Most cysts, tumors, and other lesions can be diagnosed and even treated in your office. A trio of experts provides step-by-step guidance.
This is the second of a two-part series. Part 1 appeared in the March issue.
Primary-care clinicians are frequently the first medical professionals to examine patients with bumps and abnormal wounds around the hand and wrist. The clinician can often initiate treatment by diagnosing cysts, referring wounds that are healing slowly or poorly, or advising observation. In many cases, referral to the hand-surgery service for definitive excision, biopsy, and additional treatment is necessary. On rare occasions, oncologists, radiation therapists, and vascular surgeons may be consulted for adjuvant treatment. Treatment decisions in all cases should be based on the “golden rule” of hand surgery—“function over cosmesis.” Patients need to be reminded that there are risks, including unsightly scarring, to every surgical procedure. Our first article in this series covered obvious lesions on the hand and wrist; this one focuses on less obvious bumps, benign and malignant.
Figure1. Note the typical yellowish-brown lobulated appearance of a benign giant-cell tumor. These slow gowing masses are fixed to underlying structures.
Benign giant-cell tumors, epidermoid inclusion cysts, and lipomas are the most common benign lesions requiring surgical excision and pathologic evaluation for definitive diagnosis. All three are characterized by minimal discomfort and feature gradual enlargement occasionally accompanied by history of trauma. Aspiration for an apparent ganglion cyst that fails to flatten the lesion will often lead to diagnosis of one of these solid masses.
Benign giant-cell tumor
Benign giant-cell tumors of the tendon sheaths of the hand are subdermal growths. As the second-most common tumor in the hand, they are insidious in onset and typically nonpainful, but they can become large enough to interfere with joint motion and cause sensory abnormalities. Benign giant-cell tumors are most common in the fourth through sixth decades of life and usually located on the flexor surface of the fingers, but dorsal involvement is not uncommon. The mass is typically nontender to palpation and does not transilluminate. It is nonpulsatile. Standard radiograph evaluation often reveals the silhouette of a soft-tissue mass. If the mass juxtaposes on bone, erosion may be noted.
Preferred treatment is directed toward excision of the tumor in toto. At the time of surgery, it appears as a lobulated yellowish-brown mass (Figure 1), well-encapsulated on its surface, with a small tail often involving an intra-articular space. Although benign, these tumors are extremely aggressive, with a high recurrence rate. It is not unusual to recommend a course of radiation therapy after a second surgery to avoid further recurrences.
One of the more frequently encountered solid tumors, lipomas arise from the subcutaneous fat and intramuscular regions as well as deep spaces, such as the carpal canal, Guyon’s canal, and deep palmar space. Histologic evaluation confirms the lipocytic nature of the tumor.
Affected patients will generally complain of insidious growth not accompanied by pain (unless the mass impinges on underlying anatomical structures, such as nerves). Physical examination will typically reveal a nontender, nontransilluminating mass with varying degrees of attendant neuromuscular and neurovascular findings. Standard radiology is typically nonspecific. MRI can be a helpful diagnostic tool in evaluating these lesions.
Treatment options range from observation in nonpainful masses that do not interfere with normal hand function to surgical excision, paying particular attention to avoiding injury to adjacent structures (Figure 2). Recurrence is uncommon.
Figure 2. The location of this lipoma affected the motor branch of the ulnar nerve, causing weakness in the hand.
Epidermoid inclusion cyst
Epidermoid inclusion cysts are the third-most commonly encountered benign tumor of the hand. These lesions result from trauma that allows the epithelial layer of skin to be introduced subcutaneously. Even the slightest rent in the skin can produce an epidermoid inclusion cyst. Histologically, the mass is filled with reproducing epithelial cells and keratin. Patients will note a slowly enlarging, nonpainful, firm-to-cystic mass. Clinically, the lesions are nontender, well-circumscribed, and slightly mobile, and they do not transilluminate.
Often, the evaluation is precipitated by onset of increased swelling, pain, and redness indicating infection of the mass. Standard radiograph evaluation may reveal corticolysis if the mass is eroding into the bone. Treatment should first focus on controlling any infection followed by complete excision of the mass. Malignant transformation has not been reported.
Vascular malformations (VMs) are among the most common hand lesions that appear as masses. Unlike hemangiomas, VMs may not be clinically apparent at birth, tend to grow proportionately to the child, and do not undergo involution. In fact, because of their appearance in patients in their teens through the fourth decade, VMs have been reported as acquired.
VMs tend to be subdermal and are not appreciated by the patient until they become a painful mass. There are no typical locations, and the lesions have been reported throughout all aspects of the hand and digits. A palpable nontender-to-tender mass is a common finding. Patients may complain of numbness secondary to involvement of the adjacent nerves or loss of motion due to involvement of tendons and joints but do not typically report color and temperature changes.
Standard radiographs should be obtained to evaluate for possible lysis of the bone due to compression by the tumor mass, as well as calcification within the mass itself. The evaluation for vascular lesions in the upper extremity also includes arteriography, magnetic resonance angiography (MRA), and three-dimensional computed tomography angiography. These radiographic modalities are useful in identifying the location of the lesion as well as the involvement of the adjacent structures. This information helps in operative planning and advising the patient of the possible long-term sequelae of attempting to remove the mass.
Treatment options include observation and surgical interventions. Simple observation may be all that is required for a small VM that is not painful, does not cause inhibition of hand function, and does not appear to be increasing in size. In lesions that are painful, rapidly growing, and causing loss of hand function, surgical treatment is recommended. This should be a multidisciplinary approach involving an interventional radiologist as well as a surgeon. The interventional radiologist may embolize the lesion while the surgeon attempts to resect and debulk the mass. The masses are often difficult to excise in toto, and injury to adjacent structures, such as muscles, tendons, joints, and nerves, must be avoided in order to recover maximal function of the hand.
Glomus bodies are ubiquitous thermoregulative structures that are most numerous in the fingertips and nail beds. Approximately 1%-5% of soft-tissue tumors in the hand occur in glomus bodies. These tumors present with a classic triad of severe pain, exquisite tenderness to palpation over the nail bed or fingertip mass, and profound exacerbation of the discomfort on exposure to cold. Glomus tumors are most often seen in adults but have been reported in children. The lesions are usually benign, but rare malignancies have occurred. There is no gender predilection, and recurrences are common.
Figure 4. Note the violaceous discoloration at the tip of the arrow indicating the glomus tumor in the nail bed.
Physical examination will typically reveal a small discoloration beneath the nail plate (Figure 4) or a palpable mass within the pulp of the tactile pad of the distal phalanx of the digit. The lesions are exquisitely tender to palpation, and the patient is often unwilling to allow more than a brief examination. Placing the patient’s finger into a cup of ice water will elicit loud protestations. Warming the affected area quickly resolves the discomfort. Standard x-ray examination is rarely helpful. Ultrasound can provide excellent localization of the mass if it is not visible.
Treatment is surgical excision (Figures 5, 6, and 7), but complete pain relief has also been reported using pulsed laser therapy. Malignancy is rare.
Figure 5. The tumor becomes even more visible after the nail plate has been removed
Malignant neoplasms of the hand are not common and range from visible lesions (e.g., malignant melanoma and squamous cell carcinoma) to less apparent growths (e.g., osteosarcoma or metastatic disease). Patients will complain of chronic pain (often severe and occurring at night), wounds that fail to heal with appropriate intervention, ulcerative lesions with indurated borders, and rapidly expanding masses. Masses accompanied by x-ray findings of lytic lesions of the bone should arouse suspicion of malignancy. In addition to standard radiology, technetium 99 three-phase bone scans, CT scans, and MRI, as well as incisional or excisional biopsy, are valuable diagnostic adjuvants. Treatment can range from local excision to more complicated amputations and reconstructive procedures that may lead to use of a prosthesis. Often, patients succumb to their illness.
Figure 6. The nail bed following tumor excision.
Osteogenic sarcoma of the hand
A rare condition, osteosarcoma of the hand is most frequently seen in the metacarpals and phalanges. There is no gender predilection, and the condition typically develops in the second and third decades of life. Patients will present with pain (often worse at night) accompanied by swelling and rarely pathologic fractures through the tumor. A remote history of trauma may cause significant delay on the part of the patient prior to initial evaluation.
Figure 7. The tumor mass.
Physical examination may reveal a mass with localized tenderness, but standard radiographs lead to suspicion of the lesion. The classic radiographic appearance shows a lytic lesion with areas of ossification immediately adjacent to the metaphysis of the bone (Figure 8). An attendant metastatic workup should be performed.
Figure 8. Osteogenic sarcoma of the phalanx. The bone is sclerotic and irregularly enlarged.
Treatment includes preoperative chemotherapy followed by surgical intervention to include excision of the lesion or amputation. Prognosis is directly dependent upon the presence of metastatic disease. The current five-year overall survival rate is approximately 70%.
Metastatic disease in the hand is rare (0.1% of all metastatic skeletal lesions). A comprehensive review of the literature indicated that the three most common sites of the primary tumor were the lung, kidney, and breast. A subsequent review confirmed this and further identified 37 additional primary sites as having been responsible for acral metastases.
Patients will complain of a significantly painful swollen digit, most commonly the distal phalanx. Physical examination will reveal a swollen, tender, and indurated digit in a patient with a known primary malignancy. Radiographic findings may be typical for bone lysis. The CT evaluation is most helpful in determining the extent of both bone and soft-tissue involvement (Figure 9).
The appearance of a metastasis in the hand is a poor prognostic sign and usually heralds a rapid decline in the patient’s health. The median survival for a patient with a metastatic tumor in the hand is approximately six months. The management of the metastatic hand lesion should not interfere with the overall management of the primary cancer and usually involves wide resection and/or amputation of the involved portion of the hand.
Figure 9. CT scan of a metastatic lesion in a patient with known prostate and colon cancer. Note erosion of the bony cortex.
In evaluating patients presenting with a hand or wrist mass, the primary-care clinician can frequently determine the specific pathology using key historical information. Such information includes insidious onset vs. trauma and the presence of pain (especially at night or following exposure to cold or sensory or motor changes) along with physical examination findings, including location, consistency, and appearance. Diagnostic studies (e.g., standard radiographs, arteriography, and CT scans) will be helpful in making the diagnosis. Appropriate intervention, including observation or referral to a hand surgeon, can then be initiated.
For a list of references used in this article, contact the editor via e-mail ([email protected]) or telephone (646.638.6077).