Hand Tumors: I. Skin and Soft-Tissue Tumors of the Hand

A multivariate analysis on characteristics of hand and wrist tumours: a multiethnic study

INTRODUCTION

Hand tumours are frequently encountered in clinical practice. However, large-scale epidemiological data of soft tissue tumours in the hand are infrequently published. Epidemiological data provide diagnostic cues to guide the workup and management of hand tumours. Assessing significant independent demographic factors and tumour characteristics associated with hand tumours is essential in health care.

METHODS

A retrospective review of patients who underwent excision of hand tumours in Singapore General Hospital between 2004 and 2015 was conducted. The data collected included age, gender, ethnicity, histological diagnosis, malignancy and location of tumour. Generalised linear latent and mixed models (GLLAMM) analyses were performed.

RESULTS

A total of 4476 tumours were identified from 4226 patients with a mean age of 51.3 (range 8-101) years and male to female ratio of 1 to 1.15. Most patients were Chinese (75%), followed by Malay (9%), Indian (8%) and others (8%). The most common hand tumours excised were ganglions (43%) (majority in the wrist), followed by giant cell tumours (9%) (commonly in the digits). Most soft tissue tumours were benign (97%), with only 3% of malignant cases. The GLLAMM analyses revealed further potential factors on the status of malignancy, tumour origin and tumour location.

CONCLUSION

Most soft tissue tumours in the hand and wrist are benign. This can guide workup and counselling of patients before the operation. While malignant tumours are uncommon, they have the potential for significant morbidity and mortality if not appropriately evaluated or treated. The application of GLLAMM analyses showed that age, ethnicity and gender were significant predictors of malignancy.

Is a routine histopathological examination justified for all tumours resected from the upper extremity?

Most lesions of the upper extremity are common and benign, and the need for a routine pathology evaluation of these specimens has often been questioned. This study aimed to evaluate the concordance of the initial clinical and final histological diagnoses of tumours which, based on clinical presentation and intraoperative findings, are most likely benign or malignant, and to answer the question whether or not a routine histopathological examination is justified for all tumours in the upper extremity.

MATERIAL AND METHODS

We analysed the results of histopathological examinations of benign tumours resected in 346 patients and malignant tumours resected in 6 patients.

RESULTS

Our analysis showed a 100% concordance between the initial (clinical) diagnoses of the tumours as benign or malignant and their final histopathological diagnoses. Only in 12 cases (3.5%) of initially benign tumours did the clinical presentation and/or intraoperative findings raise doubts.

CONCLUSIONS

The results of this study show that a routine histological evaluation of all tumours resected from the upper extremity is not justified and may be confined to selected cases in which clinical presentation and/or intraoperative findings raise doubts.

Outcomes of Surgery for Benign Tumours in The Upper Extremity

Benign tumours of the upper extremity are common in hand surgeons' practice. The most commonly diagnosed are giant-cell tumours of the tendon sheath and lipomas.

THE OBJECTIVE

of this study was an investigation into the distribution of tumours in the upper limb, their symptomatology and outcomes of surgery, particularly regarding the rate of recurrence.

MATERIAL AND METHODS

A total of 346 patients, 234 women (68%) and 112 men (32%), who had undergone surgery for tumours located in the upper extremity which were not ganglion cysts were enrolled into the study. The follow-up assessment was performed at a mean of 21 months (range 12-36) post-operatively.

RESULTS

The most common tumour in this study was giant cell tumour of the tendon sheath - 96 cases (27.7%), followed by lipoma - 44 cases (12.7%). Most lesions - 231 (67%) were localized in the digits. A total of 79 (23%) recurrences were noted, the most common after surgery for rheumatoid nodules - 43.3% and the giant-cell tumours of the tendon sheath - 31.3%. The independent factors increasing risk of recurrence following the tumour's resection were: histological type of the lesion - the giant-cell tumour of the tendon sheath (p=0.0086) and the rheumatoid nodule (p=0.0027), as well as a combination of incomplete (non-radical) and not "en block" resection of tumours. A brief review of the literature referring to the presented material is offered.

Differential Diagnoses of Pediatric Upper Limb Masses

PURPOSE

Upper limb masses are one of the most common presentations in the outpatient setting. However, there is a paucity of information in the literature regarding the epidemiology of upper-extremity masses in the pediatric population. The aim of this study was to determine the differential diagnoses and clinical characteristics in children aged ≤18 years presenting with upper limb masses.

METHODS

A retrospective review of patients aged ≤18 years managed at our institution over a 5-year period was performed. We obtained information on patient demographics, clinical features, radiological investigations, intraoperative features, and histology. We also evaluated the correlation between the clinical and histopathological diagnoses in patients who underwent surgery.

RESULTS

There were 141 upper limb masses in our series. The mean age at presentation was 12 years (SD, 5 years). The most common presenting complaints were asymptomatic swelling, pain, and paresthesia. The majority (128; 91%) of tumors were benign; there were 5 locally aggressive tumors and 6 malignant tumors. The dominant hand was involved in 60 patients. Of 140 patients, 43 (31%) patients had surgery. The procedures included incisional biopsy, excisional biopsy, wide resection, and reconstruction. One patient required a below elbow amputation for an osteosarcoma.

CONCLUSIONS

Ten percent of cases represented malignant or locally aggressive disease. We have used our observations to develop a clinical algorithm that can assist clinicians in evaluating and managing children and adolescents presenting with upper-extremity masses.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

An analysis of cases presenting with a mass in the hand and an evaluation of treatment methods

The aim of this study was to present and discuss our clinical experience of patients presenting with a mass in the upper extremity, in respect of demographic characteristics, localisation of the mass, clinical and pathological characteristics. A retrospective evaluation was made of 114 cases (60 females, 54 males) who presented at our clinic with complaints of localised pain and swelling in the upper extremity between 1 June 2016 and 31 December 2018. The cases were separated into 3 groups; Group 1 with a mass determined in the carpal region, Group 2 with localisation between the wrist and the metacarpophalangeal joint, and Group 3, in the distal of the metacarpophalangeal joint. The mass was of soft tissue origin in 90 cases, and of bone origin in 24 cases. The distribution of cases was 6 in Group 1, 20 cases in Group 2, and 88 in Group 3. The tumour was benign in 105 (92%) cases and a primary malignancy in 9 (7.8%) cases. Recurrence occurred in 4 cases, of which 2 were enchondroma, 1 was a giant cell tendon sheath tumour, and 1 was hemangioma The majority of painful masses seen in the hand are benign and very few are malignant. In the approach to hand tumours, clinical evaluation guided by demo- graphic data, and the evaluation of diagnostic and treatment options according to the radiological ap- pearance and anatomic localisation will determine the ideal approach providing a full cure.

[Fibro-osseous Pseudotumor of the Digits - a Chameleon among generally rare Hand Tumors]

Der fibro-ossäre Pseudotumor der Finger (FOPD = fibro-osseous pseudotumor of the digits) ist unter den Handtumoren insgesamt als auch unter den benignen Handtumoren eine seltene Entität. FOPD können sowohl klinisch als auch radiologisch eine maligne Neoplasie nachahmen. Hauptsächlich tritt dieser Tumor bei jüngeren Erwachsenen, vorwiegend Frauen, auf. Bis dato ist eine maligne Transformation nicht beschrieben. Allerdings führen klinische und histologische Befunde fälschlicherweise immer wieder zur Diagnose eines bösartigen Tumors.

Diagnosis and treatment of hand tumors

Hand tumors are a very common problem in hand surgery. While these lesions are most often benign, malignant lesions often have an atypical presentation and are discovered late, very often during an inappropriate treatment. To optimize the care of hand tumors and to reduce diagnostic and treatment errors, we will review the broad diagnostic and therapeutic principles and the most common clinical presentations.

Hand Tumors: An Individual Surgeon's Retrospective Review

BACKGROUND

Tumors of the hand are encountered frequently and represent a variety of pathologic diagnoses, both benign and malignant. Even within a single pathologic type, presentation can vary. This study reviews hand tumors encountered by an individual surgeon and described presenting features to better aid in clinical decision making.

METHODS

A retrospective chart review of patients presenting with a hand tumor between January 2005 and December 2017 from an individual surgeon's perspective was performed. Pertinent data were extracted by researchers and statistical analysis was completed with GraphPad Prism (GraphPad Software, Inc).

RESULTS

A total of 101 patients aged 14 months to 87 years (mean age, 40.52 years) were included. Within this patient group, soft tissue tumors accounted for 97%, malignant neoplasm 2%, and bone tumors 1%. Ganglion cysts were most common (54.5%) followed by hemangiomas (9.9%), giant cell tumors (6.9%), granulomas (5.9%), and fibromas (5%). A total of 54.5% of patients reported pain and 43.5% reported decreased range of motion (ROM).

CONCLUSIONS

In this patient cohort, ganglion cyst was the most common tumor type and presented with pain and deficits in ROM. This is contrary to the asymptomatic presentation of such cases in the literature. Other common tumors were hemangiomas, giant cell tumors, granulomas, and fibromas. Malignant tumors were rare, as expected, and both cases presented without pain or tenderness.

Digital Myxoid Cysts: Correlation of Initial and Long-Term Response to Steroid Injections

BACKGROUND

Digital mucous cysts (DMCs) are benign myxoid pseudocysts that develop on the distal interphalangeal joint's lateral or dorsal aspects. Management consists either of a surgical approach, conservative therapy, or simple follow-up.

OBJECTIVE

To correlate the initial and long-term response with clinical and ultrasound parameters in DMCs treated with intralesional steroids as first-line therapy.

METHODS

A single-center prospective open-label study recruited 15 patients affected by DMCs, who had been treated with a cycle of up to 3 steroid injections at a 6 to 9 week time interval.

RESULTS

At the first follow-up visit, 53.3% of patients were cleared of DMCs, achieving a complete response, whereas 46.7% experienced a >30% decrease in their DMC volume, and were considered partial responders. After 1 year of follow-up, the cure rate decreased to 40%, and the recrudescence rate was 27.3%. Clinical and sonographic characteristics that positively correlated with a maintained complete response at follow-up were as follows: young age, absence of osteophytes, low volume, complete clearance at T1, and short disease duration (p < .05).

CONCLUSION

Intralesional steroid therapy is an easy approach for DMC, with minimal side effects; identifying predictive hallmarks is useful to offer a straightforward surgical treatment to patients who have nonresponder characteristics.

Epidermoid Cyst in an Infected Olecranon Bursa

Epidermoid cysts are common, benign cysts that form due to follicular epithelium implanting into the dermis. Although these cysts are often painless, they can incite an inflammatory process as well as abscess formation, especially if ruptured. Our case involves a 59-year-old woman with a history of remote elbow trauma diagnosed with septic olecranon bursitis with concomitant epidermoid cyst found on histology following incision and drainage (I&D). Due to the rare presentation and inadequate preoperative imaging, the diagnosis of epidermoid cyst was not made prior to surgery, resulting in incomplete enucleation.

Soft Tissue Coverage for Severe Infections

Coverage of soft tissue defects in the upper extremity caused by infection and debridement of infected tissue is a challenging problem. Treatment starts with prompt identification and eradication of infection, including antibiotics and extensive debridement. Optimizing the patient's medical and nutritional status can facilitate eradication of infection and wound healing. Coverage of soft tissue defects caused by infection and debridement demands consideration of many factors. Options include healing by primary or secondary intention, skin grafts, local flaps, and distant flaps. Negative pressure wound therapy and acellular dermal matrices can also aid in coverage.

Deep palmar tumorous conditions of the hand

PURPOSE

Deep palmar tumors of the hand are very rare, and reported cases are usually benign. The most important issue is frequent anatomical variations with challenging surgical exposure and excision of these lesions. Some case reports or a small series of patients have been reported in the literature. The aim of this study was to present our experience with the deep palmar tumors of the hand.

PATIENTS AND METHODS

In the study, retrospective analyses of 43 patients treated with deep palmar tumors of the hand between January 1998 and June 2015 were evaluated. Tumors and tumor-like pathologies of the deep palmar space of the hand were retrospectively evaluated according to age, gender, localization, preoperative symptoms, size, site, treatment methods, histopathology, and early and late complications. Statistics and data analyses were also performed.

RESULTS

All 43 pathologies were benign, and histopathologic diagnoses were 10 lipomas, 8 ganglions, 5 giant cell tumor of the tendon sheath, 4 schwannomas, 3 hemangiomas, 3 palmar fibromatosis, 2 epidermal cysts, 2 neurofibroma, 1 angiolymphoid hyperplasia with eosinophilia, 1 granuloma, 1 calcifying aponeurotic fibroma, 1 digital fibroma, 1 foreign body granuloma, and 1 lipofibromatous hamartoma. The most common complication was temporary numbness and paresthesias of the digits. Marginal excision was performed in 40 patients, excision with nerve grafting in 2 patients (with neurofibroma) and carpal tunnel release in one patient with lipofibromatous hamartoma.

CONCLUSION

In the deep palmar space of the hand, pathologies are closely associated with tendons, muscles, and neurovascular structures. Preoperative magnetic resonance imaging is helpful for the preoperative diagnosis, evaluating tumor extension, and successful surgical planning. Level of Evidence: IV Therapautic.

Benign peripheral nerve tumors

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach.

Characteristics, Management Techniques, and Outcomes of the Most Common Soft-Tissue Hand Tumors: A Literature Review and Our Experience

INTRODUCTION

Diagnosis of the hand's soft-tissue tumors is often difficult because of the different anatomic structures present in this region and yet clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases.

MATERIALS AND METHODS

At the Department of Plastic and Reconstructive Surgery at the University of Palermo, 629 patients with hand tumors were studied. Treatment was surgical for all of them; also radiotherapy and chemotherapy were necessary based on the histological diagnosis.

CONCLUSIONS

Our retrospective study with a literature review aims to present the most commonly observed soft-tissue hand lesions, analyzing their causes, their objective and instrumental evaluation, and their treatments.

Digital Myopericytoma: A Case Report and Systematic Literature Review

A myopericytoma (MP) is an exceedingly rare perivascular tumor of unknown etiology. Given their potential for mimicry and malignancy, MP tumors pose a unique challenge for surgeons and may be overlooked on differential diagnosis. We present a case report of an otherwise healthy 33-year-old right-hand dominant male who presented to our outpatient clinic with a 2-month history of painless swelling and erythema of the pulp of his left index finger. Subsequent plain film X-ray showed near-complete bony destruction of his distal phalanx. Pathological evaluation of an incisional biopsy showed a benign variant of MP. The lesion was treated by excision with tumor shelling, and there was no evidence of recurrence 81 days postoperatively. A systematic literature review of the management and outcome of all known cases of hand and wrist MP is presented.

The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery

Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

Statistical and histological analysis of tumors of the upper extremity

Background

Tumors of the upper extremity are common and usually benign. The most commonly diagnosed are ganglion cysts: specific, non-neoplastic swellings localized mostly around the wrist.

Objective

The objective of this retrospective study was to determine the proportion of various types of nonganglionic hand tumors operated on at the authors’ institution in 2014.

Methods

A total of 246 patients, 141 women (57 %) and 105 men (43 %), with a mean age of 53 years and with tumorsof the upper extremity, were identified and treated in the authors’ institution in 2014.

Results

Almost half of the lesions were localized in the fingers (n = 119, 48 %), followed by the wrist (n=49, 20 %), metacarpus (n = 40, 16 %), and more proximal parts (n = 38, 16 %). The time between the patients noticing the lesion and surgery was a mean of 4 years (range, 1 month to 30 years). The most common lesion was giant cell tumor of the tendon sheath (n = 58, 23 %), followed by lipoma (n = 40, 16 %), epidermal cyst (n = 23, 9 %), enchondroma (n=16, 6 %), hemangioma (n = 14, 6 %), fibroma (n = 11, (4 %), glomus tumor (n = 10, (4 %), and rheumatoid nodule (n = 10, (4 %). Two cases of malignant fibrosarcoma were identified incidentally.

Conclusion

A brief review of the literature is made referring to the data presented here.

[Myxoid pseudocyst: when and how to treat?]

Myxoid pseudocysts (MPCs) are the most frequent pseudotumors of the digit and dermatologists are frequently referred. It is now believed that MPCs occur as a result of a leakage of synovial fluid through a breach in the joint capsule of the distal interphalangeal joint promoted by osteoarthritis. Many treatments have been proposed from simple repeated punctures, injections of steroids or sclerosants, cryosurgery, laser evaporation, infrared coagulation to surgical excision. Surgical procedures depend on the location of MPCs in the nail apparatus. In this review, we will discuss the best approaches to the treatment of MPCs whereas no guidelines are available for their management.