Hand mass: General basic
Download as PPTX, PDF4 likes2,574 views
This document summarizes three cases of hand masses and provides information on common benign and malignant hand tumors. Case I describes a 77-year-old man with a firm mass on his third finger. Case II describes a 55-year-old woman with a cystic mass on her third finger. Case III describes a 43-year-old woman referred for a firm mass on her third finger. The document then reviews common benign tumors like ganglion cysts, giant cell tumors, and epidermal inclusion cysts. It also discusses malignant tumors such as squamous cell carcinoma, basal cell carcinoma, melanoma, and bone tumors including enchondroma and chondrosarcoma. Diagnostic workup and treatment options are provided
Hand mass: General basic
- 1. Hand Mass Kusuma Chinaroonchai, MD. 31 Oct 2013
- 2. Case I: 0885957 • A 77-yr man • Presented with slow growing mass at base of 3rd MCP for 2 Yrs • UD CA prostate HT and COPD • Denied Hx of trauma • Denied Hx of medication allergy • PE : 4 cm of firm round, not tender mass at palmar site of base 3rd MCP joint, slightly movable • No distal pinprick sensation deficit
- 3. Case I : Clinical
- 4. Case II: 0470042 • 55 Yr woman • Mass at 3rd finger right hand 2 yrs • UD HT • Denied Hx of trauma • Denied Hx of medication allergy • PE : 2 cm cystic to firm consistency mass, not tender at palmar surface of 3rd finger, slightly movable • Transillumination test: negative • No distal pinprick sensation deficit
- 5. Case III • 43-yr woman • Refered from outer hospital • Mass at 3rd finger right hand 2 mth • No UD • Denied Hx of trauma • Denied Hx of medication allergy • PE : 1 cm firm to hard consistency mass, not tender, fixed at palmar site of right 3rd finger • No limit ROM of right 3rd finger • No distal pinprick sensation deficit
- 6. Case III : X-rays Findings
- 7. Case III : Operative Findings
- 8. Incidence • Mostly benign in type (80%) • From ASSH information (American Society for Surgery of the Hand) – 1.Ganglion cyst – 2.Giant cell tumour of tendon sheath – 3.Epidermal inclusion cyst
- 9. Incidence • Other benign eg. Enchondroma, osteoma, osteochondroma, Glomus tumour etc. • Malignancies relatively rare – Skin is most common • SCCA > BCCA – Bone is 2nd common • Chondrosarcoma
- 10. Dx & Ix • Hx taking – Age – Hx of tumour eg. duration, change in size or color or ulceration, pain – UD such as psoriasis, rheumatoid etc. – Hx of risk factor eg. Hx of cutanenous malignancies, sunburn or radiation exposed
- 11. Dx & Ix • PE : S3 C2 MN – S ize – S ite – S hape – C olour – C onsistency – M obility – N odes and Imaging
- 12. Dx & Ix • Lab : up to DDx • Plane X-ray • Accuracy of tissue biopsy – Frozen section 80% – Core needle biopsy 83-93% – Permanent section 96%
- 13. Ganglion cyst(Neligan&Green) • Woman > man • 70% in 20s- 40s • 60-70% in Dorsocarpal – Scapholunate interrossous ligament • 20% Volarcarpal – Scapho-trapeziotrapezoid interossous ligament
- 14. Ganglion cyst • Transillumnation test positive • Hypothesis formation – Synovial herniation – Synovial dermoid – New growth from synovial membranes – Modification bursae or degenarative cysts – Mucoid degeneration
- 15. Ganglion cyst • Choice of treatment (Suen et al. 2013) • Conservative – Reassure : 40-58% spontanous resolution – Aspiration : 15% recurrence – Steroid injection : no benefit – Sclerotherapy : no benefit – Hyaluronidase : in conclusive – Threat technique : 4.8% recurrence 11% infection
- 16. Ganglion cyst • Choice of treatment (Suen et al. 2013) • Surgery : 1% recurrence rate • Operative technique (Green) – Dorsal wrist ganglion : • Transverse incision • Open joint capsule to remove small intraarticular cyst – Volar wrist ganglion : • Longitudinal incision • Beware radial artery
- 17. Giant Cell Tumour of Tendon Sheath • Pigmented Villonodular synovitis • Adams et al. 2012 – Woman > men – 40s – 50s • Slow growing, firm, nodular, nontender mass • Mostly on volar site and DIP joint of 1st-3rd finger Neligan&Green
- 18. Giant Cell Tumour of Tendon Sheath • Clinical Diagnosis • Rx marginal excision **beware nerve displacement and removed satellite lesion** • Recurrence rate 5-50% Neligan&Green
- 19. Epidermal Inclusion Cyst • Invagination of epithelium after injury • Most common in fingertip • Some mimic bone lytic lesion like malignancy >> biopsy • Rx : Marginal excision • Rare recurrence Neligan&Green
- 20. Squamous Cell Carcinoma • Most common malignant tumour in hand • Common in dorsum, chronic sun exposure area • Askari et al. 2013 – Mean age 69 yr (39-89 yr) – Overall survival 5yr 88%, 10yr 57% – Recurrence free survival 5yr 67%, 10yr 50% – Rate of metastasis 4%
- 21. Squamous Cell Carcinoma • Wide excision is Rx of choice • NCCN 2013 guideline : hand region • Resection margin – Size < 6 mm : margin 4-6 mm – Size >/= 6 mm : margin 10 mm • Clinical LN or imaging LN positive : FNA • If positive FNA >> LN dissection
- 22. Squamous Cell Carcinoma Acinic keratosis : precancerous lesion Squamous cell carcinoma
- 23. Basal Cell Carcinoma • 2nd most common malignant on hand (Vandeweye and Herszkowicz 2003 : < 1% of BCAA all cases) • Sun exposure area • Mostly presented as chronic ulceration (Vandeweye and Herszkowicz 2003) • Ulcerated skin with pearly elevated edges • Rarely metastasize • Confirm Dx by biopsy (excisional or incisional)
- 24. Basal Cell Carcinoma • WLE is Rx of choice • NCCN guideline 2013 • Resection margin – Size < 6 mm : margin 4 mm – Size >/= 6 mm : margin 10 mm
- 25. Melanoma in Hand • Durbec et al. 2012 – Incidence of subungual cutanous melanoma is 0.1/100000 – Blacks = Whites – Predominate location at subungual, rarely in palm – UV light irradiation, trauma : still inconclusive risk factor – Poorer prognosis than other location of melanoma due to more advanced stage of tumour at first diagnosis
- 26. Melanoma in Hand • Rx from NCCN 2013 guideline • Main Rx still be aggressive surgical resection • Resection margin : – Insitu : 0.5-1 cm – Thick < / = 1 mm : 1 cm – Thick 1.01-2 mm : 1-2 cm – Thick 2.01-4 mm : 2 cm – Thick > 4 mm : 2 cm
- 27. Melanoma in Hand • Rx from NCCN 2013 guideline • SLNB should be done in all cases – Stage IA (thick 0.76-1 mm) – Subungual melanoma (Difficult to evaluate thickness) • Work up distant metastasis such as CT chest and abdomen : Stage III (node positive both form FNA and Clinical)
- 28. Tumour of Cartilage & Bone in Hand • Enchondroma : most common of bone tumour in hand • Osteochondroma • Chondrosarcoma
- 29. Enchondroma • Most common primary tumour in the bone of the hand (Green : 35% of all, 90% of bone tumour in hand) • Proximal phalanx > metacarpal > distal phalanx • Common present with pain and edema (pathologic fracture) • X-ray : radiolucent lesion with cortical thinning and popcorn calcification
- 30. Enchondroma • Solitary lesion 1-5% transform to chondrosarcoma (Muller et al. 2004)>> *need F/U* • Rx : – Small & asymptomatic with typical X ray >> conservative and observation – Large or symptomatic or atypical X-ray >> biopsy or curettage • 4.5% recurrence after curettage
- 31. Periosteal Chondroma • Uncommon • Confused – X-ray like enchondroma – Histology like chondrosarcoma • Men in 20s – 30s • Metaphyseal-diaphyseal junction of phalanges • Benign but need marginal resection with overlying periosteum • < 4% local recurrence
- 32. Osteochondroma • Most common benign bone tumour, but not in hand region • Distal aspect of proximal phalanx in 20s-30s • X-ray : osseous growth with cartilaginous cap from physis area
- 33. Osteochondroma • 1-2% malignant transformation in single lesion (Kitsoulis et al. 2008) • 10-25% malignant degeneration in mutiple lesion case (Neligan) • Rx : – Asymptomatic : observation – Impaired function : excision
- 34. Chondrosarcoma • Most common primary malignant bone tumour in hand • Slowly growth, firm and painful mass • Proximal phalanx (Patil et al. 2003) and metacarpal • X-ray : lytic lesion with cortical destruction and soft tissue destruction with poor defined border • 10% risk for metastasis (Muller et al. 2004 : less than other location,18%)
- 35. Chondrosarcoma • Most common metastatic site : lung (CT chest for metastatic work up) • Rx : En bloc excision