Malignant tumors of hand

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 (2 nd -4 th 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 (1/3 rd 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 (2/3 rd 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 : 3 0 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 e xposure 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%.