Most common benign tumor in the hand
Connective
tissue tumors
Epidermal
tumors:
Vascular
tumors:
Other
vascular tumors
Bone-related
tumors
Introduction
A tumor by definition is an abnormal
nodule, lump or mass that is not a normal part of the hand and the upper
extremity. The nodule may consist of skin, underyling tissue such as fat,
fluid, muscle, nerve, or bone. The nodule may be benign or malignant. Upper
extremity tumors usually represent a significant component of a hand surgeon’s
practice. These tumors can be broadly classified into their tissue of origin,
such as connective tissue, epidermal, vascular, nerve, or bone. Connective
tissue tumors include ganglion cysts, giant cell tumors, fibromas, and lipomas.
Epidermal tumors include warts, epidermal inclusion cysts. Vascular tumors
include glomus tumors, hemangiomas, arteriovenous malformations, pyogenic granulomas.
Nerve tumors include neurofibromas and schwannomas. Bone-related tumors include
chondromatosis, enchondromas, and osteophytes.
Ganglion cysts/ Connective tissue tumors
Ganglion cysts are the most common benign tumor in hand, accounting for about 60-70% of all nodules. On examination they are usually firm and are composed of gelatinous fluid, usually emanating from a joint, tendon, or tendon sheath. Ganglion cysts will transilluminate when a flashlight is held to it or to the surrounding skin. The patient will usually have a history of the cyst fluctuation in size and in discomfort. Approximately 10% of the patients will remember an antecedent trauma to the wrist or the finger. The most commonly location is on the dorsal wrist location, emanating from the scapho-lunate joint. The second most common location is on the volar radial forearm surface and in this location, often times the ganglion cyst lies over the radial artery. Ganglion cysts located at the DIP joint of the finger are due to a bony spur or an osteophyte. With chronicity, the DIP joint ganglion cyst can press on the germinal nail matrix, resulting in a depressed nail groove. The initial step is to make the diagnosis of a ganglion cyst is by physical exam. A radiograph is very helpful in ascertaining any osteophytes present that might be the cause of the cyst. Initial treatment consists of observation, as there is possibility, although low, of spontaneous resolution and accidental rupture due to an unexpected external force. Historically, ganglion cysts were treated by hitting the cyst with a heavy book. In the Americas and in Europe, this often times meant using the Christian Bible, and it is not unusual for a patient to come into the office stating that a friend or family made that recommendation. Should conservative monitoring not be effective, the next treatment option is to aspirate the fluid followed by an injection of a mixture of steroid and local anesthetic in attempts to sclerose the cystic lining. The rate of success is variable but generally there a 50% recurrence rate. Should it recur, surgery is the next option should the cyst remain symptomatic. Should there be an osteophyte, a localized ostectomy of the osteophyte needs to be done. The cyst should be resected along with its stalk and the joint capsule from which the cyst originated. With good surgical technique, the recurrence rate should be less than 5%. The surgery is an outpatient procedure done under intravenous sedation supplemented with local anesthesia. Healing time is minimal and the patient can return to work in one week if it is not a manually demanding job.
Ganglion cysts/ Giant Cell Tumors of the tendon sheath
Giant cell tumors are also known as
localized nodular tenosynovitis and fibrous xanthomas. They are the second most
common tumor in the hand, accounting for about 10%. They are non-tender, firm,
rubbery, multilobulated, do not transilluminate, and are usually adherent to
surrounding tissue. They are slow growing, and the symptoms are related to the
local effects to the finger or hand such as skin irritation or digital nerve
compression. They are generally more common in the fingers than in hand. The
tumor is yellow/brown in color, and this can be detected upon close inspection
on the skin. Given enough time and growth, giant cell tumors can be locally
destructive to bone. The diagnosis is often made by clinical exam and history.
An MRI can be ordered if the diagnosis is uncertain or if there is a need to
determine the extent of tissue involvement if it is large. The treatment is surgical
excision with meticulous technique as residual tumor can account for high
recurrence rate up to 50%.
Warts
Warts are the most common skin lesion in
the hand. Warts are caused by an infection with human papilloma virus (types 1,
2, 4, 29) and are often located in the areas of trauma, such as around the
fingernail fold and the elbow. Warts can transform into squamous cell carcinoma
under the right conditions such as exposure to ionizing radiation or in an
immunocompromised patient. Treatment is usually by the use of topical chemicals
such as squaric acid biethylester, topical salicylic acid, pulsed dye laser, or
cryotherapy. Warts can also be removed surgically.
Epidermal inclusion cyst account for 10%
of all benign hand tumors. It is caused by traumatic invagination of the
epidermal elements into the subcutaneous tissue. They present as round, slowly
growing, non-transluminating lesion, and often times seen with a small
“white-head” at the crux of the nodule. The cysts may sometimes become infected
due to skin compromise and organism is usually a staphylococcus species or a
streptococcus bacteria. Generally epidermal inclusion cysts are asymptomatic.
When they do become symptomatic, surgical excision is usually effective as long
as the cystic lining is also removed. If not, there can be a recurrence. Should
the cyst be infected, surgical excision provides the best treatment option. The
excision is done to remove the infected material and the wound is left open for
secondary healing along with a few days of oral antibiotics.
Fibromas comprise about 1-3% of benign hand tumors. Clinically they are
painless, slow growing, and well circumscribed. The treatment is surgical
excision mostly for diagnostic purposes and to remove any mechanical functional
compromise.
Vascular tumors:
Pyogenic granulomas
A pyogenic granuloma is a vascular tumor,
accounting for about 1 – 2% of benign hand tumors. On examination, they are
friable and easily bleed. They are always associated with a history of
antecedent trauma. Following the trauma, the patient will notice at the sight
of injury, a rapidly growing lesion that tends to bleed very easily and
profusely with minor irritation. There can also be a superinfection due to the
inability of the wound to heal over the pyogenic granuloma. If the pyogenic
granuloma is small, they can be cauterized with silver nitrate. Larger lesions
need surgical excision with cauterization. There is a high recurrence rate if
any tissue left behind.
Glomus Tumors
A glomus tumor is classified as a
neurovascular tumor as it contains both vascular and nervous tissue. The glomus
tumor originates from the glomus body, which regulates temperature and blood
pressure by altering local blood flow in the finger. It is usually solitary,
blue to red in color. It is most common found in the fingertips and is usually
subungual. They account for 2% of benign tumors in the hand. The classically
described symptoms are cold intolerance, paroxysmal pain, and pinpoint
tenderness. The treatment is surgical excision with repair of the nailbed, if
it is located underneath the nailplate.
Other vascular tumors include the vascular
malformations seen in isolation or in combination with syndrome such as Klippel
Trenaunay Weber Syndrome.
Nerve-related tumors:
Neuromas are by definition tumors of the nerve. They are benign and arise
almost always from a complete or partial injury to the nerve. The neuroma is a
reflection of the incomplete healing and repair of the nerve, resulting in the
thickening of the nerve either at the transected end or along the length of the
nerve where the injury occurred. They are very painful and often times require
transposition of the nerve into a more protected location such as under a
muscle or a repair to the other end of the severed nerve to try to restore
nerve integrity. These two surgical options can decrease the pain and improve
the symptoms.
Ganglion cysts/ Schwannomas
Schwannomas are the most common benign
nerve tumor in the hand. They are slow growing and are composed of Schwann
cells. Because this tumor does not involve the nerve fascicles and as it gets
larger, it pushes and separates the fascicles away from the tumor. For this
reason, schwannomas can be removed by “shelling out”. Because of its local
pressure on the nerve, schwannomas may produce neurological symptoms in the
distribution of the involved nerve in the form of paresthesias or numbness, or
weakness if the nerve involved is a motor nerve. An MRI is usually helpful in
making the diagnosis.
Neurofibromas
Neurofibroma is the second most common
benign nerve tumor in the hand. It can present as a solitary nodule or with
other multiple nodules, such as the case in neurofibromatosis NF1. The plexiform
type of neurofibromas can transform into neurofibrosarcoma. It is estimated
that this occurs about 2 to 13% of the time, and the risks are higher if the
neurofibromas are larger. Because the entire nerve is involved, neurofibromas
cannot be “shelled- out” during removal such as schwannomas can. The symptoms
usually are pain in the distribution of nerve that is involved.
Bone-related tumors
Enchondromas are benign cartilaginous
growth within the medullary cavity of bones. They usually are asymptomatic with
incidental discovery made on plain radiographs taken for an unrelated cause.
Occasionally the enchondromas have grown to the point where the outer cortex
becomes distorted and cause the finger to swell or they can weaken the cortex to
the point where the finger fractures. The patient in this case presents with a
fracture with only minor trauma. The diagnosis is made by plain radiographs. If
the diagnosis remains uncertain, an MRI is obtained. The treatment remains
surgical with resection of all cartilaginous elements. A bone graft may be
needed if the residual space is significant. Should there be a fracture, most
surgeons would recommend allowing the fracture to heal prior to surgery.
However, simultaneous resection and fracture fixation with a small external
fixator can also be done to combine the treatment of both the fracture and the
resection of the enchondroma simultaneously.
Chondromatosis/osteochondroma/and other
benign cartilaginous tumors
Benign proliferation of cartilaginous
tissue can often times occur at the joint surface of the cartilage and the
bone, resulting in a deviation of the joint. Although this occur
s mostly in isolation, it can be familial.
The treatment is surgical excision with stabilization of joint if indicated
with repair of the collateral ligament. Bizarre parosteal osteochondromatous
proliferation (BPOP) or Nora's lesion is another benign cartilaginous tumor
that is very rare tumor lesion but with aggressive growth. BPOP affects
primarily the small tubular bones in the distal extremities and treatment is
for surgical excision. It can often recur after excision. Because of its
aggressive growth, surgical excision with specimen sent for analysis should be
done to rule out a malignancy.
Hand tumors are generally benign. They can
be easily diagnosed based on the tissue of origin. Although conservative
monitoring may be indicated, generally surgical excision is both curative and
diagnostic.
