3. Most common hand tumours
• 95% hand tumours comprised of:
– Ganglion
– Giant Cell Tumour of tendon sheath
– Epidermoid Inclusion Cysts
– Haemangioma
– Lipoma
• Other tumours arise from bone & cartilage,
muscle, nerve, skin & adnexae, subcutaneous
tissue, tendon and synovium, vessel
4. Mankin’s Hand
Tumour Axioms
• Primary bone tumours are usually
benign
• The most common bone tumours are
enchondroma and osteocartilaginous
exostosis, except in distal phalanx which
is epidermal inclusion cyst
• Deep soft tissue tumours (other than
ganglion, lipoma, GCT) are often
malignant
• Epithelioid sarcoma, synovial sarcoma
and clear cell sarcoma are common
malignancies in hand/forearm. They are
highly malignant and may metastasize
to lymph nodes
• Synovial chrondromatosis, synovial
sarcoma and liposarcoma may show
calcification on radiology
• Metastatic carcinoma, except lung,
lymphoma and myeloma are rarely seen
in the hand
5. • Age
• Duration
History •
•
Pain
Neurological effects
• Nature of onset
• Variation in size
• Previous similar swellings
• Similar swellings elsewhere
• Symptoms related to other sites
7. Investigations
• Plain Xray
– Calcification
– Anatomical location
– Changes in bony architecture
– Response of host bone
– Internal contents
• Xeroradiography
• Bone scans, CT, MRI, Angiogram
• CXR
• FBC, EUC, U/A
– Also ESR, BSL, CMP, LFT, TFT, PTH
8. Enneking’s staging
Surgical Grade Anatomical Metastases
location
• Criteria for G2 G0 Benign T1 Intra- M0 No mets
– Pain & rapid growth compartmental
– Marked destruction on Xray
– Extensive uptake on bone scan G1 Low Grade T2 Extra- M1
compartmental Metastases
– Cortical disruption on CT
– Satellite lesions on MRI G2 High
– Biopsy = frequent mitoses, cellular atypia, poor Grade
differentiation and necrosis
• Compartments (T grade)
– Intraosseous
T1 T2
– Paraosseous
– Intra articular G1 IA IB
– Intra muscular
• Some locations are not compartmentalised, so
T2 by definition
– Vascular plane
G2 IIA IIB
– Mid hand
– Antecubital fossa
– Axilla
9. Ganglion
• Most common mass in the hand (50-70%)
• Probably arise from myxoid degeneration of collagen
• Lined with flattened mesothelium, not synovium, not
secretory cells
• Can be found in association with any synovial lined
cavity, but unlikely to be true synovial hernia
• 4 common sites
– Dorsal wrist ganglia are the most common type of
ganglion (60-70%), associated with scapholunate
ligament
– Volar wrist ganglion, may be associated with multiple
ligaments
– Proximal digital crease, associated with A1/A2 pulley
– Distal interphalangeal joint
• 30-40% spontaneously resolve within the first year
10. Giant cell tumour of flexor sheath
• Second most common swelling in hand
• Arises in presence of synovial tissue (flexor
sheath, IPJs)
• Usually asymptomatic
• Characteristic yellow brown colour from
haemosiderin
• High recurrence rate due to perforations in
macroscopic capsule
• Recurrence rates associated with multiple
lesions, thumb lesions, presence of bony
erosion, nm23 gene
11. Inclusion cyst
• Minor skin wound drives basal skin cells
beneath skin surface
• Forms smooth, spherical tumour
attached to skin but mobile over deep
structures
• Almost exclusively palmar surface, most
common around fingertips and
amputation stumps
• Smooth lytic lesion, no calcification,
mildly expansile, marginal sclerosis,
cortex intact, no periosteal reaction
12. Glomus tumour
• Benign growth of cells of normal glomus
apparatus, an a-v anastomosis in dermis
used to control skin circulation
• Essentially a hamartoma
• Triad of symptoms – paroxysmal pain, pin
point tenderness (Love’s test) and
temperature sensitivity to cold
• Usually solitary, most commonly subungal
• Presents due to symptoms rather than
mass
• Can precipitate pain with ethyl chloride
spray
• If found can be seen as a small purplish
patch
• MRI can detect 5mm lesions, U/S 2mm
13. Enchondroma
• 90% bone tumours of hand
• 35% enchondromas occur in hand
• Benign hyaline cartilaginous growth within medullary
cavity
• Peaks in 3rd and 4th decades, M=F
• May degenerate into chondrosarcoma (<1%) heralded
by unremitting pain, rapid growth and cortical
disruption
• Painless swelling, often incidental finding or
pathological fracture
• Central, usually in tubular bones, lytic with
calcifications, expansile, margins well defined, cortex
intact but often very thin
• Multiple enchondromatosis is found in Ollier’s disease
and Maffuci syndrome
– Rate of malignant degeneration is much higher, 30% in
Ollier’s and up to 100% in Maffuci
14. Chondrosarcoma
• Most common malignant primary bone
tumour in hand (60%), but still rare hand
swelling
• 25% arise secondary to degenerative change
of multiple enchondromatosis
• Peak incidence in 7th – 8th decades
• Pain
• Lies in subchondral bone, epiphyseal
equivalent of tubular bones
• Central, scattered lysis with punctate
calcifications, no expansile, no marginal
sclerosis, late cortical disruption
• Associated soft tissue shadow with radiating
spicules (flattened at ends unlike
osteosarcoma), Codman’s triangle
• Requires wide margins, no role for
radiotherapy or chemotherapy
• Histopath can be difficult
• 5 year survival 70%, 10 year survival 60-70%
15. Osteosarcoma
• Heterogenous group of malignant neoplasms
• Primary osteosarcoma peaks in 10-25yo,
secondary (to Paget’s, radiation etc) peaks in 5th
– 6th decades
• Aching, constant pain, worse at night
• Metaphyseal, destructive lytic lesion associated
with widely variable amount of new bone
formation
• Cortical disruption, spiculation, Codman’s
triangle
• Skip lesions and metastases
• Bone scan + MRI to define lesion and skip
lesions
• Staging Chest CT, and staging biopsy advisable
• Poor prognosis, dependent on duration,
location (proximal worse), size, histological
grade and presence of metastases
– 10 year survival up to 70%
16. Rhabdomyosarcoma
• Embryonal form peaks in infancy,
adult form peaks in young adults
• Actively growing soft tissue
masses
• Routine Xrays show spread to
bone, but better assessed by
bone scan
• MRI and angiogram are
important investigations
• Radical extracompartmental
excision
– Later generations of
chemotherapy and radiotherapy
may allow some limb sparing
• 5 year survival 50% embryonal,
30% adult
17. Giant cell tumour of bone
• Occurs in skeletally mature, peak
incidence in 3rd – 4th decades, F 57%
• 2% GCT bone occur in hand, most
commonly distal phalanx
• Intermittent pain and local swelling
• Epiphyseal equivalent, eccentric
• Central radiolucency, fine
trabeculation, expansile, no marginal
sclerosis, cortical erosion, soft tissue
extension in later or more aggressive
tumours
• Multiple GCT common, need bone scan
to locate
• May develop secondary aneurysmal
bone cysts
• 80% recurrence rate in hands (1/3
cured after 1 treatment, 1/3 after 2,
1/3 need > 2 treatments)
