Malignant tumors of hand

1. Dr Sushil Sharma
Tumorous Condition &
Malignant Tumors of Hand

2. Tumorous condition
• Ganglion
• Epidermoid cyst (Inclusion cyst)
• Mucous cyst
• Congenital AV fistula
• Pyogenic granuloma
• Gout
• Traumatic Neuroma
• Déjérine-Sottas Disease
• Calcinosis
• Calcinosis circumscripta
• Turret exostosis
• Carpometacarpal boss

3. Ganglion
• Most common cause of focal masses in the hand
• Arises from the synovium of joints or tendon
sheaths or from tendons.
• Etiology
– Not clear
– History of acute or recurrent chronic injury (possibly
occupational)
– Mucoid degeneration
• Common in females (2nd -4th decade)
• Site
– Dorsal scapholunate ligament
• palpable between the second and fourth extensor tendon
compartments.
– Radial to the FCR tendon (Volar)
– At the level of the metacarpophalangeal joint flexor skin crease
(Flexor tendon)
– Palm (pressure symptoms)

4. Ganglion
• Clinical Feature
– Dull aching pain
– Feeling of weakness
– Firm, smooth, fluctuant, and round
• Differential diagnosis
– Extensor tenosynovitis
– Lipoma
• Treatment
– Observation & patient reassurance (can disappear spontaneously)
– Rupture or aspiration (Cure rate : 65%)
– Surgical excision (Cure rate : 85-95%)
• persistently symptomatic ganglion
• Removal of capsular margin around the cyst base
• No attempt should be made to close the joint capsule.
– Arthroscopic resection of dorsal wrist ganglions

5. Epidermoid cyst (Inclusion cyst)
• Etiology
– Implantation of epithelial cells by trauma
• Clinical feature
– History of penetrating wound around the
palm or fingertip
– Hard, rubbery, nontender subcutaneous
mass
– Distal phalanx is the most common osseous
site
• Radiograph
– Cortex is expanded
– Central lytic lesion
– Can be confused with enchondroma
• Treatment
– Surgical removal
– If the bone is involved, curettage and bone
grafting

6. Mucous cyst
• Most commonly seen in dorsum
over the DIP joints in women.
• Etiology : myxomatous
degeneration of the corneum
• Clinical feature
– Cyst with clear mucoid fluid (thin
overlying skin)
– Associated with Heberden nodes
• Radiograph
– Osteophyte near the cyst
• Treatment
– Excison of osteophyte & cyst (with
its stalk)

7. Congenital AV fistula
• Etiology : Lack of differentiation of the common
embryonic anlage into a true artery and vein
• AV shunt
– Finger
– May involve an entire extremity.
• Clinical features
– Painless (but painful if secondary ulceration)
– Raised local temperature
– Hypertrophied limb
– Varicose veins of the upper extremity
• Investigation : Arteriogram
– Dilation of the arteries just proximal to the fistula
– abnormal filling of the arteries distal to it
– presence of the contrast medium within the fistula.
• Treatment
– All communications between the arterial and venous parts
of the fistula should be ligated
– Early surgery is indicated to prevent destruction by
infection and gangrene

8. Pyogenic Granuloma
• Proliferation of
granulation tissue
frequently overhanging
normal skin
• Minimal trauma to this
tissue causes bleeding
• Treatment : Complete
excision including the
vascular base

9. Gout
• Large deposits of urate crystals
– Ligaments
– Tendons & tendon sheaths
– Metaphysis
• Erosion of the diaphysis that
resemble a lytic tumor on
radiographs
• May be confused with infection

10. Traumatic Neuroma
• Etiology : Regeneration of peripheral nerves after
their fibers have been interrupted
• Bundle of all the nerve elements in one tangled mass
at the distal end of the proximal nerve segment
• Clinical feature
– Tumor not visible from exterior
– Extremely tender
• If it involves a digital nerve
• If it adheres to an amputation scar that is unprotected by a
good pad of skin and fat.
• Treatment
– Resection of neuroma
– Protect ends by a pad of subcutaneous fat and skin.

11. Déjérine-Sottas Disease
• Rare lesion
• Localized enlargement of a peripheral
nerve caused by hypertrophic interstitial
neuropathy
• Clinical feature
– Painful & tender mass at the wrist
– Associated with macrodactyly
• Treatment
– Surgical exploration reveals enlargement of
the median nerve
– It cannot be excised without resecting the
nerve so division of the transverse carpal
ligament may help to relieve pain

12. Calcinosis
• Etiology
– Connective tissue degeneration
– History of trauma (1/3rd patients)
• Calcium deposits occur in the hand much less
frequently than around the shoulder and hip
• Sites
– Near the insertion of the FCU tendon
– Wrist (2/3rd cases)
– Collateral ligaments of the fingers and thumb
– Thumb extensor tendons
– Tendons of the intrinsic muscles
• Treatment
– Conservative
– Spontaneous resoultion (rupture or by gradual
absorption)
– Large deposits require surgical treatment.

13. Calcinosis circumscripta
• Rare
• Deposit of calcific lobules in the
skin and subcutaneous tissues
• Deposits occur more densely over
pressure areas such as fingertips
and sometimes may erode through
the skin
• Associated with collagen diseases
– Lupus erythematosus
– Rheumatoid arthritis
– Dermatomyositis
– Scleroderma
• Treatment : Excision

14. Turret Exostosis
• Smooth, dome-shaped extracortical mass of
bone lying beneath the extensor apparatus
on the middle or proximal phalanx of a finger
• Cause : Traumatic subperiosteal hemorrhage
with ossification
• Clinical feature
– Firm mass on the dorsum of the phalanx
– Limited flexion of the IP joints distal to the
lesion (due to limited excursion of the
extensor apparatus)
• Radiograph
– Subperiosteal new bone located on the
dorsum of the phalanx
• Treatment
– Excision of the exostosis
• Wait for 4 to 6 months after injury (subperiosteal
bone becomes mature)
• Do not to tear the periosteum dorsally,
preserving a smooth surface over which the
extensor apparatus can glide

15. Carpometacarpal Boss
• Bony, nonfluctuant, fixed dorsal
protuberance of the second and third
metacarpal bases
• Osteoarthritic spur
• Radiograph
– Carpal boss view : 30 to 40 degrees of
supination and 20 to 30 degrees of ulnar
deviation
• Clinical feature
– Asymptomatic (cosmetic problem)
– Pain due to local pressure over the lesion or
by forced wrist extension
• Treatment
– Excision of osteophyte

16. Malignant tumors of hand

17. Introduction
• Malignant hand tumors are rare
• Of primary bone malignancies of the hand,
chondrosarcoma is the most common.
• Most common malignant tumor of hand : Squamous
cell carcinoma
• Most common soft tissue sarcoma : Malignant fibrous
histiocytoma
• During treatment preservation of function is secondary
to eradication of the disease process
• Thorough understanding of the tumor’s biologic
behavior, its patterns of local and metastatic spread,
and its response to radiotherapy and chemotherapy.

18. Soft Tissue Sarcoma
• Relatively rare in the hand and forearm.
• The majority of these lesions share a common primitive mesenchymal origin.
• The biologic behavior of soft tissue sarcomas may be more accurately
predicted by the histologic grade of the lesion
• Cell mitotic index
• Cellularity
• Tumor necrosis
• Anaplasia.
• Clinical feature
• painless mass present for a long time with recent growth.
– Misdiagnosed as infection, ganglion, and lipoma.
• Types
• Malignant fibrous histiocytoma
• Liposarcoma
• Leiomyosarcoma
• synovial sarcoma
• Fibrosarcoma
• Rhabdomyosarcoma
• Epithelioid sarcoma
• Treatment
– Surgical excision with complete removal of tumor (Negative margin)

19. Epitheloid Sarcoma
• Misdiagnosed initially because of their benign
course
• Clinical feature
– Unremarkable, subcutaneous, firm masses in young
adults
– Predilection to grow along fascial or tendinous
structures, forming multiple nodules, and may
appear to be a simple inflammatory process.
– Ulceration
• Metastasis to regional lymph nodes is
common, and metastasis to the lungs usually
follows multiple recurrences
• Treatment
– A primary wide excision or an amputation of a digit
or entire ray is indicated
– A below-elbow amputation may be necessary after
any recurrence in the hand proximal to the
metacarpophalangeal joints
– Regional node dissection in combination with the
primary excision

20. Synovial Sarcoma
• High-grade malignant soft tissue
sarcoma that commonly arises in
proximity to joints, tendons or bursae
• Most commonly occurs in the region
of the carpus and is rarely seen in the
fingers.
• Clinical feature
– A painless mass over the dorsum of
the hand or in the palm
• Spreads to regional lymph nodes in
as many as 25% cases
• Treatment : Wide excision with
chemotherapy

21. Fibrosarcoma
• Mesothelial in origin
• Risk factor
– Radiation exposure
– Scars
• Clinical feature
– Painless mass
– Compression to nerve
• Treatment
– Wide excision
– Amputation

22. Rhabdomyosarcoma
• Rare
• Deeply situated and are painless
despite rapid growth
• Three types
– Alveolar (more common in limbs)
– Embryonal
– Pleomorphic
• Bone erosion is common with tumors
affecting the hands and feet.
• Prognosis : Poor (Usu fatal)
• Treatment : Excision, Chemo & Radio
therapy

23. Chondrosarcoma
• Most common primary malignant bone tumors
of the hand
• Difficult to differentiate from enchondromas (can
arise from pre existing enchondroma)
– Pain
– Pathological fracture
– Recurrent
• Affects proximal phalanx & metacarpals
• Radiograph
– Area of lysis with poorly defined borders
– Cortical expansion & extension to soft tissue
• Majority are low-grade slow-growing lesions that
do not metastasize (Risk of metastasis : 10%)
– Most common site of metastasis : Lungs
• Radical surgery offers good prognosis & less
recurrence.
– wide en bloc excision or digit or ray amputation
– No role of chemo & radio therapy

24. Osteosarcoma
• Rare
• Average age of presentation : 50yrs
– Occurs in pre-existing disease
• Radiograph
– Expansile, sclerotic lesion with new bone
formation
– Lytic or mixed pattern with destruction and a
soft tissue mass
• Affects metacarpal & proximal phalanx
• Careful wide excision of the tumor offers a
good prognosis
• Good response to chemotherapy
(Neoadjuvant)
• The prognosis seems to be better, however,
than for the same lesions located elsewhere.

25. Squamous Cell Carcinoma
• Incidence
– Age > 50
– Sex (M:F = 4:1)
– 58% to 90% of all hand malignancies
• Clinical features
– Predilection for the sun-exposed areas of skin and are uncommon on
the palm
– Grows slowly, rarely metastasize, and usually are superficial and low
grade
– Small, desquamating, and erythematous lesions to large, fungating,
and ulcerative lesions
• Treatment
– Tumor-free margins should be at least 0.5 cm for small lesions and 3
cm for recurrent or fixed lesions
– Recurrence rates : 7% to 22%
– Poor risk factors include a
• Size > 2 cm
• Poor differentiation
• Immunosuppression
• Increased depth of invasion
• Perineural involvement

26. Basal Cell Carcinoma
• Less common
• Suspect BCC if raised, pearly-bordered
lesion in middle-aged, fair-skinned man.
• Treatment
– The tumor cells are located at the raised
areas of the nodular tumors, which makes
the excision boundaries fairly clear.
– Relatively benign tumors can be excised
with a 0.5-cm free margin.
– Recurrence rate : 1%

27. Malignant Melanoma
• Common
• Risk factor
– exposure to ultraviolet radiation
• Survival
– Related to tumor thickness
• <0.75mm : 97%
• >3 mm : 50%
• Treatment
– Excision

28. Metastatic tumors
• Rare, representing about 0.1% of all metastatic
lesions
• Preterminal event and is often part of widespread
dissemination of the primary malignancy.
• Primaries
– Bronchogenic carcinoma
– Carcinoma of the kidney
– Prostate gland
– Breast, uterus, and colon.
• Occur in the phalanges and metacarpals with equal
frequency
• Confused with infection because usually there is
tenderness, swelling, and redness
– Differential diagnosis : gout, giant cell tumor of
bone, enchondroma, aneurysmal bone cyst
• Radiographs
– Osteolytic lesions that usually are destroying the
adjacent cortical bone
• Prognosis : Poor (Median survival: 5-6 months)

29. Ewings Sarcoma
• Rare
• Highly aggressive tumor
• Epidemiology
– M>F ; Occurs during the second decade of life
• Clinical feature
– Pain, swelling, fever, and general malaise (may be
mistaken for local infection)
• Radiograph
– Lytic, destructive & expansile lesion with periosteal
reaction & soft tissue involvement
• Laboratory
– Leukocytosis and elevation in the erythrocyte
sedimentation rate
• Prognosis
– Newer chemotherapy and radiation therapies combined
with surgical excision, survival rates have improved to
50% to 75%.