Hand Tumors: An Individual Surgeon’s Retrospective Review

Tumors of the hand are encountered frequently by physicians and can be difficult to accurately identify due to the wide variety of differential diagnoses. Although an estimated 95% of hand tumors not involving the skin are benign, malignant tumors are possible and must be identified for proper treatment.¹ Distinguishing between benign and malignant lesions on clinical presentation alone, however, can be difficult.

Ganglion cysts are the most common benign tumors of the hand, with a higher predominance in women and often occurring in the second through fourth decades of life.² These lesions are frequently located in the dorsal wrist (70%) and less frequently in the volar wrist (20%), though appearance in the tendon sheaths and distal interphalangeal (DIP) joints has also been reported.³ Median and ulnar nerve compressions have been reported which can cause pain and functional deficits.⁴

There are several other benign tumors that may occur in the hand. Lipomas are well-defined, soft, subcutaneous nodules that may present anywhere within the hand. (Figure 1) 

While generally asymptomatic, lipomas present in the carpal tunnel, Guyon’s canal, or deep palmar space may result in nerve compression.⁵ Neurofibromas which are benign tumors of the nerve sheath, may raise suspicion for genetic conditions such as neurofibromatosis or, if multiple are present, Von Recklinghausen’s disease. (Figure 2) 

These conditions increase the risk of malignant transformation.^6,7 Osteochondromas are most commonly found in the proximal phalanx and show the presence of bony exostosis on radiographs.⁹(Figure 3) 

Although malignant degradation to chondrosarcoma may occur elsewhere in the body, this has not been described with lesions of the hand.^4,8

Malignant tumors, although less common, are also possible in the hand. They can arise from a variety of different areas including cutaneous tissue, bone, and connective tissue. The most common is chondrosarcoma, a malignant soft tissue tumor derived from cartilage-producing cells which may arise as a primary or secondary lesion.⁹ This tumor can be seen in adults over 60 years of age, most commonly in the proximal phalanges, specifically of the fifth digit.⁸ They present as a chronic, painful swelling that is poorly defined on radiograph.^8,10 Metastasis is very rare (<10%) with the most common site being the lungs. A computerized tomography scan of the chest may be warranted if metastatic spread is suspected.⁸

This retrospective review is a single surgeon’s perspective on these complex and varying hand tumors. The purpose is to better understand how these tumors present in a specific population of patients. Variables assessed include patient demographics, tumor type, and presenting symptoms. Understanding the features of hand tumors in this cohort of patients may further guide treatment for these complex cases in the future.

The authors conducted a retrospective chart review of all patients that underwent surgery for a suspected hand tumor from an individual surgeon’s perspective between January 2005 and December 2017 (R.D.) Hand tumors included in the review were defined as those distal to the carpus. Exclusion criteria included insufficient data and surgery outside the determined date range. Patient records were pulled based on lists and past schedules, and information was obtained through the electronic medical record system. Pertinent data were extracted by researchers, including patient demographics, diagnosis, pathology, type of surgery, and comorbidities. This study was done under the approval of the Internal Review Board. Given this was a retrospective chart review, no consent was attained from study subjects. All procedures had been performed and could not be affected by including the patient in the study. Statistical analysis was performed in GraphPad Prism.

A total of 101 patients aged 14 months to 87 years with a mean age of 40.52 years (+/- 19.11 years) was included for analysis.  Thirty-eight patients were male, 62 were female, and 1 patient did not have gender data available. Of the hand tumors in this patient group, 97% were soft tissue tumors, 1% were bone tumors, and 2% were malignant neoplasms. A breakdown of the tumor pathology diagnoses for patients included in the review is presented in Table 1. 

Ganglion cysts were by far the most common tumor type in this cohort, comprising 54.5% of final pathological diagnoses. Hemangiomas (9.9%), giant cell tumors (6.9%), granulomas (5.9%), and fibromas (5%) were also relatively common. The number of pathological diagnoses in each age group is presented in Table 2. 

In terms of clinical symptoms, 54.5% of patients reported preoperative pain and 4% reported tenderness, while 41.6% of patients reported no pain or tenderness. The percentages of patients reporting pain or tenderness by age group and pathologic diagnosis are presented in Table 3 and Table 4. 

Decreased ROM was reported in 43.5% of patients, and the percentages of patients reporting decreased ROM by age group and pathologic diagnoses are presented in Table 5 and Table 6. 

This analysis provides a better understanding of the frequency in which different tumors of the hand presented to an individual surgeon. The overall most common tumor was the ganglion cyst, seen in 54.5% of the patient sample. This coincides with the 50% to 70% reported in the literature.¹¹ Unlike the published 25% of patients that present with pain, however, this study found that two-thirds of those with ganglion cyst complained of pain.¹² Further, half of these patients also experienced deficits in ROM. This contradicts the generally accepted asymptomatic appearance of these lesions and indicates that excision is not primarily for cosmetic reasons.⁸ However, this may reflect a selection bias in that patients seeking treatment from a surgeon are less likely to be asymptomatic.

Ganglion cysts were the most common tumor type among all age groups with most occurring between the ages of 25 and 64 years. This range extends above previous reports of 30 to 50 years of age.^{2, 11} Hemangiomas were the only other tumor type that showed a predilection for a particular age group with most occurring in those aged 25 to 34 years (overall age range, 18 to 65+ years). They were one of the more common tumor types observed at 9.9% with 50% of patients reporting pain. Giant cell tumors, cited to be the second most common tumor type, were also found in this sample at 7%. (Figure 4 and Figure 5) 

 The age range of these patients was 18 to 64 years, which falls just outside of the published range of 30 to 50 years.^8,13 This may not represent a meaningful difference as the sample size of patients with this tumor type was small.

Other common tumor types included fibromas and granulomas. (Figure 6) 

Fibromas were observed in an older population within the cohort with ages ranging from 25 to 65+ years. Granulomas seemed to have a more bimodal distribution with ages ranging from 8 to 34 years and 55 to 64 years.

Malignant tumors, although important to discuss due to their implications, were rare, as has been described previously.¹⁴ The 2 cases described were a squamous cell carcinoma and digital papillary eccrine adenocarcinoma. Both tumor types presented without pain or tenderness, but decreased ROM was described with the eccrine adenocarcinoma.

The limitations of this study are those inherent to retrospective chart review studies. Researchers were only able to gather information documented in the patient chart. As an individual surgeon review, the sample size was limited and therefore cannot be used to draw generalized conclusions about the various types of hand tumors that may be encountered in the clinical setting. As many of the tumor types were rare involving less than 5 patients included in this sample, more detailed studies would be needed to elucidate their relationship to age, pain, and deficits in ROM. However, by looking through the lens of an individual surgeon over a period of 13 years, some of the common features of the more frequently encountered tumor types may be better understood.

Hand tumors are frequently encountered by physicians and can represent a variety of underlying pathology, both benign and malignant. From looking at the patients seen by 1 surgeon over an extended period of time, it is possible to gain perspective into the common types of hand tumors and some of their presenting features.

Affiliations: ^aRutgers New Jersey Medical School, Department of Orthopaedics, Newark, New Jersey; ^bRutgers New Jersey Medical School, Division of Plastic Surgery, Newark, New Jersey

Correspondence: Kamil Amer, MD. 140 Bergan St, Ste D-1610 Newark NJ 07103; kamil.amer@rutgers.edu

Disclosures: The authors disclose no financial or other conflicts of interest.