What is the role of computed tomography (CT) in assessing upper extremity tumors?
CT is used to evaluate extent of bone destruction as well as calcified lesions.
What is the role of magnetic resonance imaging (MRI) in assessing upper extremity tumors?
MRI is used for evaluation of lesions involving bone and soft tissue.
How is clonality used to differentiate between neoplasms and benign tissue growths (i.e., Dupuytren disease)?
Benign and inflammatory conditions are typically polyclonal, whereas neoplasms are monoclonal.
In which direction should the incision be oriented when obtaining a biopsy of an upper extremity mass?
Orient the incision longitudinal (rather than transverse or zigzag) so as to incorporate the biopsy site within the definitive excision or amputation.
When performing a biopsy on a lesion, should one dissect around muscle planes or split the muscle sharply?
Split the muscle sharply (to avoid seeding other muscle compartments).
Should drains be placed after performing an open biopsy?
No, drains can seed tumor cells along their tracts. Thus, use diligent hemostasis to prevent hematoma formation.
Should a tourniquet be used when operating on a neoplasm of the upper extremity?
Yes, a tourniquet should be used, but exsanguination of the arm should be done through elevation. Do not use an Esmarch bandage.
BENIGN TUMORS 
What is the usual etiology of epidermal inclusion cysts?
Epidermal cells become embedded in the dermis, which is usually the result of trauma.
Where do epidermal inclusion cysts usually occur?
In the glabrous, non–hair-bearing skin of the palms and fingertips (especially perionychium).
What is the treatment of epidermal inclusion cysts?
Complete excision along with the skin puncture wound (or punctum, if present).
What is a glomus tumor?
A glomus tumor is a benign hamartomatous neoplasm formed from the thermoregulatory neuromyoarterial apparatus in the stratum reticulare.
What are the clinical findings seen with a subungual glomus tumor?
Severe pain, cold sensitivity, tenderness, nail deformity, or discoloration.
What is the treatment of a subungual glomus tumor?
Removal of nail plate and complete excision of the tumor.
What is the most likely diagnosis in a patient with a subcutaneous elevation just proximal to the eponychial fold and associated nail grooving?
Mucous cyst. Mucous cysts are fluid-filled ganglia of the distal interphalangeal joint associated with bony spurs and nail grooving.
What is the treatment of mucous cysts?
Cyst excision and removal of bone spurs.
What is a pyogenic granuloma? What demographic does it affect most commonly?
Pyogenic granuloma is a rapidly growing vascular, friable nodule. It is frequently seen on fingertips in young adults, and notably most common after pregnancy.
What is a Keratoacanthoma?
Keratoacanthoma is a lesion commonly found on the dorsal hand that is round, elevated, and usually has a central crater. This lesion usually resolves spontaneously and only occasionally progresses to squamous cell carcinoma.
What is the natural history of keratoacanthomas?
They undergo three phases:
1. Proliferation
2. Maturation
3. Involution
The history and clinical presentation will usually include the rapid growth of a pre-existing lesion that then gradually gets smaller as the central crater expels a keratin plug.
What is the recommended treatment for keratoacanthomas?
Surgical excision or intralesional injection using 5-fluorouracil (5-FU) or methotrexate.
What are the first and second most common tumors or masses of the hand?
Ganglions and giant cell tumors (GCTs), respectively.
What is the predominant cell type in GCTs (aka localized nodular synovitis)?
Histiocytes.
What is the usual site of origin of GCTs?
Flexor tendon sheath.
What is the treatment of GCTs?
Complete excision along with stalk (if present).
How is a lipoma diagnosed?
Physical examination demonstrating a soft, mobile, nontender mass that does not transilluminate along with a consistent clinical history of slow growth.
What is the difference between a neurofibroma and a neurilemmoma?
Neurofibroma: tumor arising within the nerve fascicles. Neurilemmoma (also known as schwannoma): tumor of Schwann cells on the nerves surface.
How does this difference impact treatment?
Neurilemmoma can be “shelled out” easily leaving the nerve intact, while neurofibroma requires transection at the proximal and distal fascicles.
Are these common tumors?
Neurilemmomas are the most common benign nerve tumors in the upper extremity.
A patient presents with multiple neurofibromas of the upper extremity and cutaneous café-au-lait spots. What is your diagnosis?
Von Recklinghausen disease or neurofibromatosis type 1.
A patient presents with bilateral acoustic schwannomas. What is the likely diagnosis?
Neurofibromatosis type 2. Of note, these patients rarely have neurofibromas.
What diagnostic studies can be used to differentiate between neurofibroma and neurilemmoma?
Magnetic resonance (MR) and nerve conduction studies.
What is the treatment of fibromatosis and juvenile aponeurotic fibromas?
Treatment involves wide excision with skin grafting or free tissue transfer. Despite this approach there remains a high potential for recurrence.
What is infantile digital fibromatosis (IDF)?
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
