Tumorous Conditions of the Hand: A Retrospective Review of 402 Cases
Ali CAVİT1, Haluk ÖZCANLI1, Mesut SANÇMIŞ2, Güzide Ayşe OCAK3, Elif İnanç GÜRER3
1Department of Orthopaedics & Traumatology, Akdeniz University Faculty of Medicine, ANTALYA, TURKEY
2Manavgat State Hospital ANTALYA, TURKEY
3Department of Pathology, Akdeniz University Faculty of Medicine , ANTALYA, TURKEY
Keywords: Hand, Neoplasms, Bone, Soft tissue, Metastasis
Knowledge concerning treatment and care of hand lesions is often based on small case series, case reports and a few large general
case series. The aim of this study is to present our experience with hand tumors and tumor-like lesions incidence, age range and localizations.
Material and Method: Between 2006-2016, 402 patients operated and histopathologically diagnosed with bone and soft tissue tumorous
conditions of the hand were evaluated retrospectively.
Results: Three hundred sixty one out of 402 cases (89.8%) were soft tissue tumors and 41 cases (10.2%) were osseous tumors of the hand. A total
of 10 malignant tumors (2.5%) were encountered in the hand. The average age of the patients was 41.9 years (ranged from 1 to 83 years). Among
361 soft tissue tumors, only 6 cases (1.6%) were malignant and they were squamous cell tumors (n=5) and synovial sarcoma (n=1). The most
common soft tissue pathology was ganglion cyst (n=125). The most common bone tumor was enchondroma, diagnosed in 26 patients (6.4%
of all patients). Primary malignant bone tumors were extremely rare in the hand; one osteosarcoma and one chondrosarcoma were reported.
Metastatic tumors to the hand were seen in two patients; and they were lung carcinoma and chondrosarcoma metastasis.
Conclusion: Up-date knowledge and a thorough understanding of the nature and demographic characteristics of the tumorous conditions of the
hand are crucial for accurate diagnosis and appropriate treatment.
Tumorous conditions of the hand are frequently
encountered by hand surgeons throughout their career.
Because of the conspicuous nature of the hand, a larger
variety of abnormalities and variations become apparent.
The presence of an enlarging mass lesion is the most
frequent presenting complaint. Undescribable, localised
pain can sometimes be the only symptom. Most of the
tumorous conditions can be diagnosed by thorough history
and physical examination, but the establishment of a
definitive diagnosis is completed through biopsy (1). Early
diagnosis and initiation of treatment is important to realize
the aim of preservation of hand function. Clinicians should
be familiar with the frequency, distribution and clinical
characteristics of hand tumors and tumor-like lesions as
they differ from those seen elsewhere in the body. Thus
a thorough working knowledge of benign and malignant
diseases affecting the hand is necessary (1). Knowledge
concerning treatment and care of hand lesions is often
based on small case series, case reports and a few large
general case series (2). The aim of this study is to present our experience with hand tumors and tumor-like lesions
incidence, age range and localizations.
A total of 402 patients operated and histopathologically
diagnosed with bone and soft tissue tumorous conditions of
the hand between 2006-2016 were evaluated retrospectively.
Approval from the ethics committee was obtained. The
average age of the patients was 41.9 years (range 1 to 83
years). Analysed data of the patients were sex, age, clinical
presentation, radiological investigations, localization of the
tumor and histopathological features.
The biopsy procedures were undertaken by either
excisional biopsy, in which the whole lump or suspicious
area is removed, or incisional biopsy, in which only
a sample of tissue is removed with preservation of
the histological architecture of the tissues cells (3). All
lesions were treated surgically. Patients with malignant
or metastatic tumors underwent full metastatic workup,
including laboratory studies, chest radiography, computed
tomography of the abdomen, chest and pelvis, and MRI for
Three hundred sixty one out of 402 cases (89.8%) were soft
tissue tumors while 41 cases (10.2%) were osseous tumors
of the hand. A total of 10 malignant tumors (2.5%) were
encountered in the hand; 4 of them were osseous and 6 were
of soft tissue origin. Two hundred sixteen patients (53.7%)
were female and 186 (46.3%) were male. The average age
of the patients was 41.9 years (range 1 to 83 years). A mass
growth and pain were the major complaints of the patients.
Demographic data of all patients with soft tissue tumors
and tumor-like lesions and localizations are presented in
and Table II
, respectively. Among the 361 soft tissue
tumors, only 6 cases (1.6%) were malignant and they were
squamous cell tumors (n=5) and synovial sarcoma (n=1).
The most common soft tissue pathology was ganglion cyst
(GC) (n=125). Female predominance was seen in ganglion
cysts (n=71, 56.8%). Among all lesions, 64 cases occurred
in the left hand, 61 in the right hand. The majority of the
lesions were located in the wrist (n=86, 68.8%), and the
majority of the wrist location was the dorsal side (n=49).
The distribution of the other locations of the lesions were
the dorsum of the hand, palm, and the 1st, 2nd, 3rd, 4th
and 5th fingers at 13.7%, 1.6%, 3.2%, 2.5%, 6.5%, 3.2% and 0.8% respectively. All lesions were treated surgically. Giant
cell tumor of tendon sheath (GCTTS) accounted for 22.1%
of all soft tissue tumors as the second most common tumor
(n=80) (Figure 1A-D). The index finger was the most
common site for GCTTS with 27 cases (33.75%). Only one
case developed recurrence during the follow-up period.
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|Figure 1: A,B) Pre-operative view of the GCTTS of the third finger. C,D) Microscopic view showing GCTTS. Small, histiocyte-like,
rounded or polygonal mononuclear cells and larger epithelioid mononuclear cells with varying numbers of osteoclast-like giant cells
(H&E; x200 and x400).
Forty one cases (10.2%) were diagnosed as hemangioma.
The distribution of the types of the hemangiomas were
lobular capillary hemangioma (pyogenic granuloma) in
21 cases, cavernous hemangioma in 10 cases, capillary
hemangioma in 7 cases, intramuscular hemangioma in
one case, Massons hemangioma in one case and hobnail
hemangioma in one case. Another tumor of vascular
origin, glomus tumors were found in 18 patients. The main
clinical presentation was pain. Other soft tissue tumors and
tumor-like lesions are listed in Table I.
A total of 41 patients (10.2%) were diagnosed with osseous
tumors of the hand (Table III). The majority of bone
tumors were benign (n=37, 90.2%). The most common
bone tumor was enchondroma, diagnosed in 26 patients
(6.4% of all patients). Thirteen patients (50%) were female
and 13 patients (50%) were male with a mean age of 32.7
years (range 6 to 61 years). The location of the tumors were as follows: proximal phalanx in 13 cases, middle phalanx
in 5 cases, distal phalanx in 5 cases, and the metacarpal
bones in 2 cases. The ring finger was the most common site
for enchondromas (n=8, 30.7%). Surgical treatment with
curettage and bone grafting was performed in all patients.
Other benign osseous tumors reported in this study were
aneurysmal bone cyts (n=2), osteoid osteomas (n=4), giant
cell tumors of the bone (n=2), osteochondroma (n=1)
and giant cell reparative granuloma (n=2). Os capitatum,
hamatum, trapezoideum and the proximal phalanx of
the middle finger were the locations of osteoid osteoma.
Localizations of all osseous tumors are presented in Table
IV. Primary malignant bone tumors were extremely rare
in the hand; one osteosarcoma and one chondrosarcoma
were reported. Tumors metastatic to the hand were
seen in two patients and they were lung carcinoma and
chondrosarcoma metastasis (Figure 2A-D).
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|Figure 2: A) Lung carcinoma metastasis to the left thumb. B) X-ray of lung carcinoma metastasis; destructive osteolytic lesion in proximal
phalanx. C) Coronal image of the lesion on MRI. D) Metastatic carcinoma in the soft tissue as irregular adenoid structures and solid
communities (H&E; x 200).
Tumorous conditions of the hand are commonly seen by
clinicians. Soft tissue lesions of the hand consist of 15% of all
soft tissue tumors. Of all bone tumors, 6% occur in the hand
(5). A systematic diagnostic workup should be initiated
when a hand mass is encountered. Plain radiographs can be
helpful to determine whether the tumor is of soft tissue or
bone origin. As hand lesions are mostly of soft tissue origin,
magnetic resonance imaging (MRI) plays a major role in
the diagnosis and pre-operative evaluation (6). Especially
for the masses that are deeply located with close proximity
to neuro-vascular structures, MRI can reveal fine detail and
signs of tissue invasion and satellite lesions. MRI is also the
imaging technique of choice to distinguish benign tumors
from malignant ones.
In Campanaccis series of patients with hand tumors and
tumor like lesions, benign ones accounted for 89.8% and
malignant tumors for 10.2% (7). These incidences were
similar in Dahlins series; out of 194 hand tumors, 86.6% of
the patients had benign lesions (8). In this study including
402 patients with hand tumors and tumor like lesions,
patients with benign lesions accounted for 97.5% (n=392)
and malignant tumors for 2.5% (n=10). Nonagressive, benign neoplasms are usually treated with simple surgical
excision. Although the majority of the lesions are benign,
malignancy should always be suspected with rapid growth
and rapid change in the characteristics of the lesions.
Ganglion cysts (GC) are the most frequently encountered
masses of the hand and wrist, affecting women more
commonly than men (9,10). Ganglions generally (70%)
occur between the second and fourth decade of life (2).
Clinically, ganglions usually occur singly, and there are
four typical locations at which GCs are most likely to arise;
dorsum of the wrist, volar wrist, dorsal distal interphalangeal
joint and volar metacarpophalangeal joint (10). In a series
of 134 hand masses, 27% of cases were diagnosed as GC
(11). In the present study, GC was the most frequent
pathology encountered in the hand, including 125 out of
402 patients with bone and soft tissue tumors of the hand
(31%). Our findings are also consistent with the literature
as the majority of the ganglion cysts were seen in females
and between the second and fourth decade. GCs do not
pose a risk for malignant degeneration, and conservative
management with observation or splinting is initially
recommended. Other nonoperative treatments such as
aspiration, closed rupture or injection of hyaluronidase
or sclerosing solutions have higher recurrence rates
(10). Surgery should be considered in the presence of a
consistent symptomatic cyst, limitation of movement and
nerve palsies. If a stalk is visualized during the excision of
a ganglion cyst by either open surgery or arthroscopically,
it should be completely removed to prevent recurrence
(3,10). Recurrence has been reported to be as high as 40%
following incomplete removal (12).
Giant cell tumor of the tendon sheath (GCTTS), also
known as fibrous xanthoma or pigmented villonodular
tenosynovitis, is a benign soft tissue tumor which is the
second most common tumor seen in the hand (2). GCTTS
mostly occurs in the third to fourth decade, with a female
predominance (2/1) (13). Our results were correlated with
the literature; GCTTS was the second most common tumor
with 22.1% of all bone and soft tissue tumors (n=80). There
was female predominance (1.9/1) with a mean age of 44.2.
In their study on 191 patients, Saglık et al. reported GCTTS
to be the most common soft tissue tumor; however patients
with extraosseous ganglion cyts were not included (14).
Volar surfaces of the radial three digits are typical locations
for GCTTS (2,16). The index finger was the most common
site in our study. Marginal excision is the recommended
treatment, although the reported risk of recurrence is from
0 to 44 percent (15,16). High recurrence rates are associated
with poor encapsulation, satellite lesions, concurrent
degenerative joint disease, intraosseous involvement, distal
locations or involvement of the adjacent joint/tendon
Hemangiomas are neoplastic proliferations of the
endothelium. The hand is the third most common site,
involving 15% of whole body hemangiomas (18). These
neoplasms arise during the first weeks of life, experience
a period of growth followed by involution, and typically
regress over the first 7 years of life (9-19,20). Hemangiomas do not undergo malignant degeneration and, bleeding and
ulceration are uncommon in the hand (3,21). Management
of hemangiomas is usually conservative but medical (steroid,
vincristine, interferon alfa, laser ablation) or surgical
treatment should be considered when the lesions are large
enough to interfere with hand function, noninvoluting, or
symptomatic (ulceration, bleeding, recurrent infection) (2-
3-9-22,23). Surgical treatment should be complete excision
of the lesion, and the 5-year recurrence after excision is
reported as 19% (24). In our series, hemangiomas were the
third most commonly observed soft tissue pathology and
the most common type was lobular capillary hemangioma
(pyogenic granuloma), seen in 21 cases.
The most common primary bone tumors arising from the
hand are enchondromas (2,3). Approximately 35% of all
enchondromas arise in the hand and enchondromas account
for 90 percent of all primary bone tumors encountered
in the hand (1,2). Farzan et al. assessed 99 patients with
osseous hand tumors and 31 cases (31.3%) were diagnosed
as enchondromas (25). Sağlık et al. reported 59 patients
with enchondroma in the hand (four within soft tissue)
out of 210 patients with enchondroma located elsewhere
in the body (28.09%); enchondromas also constituted
52.3 percent of the whole bone tumors of the hand in the
same study (14). In another study, enchondromas were
diagnosed in 297 patients (%47.1) out of 631 patients with
primary bone tumors (26). Our findings are consistent
with the literature. In this study, 26 cases (63.4 percent of
all bone tumors) were diagnosed as enchondroma.
Soft tissue sarcomas are relatively rare in the hand.
Various soft tissue sarcomas of the hand exist and the
most common ones are synovial and epithelioid sarcomas
(2,27). Rhabdomyosarcoma is most frequently seen in
childhood and alveolar rhabdomyosarcoma is the most
common histologic variant seen in the hand (2). Sağlık et al.
reported alveolar rhabdomyosarcoma as the most common
malignancy in soft tissue in their study (14). There were 4
cases of squamous cell carcinoma and one case of synovial
sarcoma in the present study.
Bone sarcomas are also rarely seen in the hand; however
careful preoperative planning is required to ensure
complete removal of the tumor. Chondrosarcoma is the
most common primary malignant bone tumor occurring
in the hand. These tumors are either, arising de novo, or
secondary, arising from a pre-existent cartilaginous mass
such as enchondroma or osteochondroma. Malignancy
should be kept in mind when there are signs like rest pain,
advanced patient age, bony cortical disruption, associated
soft tissue mass, and permeative lytic pattern on x-ray (28).
Osteogenic sarcoma is the most common primary bone
tumor seen in children and adolescents, but it is rarely
seen as a primary lesion in the hand. As Ewings sarcomas
clinical features resemble infection, care must be taken to
Metastatic tumors of the hand are extremely rare,
encompassing 0.1% of all skeletal metastases. The most
frequent sites of primary cancer are the lung, breast and
kidney (3). There is a predilection for the distal falanx. In
Campanaccis series, patients with metastasis to the hand
comprised 0.5% of whole bony metastases (7). In another
study of hand tumors with 191 patients, this rate was
1.4% (14). Ozcanli et al. reported three patients with hand
metastasis, composed of one transitional cell carcinoma,
one chondrosarcoma, and one colonic adenocarcinoma,
during a 20-year period, from 1980 to 2000 (29). In the
present study, we observed 2 cases of metastatic tumors of
the hand among 402 patients (0.5%), consisting of one lung
carcinoma and one chondrosarcoma metastasis.
In conclusion, up-to-date knowledge and a thorough
understanding of nature and demographic characteristics
of the tumorous conditions of the hand are crucial for an
accurate diagnosis and appropriate treatment.
CONFLICT of INTEREST
The authors declare no conflict of interest.
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