumour of tendon sheath feels like a small firm swelling usually found on the flexor tendon sheath of the finger (wiki states - most commonly attached to the tendons of the fingers, hands, and wrists, with a predilection for the flexor surfaces)

Question 10

How does the giant tumour of tendon sheath appear both macroscopically and histologically?

Answer 10

Macroscopically, the giant cell tumour of tendon sheath is a pigmented lesions

Histologically, they contain multinucleated giant cells and haemosiderin

Question 11

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

Answer 11

They can be excised but they have a fairly high chance of recurrence

Question 12

What is it known as when giant cell tumours of the tendon sheath occur within a joint? Which joints is commonly affected?

Answer 12

When giant cell tumour of the tendon sheath occurs in a joint, it is known as Pigmented villonodular synovitis (PVNS) , also known as intra-articular giant-cell tumor of the tendon sheath

Most commonly affects the knee joint

Question 13

What is a ganglion cyst and where do they occur around?

Answer 13

A ganglion cyst is a small sac of fluid that occurs around a synovial joint or a synovial tendon sheath - most commonly the wrist

Question 14

What may cause the development of a ganglion cyst?

Answer 14

They may form as a result of herniation or out-pouching of a weak portion of joint capsule or tendon

Weakness can be developmental or as a result of underlying joints damage/arthritis

Question 15

How would you describe a ganglion cyst on examination? What test can be done to make sure it is a ganglion cyst?

Answer 15

Ganglion cysts are well defined, may be quite firm and when transilluminate when a transillumination test is carried out (shining a light on it)

Question 16

What is the treatment of a ganglion cyst?

Answer 16

Treatment is usually not necessary however excision may be required for local discomfort or cosmesis

Question 17

What is bursitis? Define a bursa

Answer 17

Bursitis is inflammation of the bursa - a small fluid filled sac lined by synovium around a joint which prevents friction between tendons, bones, muscles and skin

Question 18

There are numerous bursae around different joints and bony prominences. Name commonly inflamed bursae which usually occur after repeated pressure or trauma and which may present as a soft tissue swelling?

Answer 18

Pre-patellar bursitis (housemaid’s knee)

Olecranon bursitis

Bunions - bursitis over the medial 1st metatarsal head in hallux valgus

Question 19

Bacterial infection can cause a bursal abscess (usually from a small wound on the limb) and gout may cause a bursitis. What may happen to the burse in an inflammatory bursitis?

Answer 19

With inflammatory bursitis the fluid component of the swelling usually subsides but a thickened bursal sac may be left.

Question 20

What is a seabeous cyst?

Answer 20

Sebaceous cysts are common noncancerous cysts of the skin.

A sebaceous cyst is a closed sac found under the skin, usually on the trunk, neck, or face

Question 21

What is an abscess? What are the symptoms?

Answer 21

An abscess is a collection of pus that has built up within the tissue of the body.

* Signs and symptoms of abscesses include redness, pain, warmth, and swelling.

* The swelling may feel fluid-filled when pressed.

Question 22

What is the treatment of an abscess?

Answer 22

Abscesses will not resolve with antibiotics alone and require incision and drainage

Question 23

Malignant soft tissue tumours arising from the connective tissues are known as what? What percentage of all malignant tumours do they account for?

Answer 23

Malignant soft tissue tumours arising from the connective tissues are known as sarcomas

They are relatively uncommon and account for less than 1% of all malignant tumours

Question 24

Sarcomas can arise from and are named according to the tissue type from which they arise Where do each of these soft tissue tumours arise from

Angiosarcoma

Fibrosarcoma and malginant fibrous histiocyoma

Liposarcoma

Rhabdomyosarcoma

Synovial sarcoma

Answer 24

Angiosarcoma - arises from blood vessels

Fibrosarcoma and malignant fibrous histiocytoma - arise from fibrous tissue

Liposarcoma - arises from fat

Rhabdomyosarcoma - arises from skeletal muscle

Synovial sarcoma - arises from synovial lining of joints or tendons

Question 25

What age group do sarcomas commonly present in?

Answer 25

Sarcomas most commonly present between the ages of 50 and 70 but can occur at any age.

Question 26

If there is any doubt as to the nature of a soft tissue swelling, what should be done?

Answer 26

If there is doubt over the nature of a soft tissue swelling, referral to a specialist is recommended with imaging and biopsy as required.

Question 27

Once the diagnosis is established, the cancer is graded and staged What is the usual treatment of soft tissue tumours?

Answer 27

Usual treatment is surgical with adjunctive chemotherapy and / or radiotherapy