Tumours of the Hand

Classification

  • Benign Bony
  • Benign Soft Tissue
  • Malignant Bony
  • Malignant Soft Tissue
  • Neural Origin
  • Skin Malignancy

Benign Bony Tumours

Enchondroma

  • Usually solitary incidental finding
  • Cartilage tumour

X-Ray Features

  • Expansile lytic lesion with cortical scalloping and calcified matrix
  • Usually in MC – less common as move distally in finger
  • Never undergoes malignant change if isolated

Management

  • Leave alone; usually heal after fracture
  • Curettage and grafting if not or re-fracture and symptomatic

Olliers Disease

  • Multiple enchondromatosis all over hand
    • 20% undergo malignant change to osteo- or chondrosarcoma

Maffuci Syndrome

  • Osteochondromatosis with associated haemangiomas
    • 100% malignant transformation

Osteochondroma (Exostosis)

  • Benign – grows away from joint – has a cartilage cap
  • Histology similar to growth plate – stops growing with maturity usually
  • May be associated with Hereditary Multiple Osteochondromatosis (HME)
    • 1% risk of malignant change in HME

Osteoid Osteoma

  • 10-30 years old
  • Proximal phalanx or carpal bones
  • Night pain – dull, diffuse, and achy
  • Natural history is to resolve after 18 months

X-Ray Features

  • Osteolytic nidus with surrounding sclerosis – round and small (<1cm)

Management

  • NSAIDs and reassurance
  • Otherwise excise
    • Pre-op CT/MRI to accurately define location
    • Otherwise recurrence high with incomplete excision
    • CT-guided RF ablation

Giant Cell Tumour of Bone

  • 2nd most common location is distal radius
  • May be incidental, cause ache, or present after fracture

X-Ray Features

  • Eccentric metaphyseal lesion which is locally aggressive
  • Heterogeneous matrix and expansile with cortical thinning
  • Campannaci classification
  • Can metastasize to lung in 2%

Management

  • Curettage and grafting/cementing/allografts etc.
    • En bloc excision and endoprosthesis
    • Arthrodesis with grafting
    • Recurrence rate up to 30% (worsened by radiotherapy)

Turret Exostosis

  • Traumatic sub-periosteal new bone formation
  • Symptomatic if forms under nail or within extensor expansion of digit
  • Causes mechanical symptoms

Management

  • Excision once mature (to minimize recurrence)

CMC Boss

  • Juxtaarticular Osteochondroma usually from 3rd CMCJ
  • Excision if symptomatic – consider CMCJ fusion if degenerate

Malignant Tumours of Bone & Cartilage

  • Very rare
  • Most common: Chondrosarcoma > Osteosarcoma

Chondrosarcoma

  • Only 1% of all chondrosarcomas occur in the hand
  • Usually transformation in enchondromatosis
  • MC or proximal phalanx usually
  • Chondroid matrix

Management

  • Radio/Chemo not effective
  • Surgical excision/Amputation

Benign Soft Tissue Tumours

Giant Cell Tumour of Tendon Sheath

AKA - PVNS/localized nodular tenosynovitis - Benign but locally aggressive with high recurrence - Slow-growing mass over years – may cause discomfort - Unknown etiology

X-Ray Features

  • Soft tissue mass sometimes with bony erosions

Histology

  • Haemosiderin, multinucleated cells (not giant cells)

Macroscopic Appearance

  • Lobulated, orange/brown lesion often encircling other structures

Management

  • Marginal excision – high recurrence if incomplete

Glomus Tumour

  • Arises from glomus bodies in fingertips (modulate heat)

Presentation

  • Intense pain
  • Temperature sensitivity
  • Fingertip reddish mass
  • Nail beds obliterated

X-Ray Features

  • Bone scalloping
  • MRI to confirm

Management

  • Marginal excision – recurrence high if incomplete

Pyogenic Granuloma

  • Neither pyogenic nor granulomatous!
  • Disorder of angiogenesis
  • Post-traumatic, pedunculated, friable red lump

Management

  • Silver nitrate if small
  • Surgical marginal excision

Epidermal Inclusion Cyst (Dermoid Cyst)

  • Traumatic implantation of keratinizing epithelium into dermis
  • Anywhere on hand, often between fingers

Management

  • Marginal excision
  • Can mimic other diagnoses

Dermatofibroma

  • Locally invasive, recurrent lesions
  • Excise but biopsy to differentiate from malignancy

Ganglions

  • See separate notes

Tumours of Neural Origin

Schwannoma

  • Most common peripheral nerve tumour of the upper limb
  • Painless mass with positive Tinel’s sign
  • Eccentric on nerve fibre
    • Can be shelled out while preserving the nerve

Histology

  • Cell of origin: Schwann cell
  • Composed of Antoni A (cells) and Antoni B (matrix) regions

Neurofibroma

  • May be isolated or part of NF1
  • Slow-growing painless mass
  • Arise centrally from nerve fascicles
    • Can’t be shelled out without sacrificing nerve – may need graft

Dejerine-Sottas Disease

  • Type 3 HSMN
  • Localized swelling of peripheral nerve
    • Due to hypertrophic interstitial neuropathy
    • Usually seen in median nerve – may require CTR
    • Can occur in foot → cavovarus foot

Management

  • Cannot be shelled out without sacrificing axons

Soft Tissue Malignant Tumours

  • Rare
  • Most common:

Squamous Cell Carcinoma (SCC)

  • Most common malignant hand tumour
  • Arises from skin or subungual areas

Other Malignant Tumours

  • Synovial Sarcoma
  • Epithelioid Sarcoma
  • Melanoma (can also occur subungual – more common in foot)

Soft Tissue Sarcomas

  • Usually >5cm in size
  • Young adults
  • Irregular, painful, fast-growing, and invasive

Epithelioid Sarcoma

  • Most common tumour of the hand
  • Young adults
  • Spreads to lymph nodes
  • Wide or radical excision
  • Chemo/radiotherapy not fully proven to be useful

Synovial Sarcoma

  • Poor prognosis
  • Epithelial and spindle cells
  • Young adults
  • More common in the foot
  • Wide or radical excision is treatment of choice
  • Adjuvant chemotherapy is useful
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