Hand tumors

Introduction

Tumors in the hand pose unique challenges due to their obvious psychosocial significance as well as the kind of tumors they present with. Generally it takes many years of managing such cases before one can present a management plan that speaks to the aims of preservation of function while maintaining cure.

Pathological considerations

Perhaps the most common tumor of the soft tissue in the hand is the giant cell tumor of the tendon sheathe (aka pigmented villonodular synovitis or PVNS). This is not to be confused with Giant Cell Tumors of bone which can also occur in the hand (see below) but are a completely different entity. This condition is locally aggressive and can destroy a finger but it is ultimately benign. Management involves careful microscopic dissection to remove these tumors from surrounding vital structures like nerves and vessels. This condition has been handled by most surgeons and it would seem that the principles of management here may be adapted to other tumors but this is a grave oversight.

In the many cases we have managed or had to salvage after a previous attempted excision a recurring theme appears to be the diagnosis of the lesion (Figure 1). This requires a close partnership between surgeon and pathologist. By understanding the nature of the tumor, it is sometimes possible to offer salvage to a seemingly unsalvageable situation.

Similarly we have found that by being able to review slides within the clinic, we would be able to offer an added dimension to diagnosis beyond imaging (ie. Xray, angiogram, MRI, etc) – these imaging modalities are considerably less useful than with bigger areas as the hand and fingers is a very small place. Histological evaluation where possible remains the best arbiter of the feasibility of limb salvage and is offered within our premises (Figure 2).

Bony tumors are surprisingly better in terms of outcomes because although they present in smaller bones that would seem less salvageable, these tumors tend to be more benign. Therefore a chondrosarcoma in the hand is actually more benign than one in the pelvis- even if they appear the same (Figure 3). This allows us as tumor surgeons to tailor certain approaches to salvage such limbs.


Figure 1. This girl presented to us for an amputation when two operations to the finger were unable to control a tumor there (a). We were convinced that this was a misdiagnosed glomus tumor of the nail bed and we offered to resect the tumor and save the finger (b). The diagnosis was in fact a glomus tumor (c) and it the finger went on to full recovery (d).


Figure 2. This gentleman presented for an amputation to the thumb when 2 previous surgeries showed the presence of a squamous cell carcinoma. We evaluated the slides in our own clinic and were unconvinced by the diagnosis (a). We offered a thumb conserving excision of the nail bed (b) and the final diagnosis was onychodystrophy (c). The thumb was therefore preserved (d).


Figure 3. Chondrosarcomas and giant cell tumors of the finger bones can be fairly common (a). Diagnosis is fairly straightforward with the MRI (b). We were able to conserve the finger in this case with a bone transplant (c)

When is it necessary to amputate?

We have found that the most common reason for amputation of fingers is when a case is a high grade malignancy or has been operated in the past leaving a mangled extremity. We do not advocated amputations for benign conditions like aggressive fibromatosis  as they do not present with fatal disease (Figure 4).



Figure 4. This newborn baby developed a congenital infantile fibrosarcoma in utero. These heart-rending photos were taken immediately after birth (a,b). A number of attempts at removal were done in various institutions (c,d,e) and by the time they presented to us the hand was severely disfigured. We were able to save the three digits and afford a cure (f). The child was able to use the hand in a pincer grip afterwards (g).



Figure 5 (video). This is a glomus tumor presenting as a painful subungal (under the nail) lump. The diagnosis was missed even despite scans as the lesion was so small that a normal MRI had missed it. Following a strong clinical suspicion we did another specialised hand MRI which revealed the presence of the lesion just below the nail bed.


Figure 6 (video). This is a pigmented villonodular synovitis tumor of the dorsal tendon of the finger  presenting as a painful lump. The diagnosis can be confusing known simultaneously as PVNS and Giant Cell Tumor of the tendon sheathe which in turn should not be confused with Giant Cell Tumor of bone (GCTB).