23 Tumors of the Hand

Samir Sabharwal and Sophia Anne Strike

Abstract

Hand tumors comprise benign and malignant soft tissue and bony lesions. Thorough evaluation—generally comprising history and physical examination, plain radiography and cross-sectional imaging, and biopsy—is necessary to guide appropriate treatment. Of the benign pathologies, ganglion cysts, epidermal inclusion cysts, and tenosynovial giant cell tumors are the most common soft tissue lesions, and enchondromas are the most common bony lesions. Of the malignancies, epithelioid and synovial sarcomas are the most common soft tissue lesions and chondrosarcomas are the most common bony lesions. Benign lesions may be treated with observation or marginal/intralesional excision. Malignancies mandate wide resection and multidisciplinary oncologic care.

Biopsy – local recurrence – wide resection – observation – ganglion cyst – enchondroma – sarcoma – carcinoma

23 Tumors of the Hand

I. Introduction

Although benign bone and soft tissue lesions in the hand are more common than malignancies, thorough evaluation is necessary prior to treatment.

II. Epidemiology

Soft tissue tumors of the hand accounts for 15% ofall soft tissue tumors.
Benign lesions are more common than malignancies:
- Ganglion cysts, epidermal inclusion cysts, and giant cell tumors of tendon sheath (a.k.a. tenosynovial giant cell tumor) are the most common benign soft tissue lesions.
- Enchondromas, benign cartilage tumors, account for 90% of primary bone tumors of the hand.
- Epithelioid, synovial sarcoma and chondrosarcoma are the most common malignant soft tissue and bony sarcomas of the hand, respectively.
- The hand is involved in 0.1% of bony metastases.

III. Diagnosis

As with other hand pathology, begin with a thorough history and physical examination:
- Important points to include: Date of symptom onset, mass presence, timeline of progression, character of pain, and neurologic and mechanical symptoms.
- Intermittent size fluctuations of mass—more likely cystic or vascular, less likely neoplasm.
- Note mass firmness, mobility, overlying skin changes, local discoloration, neighboring joint range of motion (ROM), neurologic findings, and transillumination.

A. Imaging

Anteroposterior (AP), lateral, and oblique radiographs generally obtained for all hand masses:
- Osseous lesions are typically well-demonstrated on plain radiographs.
- Enchondromas and aneurysmal bone cysts present as lytic, expansile lesions.
- Soft tissue calcifications, shadows, and local osseous erosion may indicate soft tissue tumor.
Cross-sectional imaging:
- MRI is required for diagnosing many tumors, particularly soft tissue tumors. Hyperintensity on T2-weighted fat-suppressed or short-tau inversion recovery with nodular or mass-like enhancement on T1-weighted postcontrast sequences is concerning for malignancy.
- CT scan may be useful to further evaluate bony detail, particularly of a presumed osteoid osteoma.
- Metastatic disease requires appropriate staging studies, including chest CT scan for all sarcomas and whole-body imaging for bone sarcomas.
Biopsy is generally required for definitive diagnosis of hand tumors. It should be performed by the surgeon planning to definitively treat the tumor:
- Needle biopsy includes both fine-needle aspiration and core-needle biopsy. These may be image-guided by ultrasound (US) or CT to improve accuracy, but sampling error may still be of concern.
- Open incisional biopsy should be designed with a subsequent wide resection in mind—the biopsy tract must be excised during final resection. Otherwise commonly used hand incisions (e.g., Bruner’s) may not accommodate later digit
  - or hand-sparing resection.
- Excisional biopsy may be performed in cases where a benign lesion is suspected with a high degree of certainty, and when excision would not compromise future wide resection if the mass is found to be malignant.

IV. Treatment

A. Benign Lesions

Benign lesions may often be treated with observation, which may include interval imaging. Diligent monitoring for signs of malignancy is necessary.

1. Soft Tissue Lesions

Ganglion cysts represent >50% of hand masses:
- Usually connected to joint by stalk; fluid shifts associated with size fluctuation
- Most common in dorsal wrist (~65%).
- Often self-resolving; open or arthroscopic excision is an option for persistent, symptomatic cysts.
Epidermal inclusion cysts form after subdermal deposition of an epithelial cell, typically in the setting of trauma:
- Slow-growing, but may erode bone locally.
- Surgical excision is recommended
Lipomas may be safely observed or excised, according to size and symptoms:
- Well-encapsulated, facilitating excision (► Fig. 23.1).
- Atypical lipomatous tumors rarely undergo malignant transformation to liposarcoma.
Peripheral nerve sheath tumors include schwannomas and neurofibromas:
- Neurofibromas associated with neurofibromatosis have a higher risk of malignant transformation.
- If symptoms warrant excision, sacrifice of a nerve may be necessary particularly for neurofibromas—nerve grafting is an option in these cases. Schwannomas may be more easily shelled out from the associated nerve, preserving function.
Vascular malformations, depending on symptom severity, may be treated with compression garments, sclerotherapy, embolization, or surgical excision in coordination with interventional radiology.
Tenosynovial giant cell tumor, histologically identical to pigmented villonodular synovitis (PVNS), typically occurs on the palmar hand, but can be found throughout the hand and wrist.
- Often locally aggressive, warranting excision.
- Reported recurrence rates as high as approximately 50 to 60%.
Glomus tumors occur in the subungual region:
- Arise from the glomus body, a vascular temperature regulator—frequently cause cold hypersensitivity.
- Surgical excision via nail bed is recommended
Periosteal chondromas are rare extramedullary cartilaginous tumors:
- Typically juxtacortical, may cause scalloping of underlying bone.
- Recommend resection of adjacent cortex with mass to reduce risk of local recurrence.