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Digital Mucous Cyst Workup

  • Author: Murad Alam, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Mar 20, 2015
 

Imaging Studies

Plain radiography findings are not diagnostic for digital mucous cysts (DMCs) but will demonstrate a nonspecific soft-tissue density and adjacent bony involvement consistent with osteoarthritic changes.

Ultrasonography evaluation reveals a rounded or lobulated mass of markedly hypoechoic appearance with smooth, well-defined walls immediately adjacent to the involved synovial compartment. A tapering margin, which constitutes the "neck" of the cyst, is observed. Ultrasound is faster and better tolerated than MRI, but MRI is less operator dependent.

CT scanning usually demonstrates a well-defined water density mass with normal surrounding soft tissue.

On MRIs, homogenous low-intensity lesions are seen on T1-weighted images, with markedly increased signal and sharp borders on T2-weighted images. Other cyst features that may be observed are intracystic septa, satellite cysts, cyst pedicles, osteoarthritis of the distal interphalangeal (DIP) joint, subungual cysts, and multiple flattened cysts. MRI is an excellent modality for visualizing soft tissue cyst structures and may be particularly useful preoperatively.[6]

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Other Tests

Transillumination with a penlight may assist in making the diagnosis and in differentiating digital mucous cysts from giant-cell tendon sheath tumor.

Approximately 12 hours before surgery, the DIP joint may be injected with methylene blue and local anesthetic. The coloring of the entire cyst and pedicle at the time of surgery may facilitate removal of the entire cyst and minimize the risk of recurrence.

Injection of radio-opaque contrast material into the cyst and passage of this material into the adjacent joint may yield a radiograph that reveals the entire extent of the cyst. This technique provides an image of the cyst extent prior to the surgery itself; therefore, it may be more practical than methylene blue infusion.[7]

Chemical analysis of matrix is a research test that has no role in routine diagnosis. Cellulose acetate paper electrophoresis and enzymatic digestion liquid chromatography demonstrates that digital mucous cysts contain copious quantities of glycosaminoglycans, primarily hyaluronic acid.

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Procedures

Fine needle aspiration may have an ancillary role in diagnosis. On such aspiration, a large amount of clear gelatinous fluid is expressed. Rare macrophages and histiocytes are found in the thick, mucoid matrix, as are a few tight clusters of cells, some collagen fibers, and red blood cells with altered shapes.[8]

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Histologic Findings

On microscopy, a pseudocyst with a fibrous capsule and myxomatous stroma with scattered fibroblasts is seen. A partial mesothelial lining, but not a true cyst wall, may be found. The overlying surface epithelium demonstrates compact hyperkeratosis with a collarette of hyperplastic epidermis. The mucinous contents stain basophilic with hematoxylin and eosin and can be seen clearly when stained for acid mucopolysaccharides with colloidal iron or Alcian blue. Note the image below.

Histopathology of digital mucous cyst. Histopathology of digital mucous cyst.

On scanning electron microscopy, a porous network of collagenous fibers form the cyst wall and a fibrillated inner surface composed of a random arrangement of collagen fibers is observed. An intermittent thin membrane occurs on the inner surface, but no evidence of a cellular lining is apparent.

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Contributor Information and Disclosures
Author

Murad Alam, MD Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery, Department of Dermatology, Northwestern University; Director, Mohs Micrographic Surgery, Northwestern Memorial Hospital

Murad Alam, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society of Transplantation, Phi Beta Kappa, Society for Investigative Dermatology, American College of Aesthetic and Cosmetic Physicians; American Society of Aesthetic/Cosmetic Physicians, Women's Dermatologic Society, Dermatology Foundation, Illinois Dermatological Society, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Natalie Ann Kim-Orden, MD Intern, Children's Hospital of Los Angeles

Disclosure: Nothing to disclose.

Melanie Warycha, MD Procedural Dermatology Fellow, Department of Dermatology, Northwestern University Feinberg School of Medicine

Melanie Warycha, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, Women's Dermatologic Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Kira Minkis, MD, PhD Director of Mohs and Dermatologic Surgery, Director of Surgical, Laser, and Cosmetic Education, Assistant Professor, Department of Dermatology, Weill Cornell Medical College; Attending Physician, New York Presbyterian Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina at Chapel Hill School of Medicine; Professor Emeritus of Dermatology, Columbia University College of Physicians and Surgeons

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

David Bickers, MD, Chairman, Carl Truman Nelson Professor, Department of Dermatology, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Mary Farley, MD Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center

Disclosure: Nothing to disclose.

References
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  7. Daffner RH, Whitfield PW. Recurrent ganglion cyst: the value of preoperative ganglionography. AJR Am J Roentgenol. 1977 Aug. 129(2):345-6. [Medline].

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  9. Epstein E. A simple technique for managing digital mucous cysts. Arch Dermatol. 1979 Nov. 115(11):1315-6. [Medline].

  10. Epstein E. Steroid injection of myxoid finger cysts. JAMA. 1965. 194:98-99.

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  14. Huerter CJ, Wheeland RG, Bailin PL, Ratz JL. Treatment of digital myxoid cysts with carbon dioxide laser vaporization. J Dermatol Surg Oncol. 1987 Jul. 13(7):723-7. [Medline].

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  16. Jamnadas-Khoda B, Agarwal R, Harper R, Page RE. Use of Wolfe Graft for the Treatment of Mucous Cysts. J Hand Surg Eur Vol. 2009 Apr 24. [Medline].

  17. Blume PA, Moore JC, Novicki DC. Digital mucoid cyst excision by using the bilobed flap technique and arthroplastic resection. J Foot Ankle Surg. 2005 Jan-Feb. 44(1):44-8. [Medline].

  18. Imran D, Koukkou C, Bainbridge LC. The rhomboid flap: a simple technique to cover the skin defect produced by excision of a mucous cyst of a digit. J Bone Joint Surg Br. 2003 Aug. 85(6):860-2. [Medline].

  19. Johnson SM, Treon K, Thomas S, Cox QG. A reliable surgical treatment for digital mucous cysts. J Hand Surg Eur Vol. 2013 Oct 25. [Medline].

  20. de Berker D, Lawrence C. Ganglion of the distal interphalangeal joint (myxoid cyst): therapy by identification and repair of the leak of joint fluid. Arch Dermatol. 2001 May. 137(5):607-10. [Medline].

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