Hand mass: General basic

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Hand mass: General basic

  1. 1. Hand Mass Kusuma Chinaroonchai, MD. 31 Oct 2013
  2. 2. 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
  3. 3. Case I : Clinical
  4. 4. 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
  5. 5. 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
  6. 6. Case III : X-rays Findings
  7. 7. Case III : Operative Findings
  8. 8. 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
  9. 9. Incidence • Other benign eg. Enchondroma, osteoma, osteochondroma, Glomus tumour etc. • Malignancies relatively rare – Skin is most common • SCCA > BCCA – Bone is 2nd common • Chondrosarcoma
  10. 10. 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
  11. 11. Dx & Ix • PE : S3 C2 MN – S ize – S ite – S hape – C olour – C onsistency – M obility – N odes and Imaging
  12. 12. Dx & Ix • Lab : up to DDx • Plane X-ray • Accuracy of tissue biopsy – Frozen section 80% – Core needle biopsy 83-93% – Permanent section 96%
  13. 13. Ganglion cyst(Neligan&Green) • Woman > man • 70% in 20s- 40s • 60-70% in Dorsocarpal – Scapholunate interrossous ligament • 20% Volarcarpal – Scapho-trapeziotrapezoid interossous ligament
  14. 14. Ganglion cyst • Transillumnation test positive • Hypothesis formation – Synovial herniation – Synovial dermoid – New growth from synovial membranes – Modification bursae or degenarative cysts – Mucoid degeneration
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Giant Cell Tumour of Tendon Sheath • Clinical Diagnosis • Rx marginal excision **beware nerve displacement and removed satellite lesion** • Recurrence rate 5-50% Neligan&Green
  19. 19. 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
  20. 20. 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%
  21. 21. 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
  22. 22. Squamous Cell Carcinoma Acinic keratosis : precancerous lesion Squamous cell carcinoma
  23. 23. 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)
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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)
  28. 28. Tumour of Cartilage & Bone in Hand • Enchondroma : most common of bone tumour in hand • Osteochondroma • Chondrosarcoma
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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%)
  35. 35. Chondrosarcoma • Most common metastatic site : lung (CT chest for metastatic work up) • Rx : En bloc excision
  36. 36. Thank You for Your attention Question ?

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