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

36. Thank You
for
Your attention
Question ?