Hand and Upper Extremity Tumors

Hand and upper extremity tumors are surprisingly common. They can occur in all age groups — from children to the elderly. Fortunately, the majority of these tumors are benign, NOT cancer. Nevertheless, every hand lesion should be carefully evaluated.

The diagnosis of these lesions is often made on clinical basis supported by a thorough physical examination and plain film radiography. Advanced imaging and excisional biopsy may be needed in cases to confirm the diagnosis given their similarity with bone and soft tissue sarcomas.

Hand and upper extremity tumors can be classified as:

  1. Benign tumors
  2. Malignant tumors

Benign Hand Tumors

  • Ganglion cyst
    • A ganglion is a benign hand tumor, which is usually painless and fluctuate in size. Ganglions usually arise near a joint or tendon in the hand or wrist, with most common site is the back of the wrist (dorsal carpal ganglion). Ganglion cyst is filled with thick, jelly-like fluid, which is thought to be related to the synovial fluid of joints or tendon sheaths. Some ganglion cysts may disappear without treatment. For symptomatic ganglion cysts, aspiration with a needle or surgical excision may be offered.

  • Dupuytrens Nodule
    • Patients with Dupuytrens disease may develop firm nodules which can be tender and painful. Many patients confuse these nodules with ganglion cysts. Often patients will have these nodules in both palms and in arches of the feet. As the disease continues to get worse, the fingers contracture may develop, making it hard to straighten the finger
  • Giant Cell Tumor of Tendon Sheath (GCT)
    • GCT is a common benign soft tissue tumor of the upper extremity. The term “giant cell” relates to the appearance of the tumor cells under the microscope. The most common sites of GCT are the palmer surfaces of the thumb, index, and middle fingers. It is a slow-growing tumor, firm, lobulated, and usually painless. The tumors can grow larger if left alone, and surgical excision is the choice of treatment. The exact etiology of GCT is unknown.
  • Lipoma
    • A lipoma is also a common, benign soft tissue tumor composed of fat cells (lipocytes). They are soft, mobile, and easily palpable beneath the skin (subcutaneous). In most cases they are usually painless and do not interfere with hand function. Deep or large lipomas may compress adjacent structures, such as nerves. For symptomatic lipomas, surgical excision is the choice of treatment.
  • Nerve Tumors
    • Nerve tumors are often benign tumors arising from the nerves.
      • A schwannoma is a common benign nerve tumor of the upper extremity. These tumors are slow-growing, usually painless, but may cause a compression symptom such as weakness or numbness in the hand.
      • Neurofibroma is another common nerve tumor of the upper extremity. Patients with neurofibromatosis disease (NF) have multiple neurofibromas at various sites in the body. There is also a risk of malignant transformation of neurofibromas in patients with NF. A rare type of nerve tumor, the neurofibrosarcoma, is a malignant condition. These nerve tumors are much less common than schwannomas or neurofibromas.

  • Vascular Tumors
    • The most common type of vascular tumor is a hemangioma, which is a benign tumor of blood vessels. Those located on the skin surface, are bright red in color (strawberry hemangioma). Deeper tumors are more bluish in color. In the first year of life, these tumors grow rapidly. After first year of life, the tumor growth rate decreases, and it slowly involute. Treatment is typically non-surgical as most hemangiomas resolve spontaneously over time (70% by 7 years of age).
  • Glomus Tumor
    • Glomus tumors are also benign tumors of vascular origin responsible for temperature regulation of the skin and nail bed. These are small, slow growing tumors which are painful to touch. In classic cases, patients report severe, sharp pain exacerbated by cold temperatures and pressure. These tumors are common in the fingertip, usually under the nail. Surgical excision is frequently successful in pain relief, but recurrence is possible.

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Malignant Hand Tumors

Soft tissue sarcomas (STS) are rare upper extremity tumors; they account for less than 1% of all malignant tumor cases.

Most STS of the hand and upper extremities present as a painless, slow growing and mobile mass. In some cases, may cause nerve compression and present clinically as hand weakness and neuropathy.

Investigation:

  • Magnetic resonance imaging (MRI) is the choice of investigation for the radiological evaluation of suspicious tumor, giving information about the origin and anatomical relations with the surrounding tissues for optimal surgical planning.
  • A percutaneous core 14G-needle biopsy or incisional biopsy is frequently performed under local anaesthesia. The biopsy allows to harvest adequate tissue volume to make the diagnosis in over 90% of cases, with a sensitivity of 95% for malignancy.

Treatment:

  1. Surgical resection in STS is the main stay of treatment. However, achieving optimal oncological resection and functional outcome as results of STS of the upper extremities may represent a challenge for hand surgeons, due to its complex anatomy.
  2. Flap reconstruction is an essential part of STS surgical treatment for tensionless primary wound healing. For small size soft tissue defects, wound closure can be achieved either by primary closure or split thickness skin grafting. Flap coverage is essential in the case of exposed vessels, nerves or bone and to prevent wound healing complications
  3. Also the addition of adjuvant chemotherapy and radiotherapy has reported to improve the outcomes of surgery in STS of upper extremity, with limb-sparing surgery performed in around 90% of patients.
  4. Thus, prior to any treatment, every STS case should be individually discussed in sarcoma specialized multidisciplinary tumor boards for better outcome and preservation of hand function.

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