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Hand tumoursw
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- 3. Most common handtumours • 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
- 6. Examination – S3,C2, M (NI) • Size • Site • Shape • Colour • Consistency • Mobility • Nodes • Imaging
- 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 tumourof 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 tumourof 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)