Hand Mass

Kusuma Chinaroonchai, MD.31 Oct 2013

Case I: 0885957

• A 77-yr man • Presented with slow

growing mass at base of 3rd MCP for 2 Yrs

• UD CA prostate HT and COPD

• Denied Hx of trauma • Denied Hx of

medication allergy

• PE : 4 cm of firm round, not tender mass at palmar site of base 3rd MCP joint, slightly movable

• No distal pinprick sensation deficit

Case I : Clinical

Case II: 0470042

• 55 Yr woman• Mass at 3rd finger right

hand 2 yrs• UD HT • Denied Hx of trauma• Denied Hx of

medication allergy

• PE : 2 cm cystic to firm consistency mass, not tender at palmar surface of 3rd finger, slightly movable

• Transillumination test: negative

• No distal pinprick sensation deficit

Case III

• 43-yr woman• Refered from outer

hospital• Mass at 3rd finger right

hand 2 mth• No UD• Denied Hx of trauma• Denied Hx of

medication allergy

• PE : 1 cm firm to hard consistency mass, not tender, fixed at palmar site of right 3rd finger

• No limit ROM of right 3rd finger

• No distal pinprick sensation deficit

Case III : X-rays Findings

Case III : Operative Findings

Incidence

• Mostly benign in type (80%) • From ASSH information (American Society for Surgery of the

Hand)

– 1.Ganglion cyst– 2.Giant cell tumour of tendon sheath– 3.Epidermal inclusion cyst

Incidence

• Other benign eg. Enchondroma, osteoma, osteochondroma, Glomus tumour etc.

• Malignancies relatively rare– Skin is most common • SCCA > BCCA

– Bone is 2nd common• Chondrosarcoma

Dx & Ix

• Hx taking – Age– Hx of tumour eg. duration, change in size or color

or ulceration, pain – UD such as psoriasis, rheumatoid etc.– Hx of risk factor eg. Hx of cutanenous

malignancies, sunburn or radiation exposed

Dx & Ix

• PE : S3 C2 MN– S ize– S ite– S hape– C olour– C onsistency – M obility– N odes and Imaging

Dx & Ix

• Lab : up to DDx• Plane X-ray • Accuracy of tissue biopsy – Frozen section 80%– Core needle biopsy 83-93%– Permanent section 96%

Ganglion cyst(Neligan&Green)

• Woman > man • 70% in 20s- 40s• 60-70% in Dorsocarpal– Scapholunate

interrossous ligament

• 20% Volarcarpal– Scapho-trapezio-

trapezoid interossous ligament

Ganglion cyst

• Transillumnation test positive

• Hypothesis formation– Synovial herniation– Synovial dermoid– New growth from

synovial membranes– Modification bursae or

degenarative cysts– Mucoid degeneration

Ganglion cyst

• Choice of treatment (Suen et al. 2013)• Conservative– Reassure : 40-58% spontanous resolution– Aspiration : 15% recurrence– Steroid injection : no benefit– Sclerotherapy : no benefit– Hyaluronidase : in conclusive– Threat technique : 4.8% recurrence 11% infection

Ganglion cyst

• Choice of treatment (Suen et al. 2013)• Surgery : 1% recurrence rate • Operative technique (Green)

– Dorsal wrist ganglion : • Transverse incision• Open joint capsule to remove small intraarticular cyst

– Volar wrist ganglion : • Longitudinal incision• Beware radial artery

Giant Cell Tumour of Tendon Sheath

• Pigmented Villonodular synovitis

• Adams et al. 2012– Woman > men– 40s – 50s

• Slow growing, firm, nodular, nontender mass

• Mostly on volar site and DIP joint of 1st-3rd finger

Neligan&Green

Giant Cell Tumour of Tendon Sheath

• Clinical Diagnosis• Rx marginal excision

**beware nerve displacement and removed satellite lesion**

• Recurrence rate 5-50%

Neligan&Green

Epidermal Inclusion Cyst

• Invagination of epithelium after injury

• Most common in fingertip

• Some mimic bone lytic lesion like malignancy >> biopsy

• Rx : Marginal excision• Rare recurrence

Neligan&Green

Squamous Cell Carcinoma

• Most common malignant tumour in hand• Common in dorsum, chronic sun exposure

area• Askari et al. 2013– Mean age 69 yr (39-89 yr)– Overall survival 5yr 88%, 10yr 57%– Recurrence free survival 5yr 67%, 10yr 50%– Rate of metastasis 4%

Squamous Cell Carcinoma

• Wide excision is Rx of choice• NCCN 2013 guideline : hand region • Resection margin– Size < 6 mm : margin 4-6 mm – Size >/= 6 mm : margin 10 mm

• Clinical LN or imaging LN positive : FNA• If positive FNA >> LN dissection

Squamous Cell Carcinoma

Acinic keratosis : precancerous lesion Squamous cell carcinoma

Basal Cell Carcinoma

• 2nd most common malignant on hand (Vandeweye and Herszkowicz 2003 : < 1% of BCAA all cases)

• Sun exposure area• Mostly presented as chronic ulceration

(Vandeweye and Herszkowicz 2003)

• Ulcerated skin with pearly elevated edges• Rarely metastasize• Confirm Dx by biopsy (excisional or incisional)

Basal Cell Carcinoma

• WLE is Rx of choice• NCCN guideline 2013 • Resection margin – Size < 6 mm : margin

4 mm– Size >/= 6 mm :

margin 10 mm

Melanoma in Hand

• Durbec et al. 2012– Incidence of subungual cutanous melanoma is

0.1/100000– Blacks = Whites– Predominate location at subungual, rarely in palm– UV light irradiation, trauma : still inconclusive risk

factor– Poorer prognosis than other location of melanoma

due to more advanced stage of tumour at first diagnosis

Melanoma in Hand

• Rx from NCCN 2013 guideline• Main Rx still be aggressive surgical resection• Resection margin :– Insitu : 0.5-1 cm– Thick < / = 1 mm : 1 cm– Thick 1.01-2 mm : 1-2 cm– Thick 2.01-4 mm : 2 cm– Thick > 4 mm : 2 cm

Melanoma in Hand

• Rx from NCCN 2013 guideline• SLNB should be done in all cases– Stage IA (thick 0.76-1 mm)

– Subungual melanoma (Difficult to evaluate thickness)

• Work up distant metastasis such as CT chest and abdomen : Stage III (node positive both form FNA and Clinical)

Tumour of Cartilage & Bone in Hand

• Enchondroma : most common of bone tumour in hand

• Osteochondroma• Chondrosarcoma

Enchondroma

• Most common primary tumour in the bone of the hand (Green : 35% of all, 90% of bone tumour in hand)

• Proximal phalanx > metacarpal > distal phalanx

• Common present with pain and edema (pathologic fracture)

• X-ray : radiolucent lesion with cortical thinning and popcorn calcification

Enchondroma

• Solitary lesion 1-5% transform to chondrosarcoma (Muller et al. 2004)>> *need F/U*

• Rx : – Small & asymptomatic with typical X ray >>

conservative and observation– Large or symptomatic or atypical X-ray >> biopsy

or curettage • 4.5% recurrence after curettage

Periosteal Chondroma

• Uncommon• Confused

– X-ray like enchondroma– Histology like chondrosarcoma

• Men in 20s – 30s• Metaphyseal-diaphyseal junction of

phalanges• Benign but need marginal resection

with overlying periosteum• < 4% local recurrence

Osteochondroma

• Most common benign bone tumour, but not in hand region

• Distal aspect of proximal phalanx in 20s-30s

• X-ray : osseous growth with cartilaginous cap from physis area

Osteochondroma

• 1-2% malignant transformation in single lesion (Kitsoulis et al. 2008)

• 10-25% malignant degeneration in mutiple lesion case (Neligan)

• Rx : – Asymptomatic : observation– Impaired function : excision

Chondrosarcoma

• Most common primary malignant bone tumour in hand

• Slowly growth, firm and painful mass• Proximal phalanx (Patil et al. 2003) and metacarpal• X-ray : lytic lesion with cortical destruction and

soft tissue destruction with poor defined border• 10% risk for metastasis (Muller et al. 2004 : less than

other location,18%)

Chondrosarcoma

• Most common metastatic site : lung(CT chest for metastatic work up)• Rx : En bloc excision

Thank Youfor

Your attention

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