INITIAL EVALUATION OF TUMORS OF THE HAND
Bone tumors and soft tissue tumors of the hand and upper limb are
uncommon, but every orthopedic surgeon seeing upper extremity problems
will see a significant number over time. Their true frequency is
unknown because many of these lesions do not require diagnosis.
Aggressive and malignant tumors in the hand and the soft tissues
of the upper extremity are very unusual.Unfortunately, this may
lead to lack of vigilance on the part of many of the physicians
who see them. Lesions that appear innocent may not be and every
mass should be considered as potentially troublesome. In the upper
extremity bone and soft tissue tumors are normally discovered slightly
earlier in their clinical course since they become visible or begin
to interfere with function, even when they are relatively small
Many of the lesions that occur in the hand can be diagnosed clinically.
On the dorsum of the wrist where joint ganglia are frequent aspiration
or transillumination can easily verify the diagnosis. The presence
of a mass without known cause and with no history of trauma should
be cause for concern. Progressive growth of a mass and a deep seated,
firm fixed mass should be considered malignant until proved otherwise
and a complete work-up is necessary.
Clinicians should remember that the biopsy is the last step in
the diagnostic process. Premature and poorly planned biopsies continue
to cause a significant number of unnecessary amputations and may
have a profoundly negative affect on chances for survival. Special
care should be taken in the case of children with masses in the
CLASSIFICATION OF LESION:
Benign tumors may be classified in three stages. Stage 1 are latent
and do not have any characteristics of growth or progressive change.
Stage 2 benign lesions are active and Stage 3 benign tumors are
aggressive and require complete work-up and a removal with wide
margins to avoid possible local recurrence.
The staging system for malignant tumors adopted by the Musculoskeletal
Tumor Society, and originally developed by Enneking is based on
the histological grade, the local extent, and the presence or absence
Grade is determined by histological parameters. Low-grade tumors
generally have few mitotic figures, little if any cellular atypia,
and have a relatively non-infiltrative growth pattern. High-grade
tumors tend to have marked cellular atypia, hyperchromatism, and
nuclear pleomorphism. They often demonstrate an infiltrative growth
When taking the medical history from a patient with a hand tumor
one should not forget to inquire about familial syndromes, or disease,
history of injury and presence of skin manifestations such as those
of neurofibromatosis. The patient's general health should be noted,
along with their temperature if infection is suspected.
One of the most valuable pieces of information is the pattern of
the pain. Insidiously increasing pain without obvious traumatic
cause is generally a bad sign. The pattern of growth of the lesion
should also be carefully elicited. Benign lesions tend to grow and
shrink, whereas malignant lesions tend to grow progressively. A
very rapid development of a tumor or swelling in the hand (hours
or days) is generally a sign of a systemic process, such as infection
The physical examination should include the hand, the entire regional
anatomy, as well as the regional lymph nodes. These include the
epitrochlear lymph nodes of the elbow, the axillary lymph nodes
and the cervical lymph nodes. The size, firmness, mobility, tenderness,
superficial or deep location, and skin reaction relative to the
lesion should be carefully noted. It is important to make an explicit
record of these findings so as to be able to document changes, if
A patient with a tumor in the hand who sees an orthopedic surgeon
should receive a complete evaluation and prompt and appropriate
initial management of the lesion. A casual examination and diagnosis
are not sufficient. Failure to diagnose cancer is one of the fastest
growing areas of malpractice litigation.
If a referral is necessary it should be made in writing and documented
in the chart. If no immediate treatment of the lesion is planned,
an appropriate follow-up in 6-10 weeks should be scheduled and documented
in the chart. A systematic, thorough, and well documented approach
to these lesions is essential for the patient's best care and will
be invaluable should the lesion develop into a malignancy and questions
about the patient's care arise at a later date.
Two orthogonal plain radiographs of highest possible quality should
be the initial examination in all patients with bone or soft tissue
tumors of the hand. The plain radiographs remain the cornerstone
of accurate diagnosis of bone tumors, and reveal useful information
about a significant number of soft tissue tumors.
In general, the plain radiographs should be examined for the features
that indicate the lesion's behavior. In addition, the location of
the lesion within the bone, the presence or absence of matrix within
the lesion, the aggressive or latent features that are seen, the
patient's age can be combined to generate an accurate differential
Bone lesions should be classified as latent, active, or aggressive.
Latent lesions generally have a sclerotic rim and a very narrow
zone of transition show no evidence of periosteal reaction, do not
destroy the cortex, and do not extend into the soft tissues.
Active lesions show a pattern of progressive growth with a narrow
border of less than 1 or 2mm thickness. They may focally thin or
destroy the cortex, and may focally extend into the soft tissues.
There may be a minor or moderate periosteal reaction.
Aggressive lesions often have a poorly defined border with a wide
zone of transition of several mm's to cm's. They permeate the normal
bone, destroy the cortex and extend aggressively into surrounding
soft tissues. They may cause a florid periosteal reaction. Further
details about the radiographic appearance of the common bone tumors
of the hand can be found in the section on each individual tumor.
If an MRI is ordered, the requisition should specify that an extremity
coil must be used. The author recommends that MRI's of musculoskeletal
tumors be obtained under the direct supervision of the radiologist.
Soft tissue tumors may be visible on plain radiographs. Soft tissue
technique should be used to reveal subtle features that are not
seen on plain radiographs. Lipomas are seen as a radiolucent mass
within faintly radiodense muscle. Hemangiomas and other tumors may
have punctate calcifications. The plain film of a soft tissue tumor
may also reveal that the lesion is invading or destroying bone,
or may have actually originated in a bone and broken out into the
ADVANCED RADIOLOGICAL IMAGING:
The advanced imaging of bone and soft tissues of the hand is beyond
the scope of this review. In general, soft tissue masses require
analysis by MRI. The orthopedic surgeon ordering an MRI of a hand
lesion should specify that the entire lesion should be characterized
in all sequences.
Unsupervised, protocol-driven MRI scans of extremity tumors, are
usually done without specialized extremity coils and are often of
mediocre quality. They may be completely useless for accurate diagnostic
or surgical planning purposes.
For bone tumors that are completely contained within bone, a fine
cut CT scan is next best imaging choice. MRI images may eventually
become necessary if the lesion's characteristics remain unclear.
Aggressive bone tumors in the hand will always require MRI imaging.The
same recommendations for MRI of soft tissue tumors (see above) apply
to bone tumors as well.
Technicium-99 bone scans are primarily used to identify lesions
in other parts of the skeleton that may not be clinically or radiologically
apparent. The presence or absence of tracer uptake on bone scan
of any individual bone lesion is not a reliable indicator of its
biologic behavior. The correlation between benign and malignant
behavior and bone scan uptake is generally quite poor.
As with all tumors, the imaging studies should be completed prior
to the biopsy. Biopsy will alter the appearance of the lesion and
may make the diagnosis uncertain or impossible. Biopsy should not
be attempted if the differential diagnosis includes more than two
or three likely entities. If the differential remains broad the
pathologist's job is much harder and the result of the pathologic
examination will be less valuable.
Constructing a differential diagnosis in the case of a bone or
soft tissue tumor of the hand is primarily an intellectual activity.
The clinical and physical exam findings are combined with the radiological
appearance of the lesion to construct a list of the two or three
most likely entities. It has been the author's experience that the
differential diagnosis included on the radiological reports of the
bone scan, the MRI scan, or the CT scan are quite variable and often
misleading. If there is still considerable doubt as to the nature
of the lesion a consultation with an orthopedic oncologist is highly
suggested. Alternatively, digital images may be sent to the consultation
service at http://www.bonetumor.org.
BENIGN TUMORS OF THE SKIN OF THE UPPER EXTREMITY:
A complete discussion of benign skin tumors is beyond the scope
of this review. An excellent chapter on these lesions may be found
in Bogumill (Ed) Tumors Of The Hand and Upper Limb, Churchill Livingstone,
1993. Section: Malignant Tumors of the Skin and Subcutaneous Tissue
Other Than Melanoma. Basal cell Non-melanotic malignancies are common
in the upper extremity and in some populations account for 50% of
The lesions may present as small, nodular growths that are skin
colored, erythematoid, or pigmented. The classic appearance is that
of a raised ulcerated lesion with a slightly raised edge. Neglected
basal cell carcinomas may become quite large and fungated. They
normally remain locally destructive but do not metastasize. The
lesions grow slowly and may appear as a cluster with normal intervening
PATHOLOGY: Basal cell carcinoma demonstrates small-to-intermediate
size cells that have a basophilic staining pattern and small, round-to-oval
nuclei. There are no bizarre or atypical nuclei seen. There is normally
an epithelial pattern with prominent palisades of cells in the periphery
of a nest of cells.
SQUAMOUS CELL CARCINOMA OF THE SKIN OF THE HAND AND UPPER EXTREMITY:
Squamous cell carcinoma is actually a diverse group of tumors. They
may develop as a result of solar radiation, burns or scars, chemical
exposure, immunosuppression, irradiation, chronic infection, virus,
and chronic draining osteomyelitis.
Patients presenting with thickened scaly lesions of the fingers,
hands or the remainder of the upper extremity should have squamous
cell carcinoma included in the differential. Squamous cell carcinomas
are commonly misdiagnosed as chronic rashes, corns, or dysvascular
ulcers. An incisional biopsy done in the clinician's office under
local anesthesia is an easy way to resolve any uncertainty. The
clinician treating malignant tumors of the upper extremity should
become thoroughly familiar with the requirements for staging, documentation,
reporting and appropriate surgical margins for excision of these
lesions. These are beyond the scope of this review. If any uncertainty
remains consider referring the lesion to an orthopedic oncologist,
or a dermatologist with a special interest in dermatological malignancy.
MELANOMA OF THE UPPER LIMB: 15% of melanomas occur in the upper
limb, and a significant number of these patients will clinically
present to a surgeon. The incidence is approximately 1 per 150 persons
in the United States, and this number is expected to increase. Melanoma
may develop from dysplastic nevi. These nevi are usually larger,
irregular in color and borders, and may be focally ulcerated. Any
mildly or variably pigmented lesion with an irregular border should
be treated with suspicion. Controversy exists as to the value of
excisional versus incisional biopsy. The most suspicious area of
the lesion should be included in the biopsy to increase the accuracy
of diagnosis. An incisional biopsy may be the best approach if the
complete (exter? Sounds like) patient of the tumor has a chance
of requiring the removal of vital structures.
The lymphatics drainage of the lesion, both locally and regionally,
must by examined. The surgeon contemplating the treatment of melanoma
of the upper extremity may want refer to Wanebo: Management of Malignant
Melanoma in: Moosa Comprehensive Text Book of Oncology, Baltimore,
Williams & Wilkins, 1988.
Stage I melanoma is a primary melanoma that is localized or has
satellite's within 5 cm of its borders. Stage Ia is the designation
for local recurrence of a primary melanoma. Stage II denotes metastases
to a single lymph node region. Disseminated cutaneous or visceral
disease is Stage III.
Stage I melanoma may be managed by wide excision and elective lymph
node dissection. Stage II may be managed by wide excision, therapeutic
lymph node dissection, and further treatments depending on the findings
of the lymph node dissection. Stage III melanoma is managed by a
multi-modality treatment including surgery, chemotherapy and radiation.