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ORIGINAL ARTICLE
Year : 2018  |  Volume : 26  |  Issue : 3  |  Page : 103-109

Management of the hand tumors


Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey

Date of Web Publication2-Jul-2018

Correspondence Address:
Isil Akgun Demir
Department of Plastic, Reconstructive and Aesthetic Surgery, Saglik Bilimleri University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_32_18

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  Abstract 

Background: Tumors of the hand are usually benign in nature, and therefore, treatment is usually nonessential. Indications for the surgical treatment are cosmetic concern and potential for malignancy. Since malignant hand tumors are seen very rarely, suspicious findings should be assessed thoroughly, and the diagnosis should be established as well. The purpose of this article is to evaluate those lesions that commonly arise in the hand region including lipomas, ganglion cysts, and glomus tumors as well as malignant tumors such as soft-tissue sarcomas and squamous cell carcinomas. Material and Methods: A retrospective review of all 528 surgically removed primary skin and soft-tissue tumors of the hand at our department between 1996 and 2016 was performed. Results: A total of 528 patients were evaluated in this study. The most common benign tumor of the hand was pyogenic granuloma (24%), and the most common malign tumor of the hand was squamous cell carcinoma (65.2%). Malignant tumors incidence was higher in males, whereas benign tumors incidence was higher in females. Conclusions: A careful history and physical examination performed by a specialist can narrow down the possibilities regarding the type of tumor. The vast majority of hand tumors tend to be benign. In contrast to skin cancers in general, those occurring on the hand frequently have a worse prognosis, with a greater propensity for recurrence, metastatic spread, and functional deficit.

Keywords: Hand surgery, hand tumors, pyogenic granuloma, sentinel lymph node dissection, squamous cell carcinoma


How to cite this article:
Irmak F, Sirvan SS, Demir IA, Sevim KZ, Yazar M, Yesilada AK. Management of the hand tumors. Turk J Plast Surg 2018;26:103-9

How to cite this URL:
Irmak F, Sirvan SS, Demir IA, Sevim KZ, Yazar M, Yesilada AK. Management of the hand tumors. Turk J Plast Surg [serial online] 2018 [cited 2018 Sep 21];26:103-9. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/3/103/235786


  Introduction Top


When people recognize a mass on their bodies, they fear that it might be a malignant tumor. However, soft tissue, skin, and bone tumors of the hand are commonly benign tumors. Most of the studies concerning hand tumors are retrospective and comprise a small series. Hence, tumors of the hand are poorly documented.

The incidence, variety, prognosis, diagnosis, and treatment options of hand tumors are clearly different when compared to other tumors of the body. Tumors occurring in hand account for 10%-15% of all skin and soft-tissue malignancies. [1]

Tumors of the hand are usually benign in nature, and therefore, treatment is usually nonessential. Indications for the surgical treatment are cosmetic concern and potential for malignancy. Since malignant hand tumors are seen very rarely, suspicious findings should be assessed thoroughly, and the diagnosis should be established as well. [2],[3]

Ganglions are the most common benign soft-tissue tumor of the hand and account for 50%-70% of all hand tumors. [4]

Hand tumors may originate from the skin, soft tissue, or bone and are divided into two groups such as tumor-like lesions and real tumors. Working with experienced radiologists and pathologists is essential for establishing a definitive diagnosis. [3],[5],[6]

Majority of the patients present with a painless mass on the hand. However, masses with a history of rapid growth and painful enlargement should be investigated in detail since they might indicate malignant transformation.

It is imperative to restore the function of the hand, if the properties of the tumor require wide excision. On the other hand, cosmetic outcomes should also be considered.


  Material and Methods Top


Five hundred and twenty eight hand tumor cases from 1996 to 2016 operated at our institution were analyzed retrospectively. The institutional review board approval was not required.

Patients were classified according to their age and gender, anatomic location and the histopathologic features of their tumor, and treatment modality. Tumors localized distal to the distal wrist crease were included in the study. Bone tumors and tumors located elsewhere in the upper extremity were excluded from the study.

Malignant tumors were also evaluated according to surgical margins, reconstructive techniques, rate of recurrence, metastatic spread, and survival rate.

Benign tumors were reported as glomus tumor, epidermal cyst, giant-cell tumors of the tendon sheath, pyogenic granuloma, neurinoma, schwannoma, lipoma, cystic hygroma, hemangioma, arteriovenous malformation, fibroma, fibrolipoma, ganglion cyst, infantile digital myofibroblastoma, dermatofibroma, and verruca vulgaris; whereas the malignant tumors were identified as squamous cell carcinoma (SCC), basal cell carcinoma (BCC), malignant melanoma, fibrohistiocytic malignant tumor, and synovial sarcoma.

Since BCC, fibrohistiocytic malignant tumor, and synovial sarcoma cases accounted only for 11.2% of all tumors, they were grouped together as "other" for statistical analysis. Data regarding surgical excision margins were analyzed with the help of the current guideline of the British Association of Dermatologists for the management of SCC and malignant melanoma. [7],[8]


  Results Top


Five hundred and twenty eight patients were evaluated for their age, gender, anatomic localization of the tumor, tumor histopathology, and treatment modality [Table 1], [Table 2], [Table 3], [Table 4]. Seventy-two tumors were malignant, and 456 tumors were benign.
Table 1: Demographics of the patients with malignant tumor

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Table 2: Demographics of the patients with benign tumor

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Table 3: Distribution of the benign hand tumors


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Table 4: Treatment modalities for malignant tumors


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The malignant tumor incidence was found to be higher in males, and the benign tumor incidence was higher in females. About 44.3% of patients with malignant tumor had a history of skin cancer, and 25.2% of benign tumor patients had a history of soft-tissue and skin lesions.

88.8% of the malignant tumors were either SCC or malignant melanoma. The remaining 11.2% were BCCs, soft-tissue sarcomas, and fibrohistiocytic malignant tumor.

Our study revealed that the most common benign tumor of the hand was pyogenic granuloma (108 patients-23.7%), followed by ganglion cysts (84 patients-18.4%), giant-cell tumors of the tendon sheath (68 patients-14.9%), other hand tumors (60 patients-13%), hemangioma (35 patients-7.7%), neurinoma and schwannoma (28 patients-6.1%), fibroma and fibrolipoma (23 patients-5%), epidermal cysts (14 patients-3.1%), glomus tumors (10 patients-2.2%), and arteriovenous malformations (7 patients-1.5%) [Figure 1] and [Table 3].
Figure 1: Distribution of all benign hand tumors

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Glomus tumor was found to occur four times, and cystic hygroma was found to occur 3.75 times more frequently in females than males. In addition, arteriovenous malformations, giant-cell tumors of the tendon sheath, and lipomas were found to be more frequent in females than males as well. On the other hand, epidermal cysts, fibromas, fibrolipomas, neurinomas, schwannomas, and pyogenic granulomas were found to occur more frequently in males [Table 3].

The most common malignant tumor of the hand was SCC (65.2%). The second most common malignant tumor was malignant melanoma (23.6%). The remaining malignant tumors were sarcomas, BCCs, and fibrohistiocytic malignant tumors. All of the malignant hand tumors were more frequently seen in males (57%) than in females (43%). The age range was 5-81 years (median age, 63 years) in males and 35-92 years (median age, 60.3 years) in females [Table 1].

Treatment

Treatment of benign tumors usually provides both functional and esthetically satisfactory results [Figure 2] and [Figure 3]. However, in malignant tumors, the surgeon's primary goal should be tumor excision with a safe margin, while preserving or restoring function as much as possible.
Figure 2: Vascular tumor of the hand (a) preoperative image (b) intraoperative view (c) appearance of lesion (d) preparation for anastomosis

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Figure 3: Lipoma (a) preoperative appearance (b) marking for extirpation of lipoma (c) excision of the specimen

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In this sense excision of benign tumors followed by primary closure is usually sufficient; nevertheless, the management of malignant tumors may require variable treatment modalities [Figure 4] and [Figure 5].
Figure 4: Malign melanoma of hand (a) appearance of the lesion (b) tissue defect after excision with safe surgical margins (c) anterolateral thigh flap
incision (d) early postoperative result (e) postoperative 3rd.week appearance


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Figure 5: Synovial sarcoma (a) preoperative appearance and markings for excision (b) ray amputation of the involved area (c) postoperative result

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The 72 malignant tumors were grouped as follows: SCC (47 patients), malignant melanoma (17 patients), sarcoma (four patients), BCC (three patients), and fibrohistiocytic malignant tumor (one patient). The treatment modality varied according to the type and invasion degree of the tumor.

Twenty of 47 patients with SCC underwent digital amputation, whereas five patients underwent ray amputation. Fourteen patients underwent tumor excision followed by skin graft adaptation, and the remaining eight patients required reconstruction with a flap after tumor excision.

Fifteen of 17 malignant melanoma cases underwent either excision or digital amputation. Two patients required reconstruction with a skin graft after tumor excision [Table 4].{Table 4}

Three of four patients with sarcoma were treated with digital amputation, whereas one patient underwent ray amputation [Figure 5]. All three patients with BCC were treated with excision followed by reconstruction with a skin graft. One patient with fibrohistiocytic malignant tumor underwent digital amputation.

Thirty-one of 47 SCC patients had a tumor diameter <2 cm. Two patients presented with a palpable lymph node underwent elective lymph node dissection (ELND), and the pathological examination of the lymph nodes revealed metastasis in both patients.

Sentinel lymph node biopsy (SLNB) results of eight of 16 patients with SCC with a tumor diameter of more than 2 cm were positive, and they all underwent ELND. The pathological examination of the lymph nodes showed metastasis in eight patients [Table 5].
Table 5: Lymph node management in squamous cell carcinoma patients


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Five of 17 malignant melanoma patients had a lesion with Breslow thickness <1 mm with a negative sentinel lymph node. Four patients had a Breslow thickness between 1 and 4 mm. Since two of them presented with a palpable lymph node, they underwent directly ELND, and the pathological examination of the nodes showed metastasis in both patients. The remaining two patients showed no sentinel lymph node involvement.

Eight of 17 malignant melanoma patients with Breslow thickness >4 mm underwent ELND, and all of the patients were found to have nodal involvement [Table 6].
Table 6: Lymph node management in malignant melanoma patients


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  Discussion Top


According to our study, the most common benign tumor of the hand was found to be pyogenic granuloma. Pyogenic granulomas are pedicled and friable lesions that are usually localized on the fingertip and easily bleed when traumatized [Figure 6]. One hundred and eight pyogenic granuloma cases have been diagnosed in the current study (26% of all benign tumors), and most of them were localized on the 3 rd phalanx. Treatment for all the pyogenic granulomas was excision followed by primary closure. Alternative treatments for pyogenic granulomas are as follows: silver nitrate, electrocauterization, laser applications, and plucking. However, the best treatment modality is excision. [5],[9],[10] Amelanotic melanoma and SCC should be considered for the differential diagnosis. [9]
Figure 6: Pyogenic granuloma

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According to some other studies, the most common benign tumor of the hand is a ganglion cyst. [4],[11] The etiology of ganglion cysts are uncertain; however, mucoid degeneration of colloid tissue is thought to play a role. [12] Angelides [11] reported that ganglion cysts are localized 60%-70% on the dorsum of the hand and 18%-20% on the volar surface of the hand. Ganglion cysts mostly occur in women, usually in the 3 rd and 4 th decades. In this study, ganglion cysts were the second most common benign tumor of the hand, accounting for 18% of all benign hand tumors. Seventy-eight percentages of the patients were females, and 22% were males. Ganglion cysts were mostly localized on the dorsal surface of the left wrist.

Pardini et al. [13] recommended that asymptomatic intraosseous ganglion cysts should be followed, and excision is considered only if it is associated with pain and restriction of movement. Uriburu and Levy [14] recommended excision for all ganglion cysts. The rate of recurrence would be lower if ganglion cysts are excised accurately and carefully.

Ganglion cysts may also be treated with compression, aspiration, and injection of steroids or sclerosing agents; however, the rate of recurrence is expected to be higher. Since volar ganglion cysts are usually located very close to the radial artery, the radial artery may be injured during dissection. [4],[11]

Although BCC is the most common malignant skin tumor, it occurs in hand in only 10% of cases. [15] In this study, we observed a lower incidence (3.2%) of this tumor. Sun exposure and particular syndromes are among the predisposing factors. Subtypes include nodular (the most common), sclerosing, pigmented, and superficial types. Small (<2 cm) or low-grade lesions require surgical margins of 4 mm and large (>2 cm) or high-grade BCC s require margins of 6 mm to prevent local recurrence. [16],[17],[18] To maximize tissue preservation, some authors advocate the usage of Mohs micrographic surgery. [19] Following excision, the 5-year recurrence rate was 3%-10% for primary tumors and more than 17% for recurrent BCC cases. [20],[21]

SCC makes up approximately 20% of all skin cancers and nearly 75% of all malignant skin lesions occurring in hand. [22],[23] In this study, the SCC incidence was 65.3%. Since dorsum of the hand is exposed to sunlight more often than the other areas are, SCC lesions tend to occur in this region [Figure 7]. Risk factors include fair skin, cumulative over-exposure to ultraviolet radiation, advanced age, and chronically damaged skin. Mostly, the treatment of choice is surgical excision. The risk for metastasis and recurrence for squamous cell cancer of the hand are greater than that of other locations. [24],[25] 95% of low-risk lesions are excised successfully with 4-mm margins. [7],[26] High-risk lesions require a margin of 6 mm for adequate resection. Digital amputation is essential if the tumor had invaded phalanges. After excision of an SCC lesion, the defect closure may be performed by either primary closure, local flaps, skin grafts, or distant flaps. Current evidence does not recommend the routine use of SLNB for low-risk lesions since they have shown a low rate of lymph node metastasis. However, SLNB may be useful for high-risk SCC lesions without a palpable lymph node. [27] Lesions <2 cm in diameter have a local recurrence rate of 7.4% and 9.1% of metastasis rate; tumors larger than 2 cm in diameter have 15.2% of local recurrence rate and 30.3% of metastasis rate. [28] If there is no clinically or radiologically positive lymph node involvement, small lesions do not require lymph node dissection. In this study, there were only two patients with palpable lymph node, who had tumors with a diameter <2 cm. On the other hand, all patients with a SCC lesion >2 cm in diameter underwent SLNB. Eight of them had a positive sentinel lymph node, and therefore, they underwent ELND and the pathological examination showed metastasis in all patients.
Figure 7: Squamous cell carcinoma of the hand dorsum

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Malignant melanoma (MM) is an aggressive, cutaneous malignancy for which early detection and intervention are essential for prognosis and survival. MM in the hand region is seen rarely, accounting for only 3% of all hand tumors. [29]

The nodal staging information was invaluable to define the prognosis for patients, to determine the need for therapeutic lymph node dissection, to identify patients for adjuvant therapy with interferon alpha-2b, and to stratify homogeneous patient populations for entry into clinical trials of new adjuvant therapies. [30]

SLNB indications in MM include a Breslow thickness >1.0 mm or <1.0 mm with a Clark level IV or V. [31] Sentinel lymph node involvement was found to be 10.1% for a Breslow thickness of 1.01-2 mm, whereas the rate was 53.7% for the lesions with a Breslow thickness >4 mm showing that there is a direct relationship between nodal involvement and Breslow thickness. [32] However, SLNB is not free of complications. Complications such as seroma, hematoma, and infection are seen frequently. Sensory morbidity occurs mostly in the axilla (e.g., pain, mobility limitation, or discomfort). SLNB performed in the neck region is associated with the highest rate of identification failure. [33]

Cryotherapy and laser therapy may also be utilized to treat MM, but they have higher recurrence rates even in in situ melanoma cases. Topical treatment with interferon-alpha and imiquimod showed promising results but needs further studies. [34] Thus, surgical excision remains the recommended treatment for melanoma cases.

When the localizations of MM and SCC lesions were compared, MM lesions were found to be mostly located in the palmar surface of the hand, whereas most of the SCC cases were usually located on the dorsum of the hand. SCC lesions were located mostly between the distal portion of the dorsal wrist crease and metacarpophalangeal joints, where the sun exposure is at a maximum level compared to other regions in the hand. Most of the actinic keratosis lesions are also located in this region. The rarity of soft-tissue sarcomas of the hand is an obstacle to conduct large prospective randomized studies and to develop specific standardized treatment protocols. Surgery remains the only option for cure. Even amputation may be necessary when clear margins cannot be obtained by other surgical approaches. In case the pathology result is uncertain or the frozen section is unreliable, additional tissue should be sent for analysis, and the definitive reconstruction should be delayed. [35]

We have analyzed 528 hand tumors treated over the past 20 years. Seventy-two (13.6%) of these tumors were malignant, and 456 (86.4%) were benign. Butler et al. [36] reported 437 cases of hand tumors, of which 24% were malignant. Pack [37] reported 389 cases and 59% of cases showed malignant change. The latter studies show that the incidence of malignancy in the hand varies widely.


  Conclusions Top


A careful history and physical examination performed by a specialist can narrow down the possibilities regarding the type of tumor. The vast majority of hand tumors tend to be benign. In contrast to skin cancers, in general, those occurring on the hand frequently have a worse prognosis, with a greater propensity for recurrence, metastatic spread, and functional deficit in addition to need for amputation and complex soft-tissue reconstruction. For all malignant hand tumors, early detection and intervention are essential for prognosis and survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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