Benign Tumors of the Hand

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Benign Tumors of the Hand

• Michael W. Neumeister, MD,FRCSC,FACS
• Southern Illinois University School of Medicine
• Institute of Plastic Surgery
• Springfield, Illinois

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Dorsal Ganglion
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Digital Ganglions
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Volar Ganglions
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DIP Ganglions
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Inclusion Cysts
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Giant Cell Tumors
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Warts
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Fibrous Tumors
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Vascular Tumors
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Hematomas
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Arteriovenous Malformations
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Glomus Tumors
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Pyogenic Granuloma
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Traumatic Aneurysm
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Nerve Tumors
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Schwannoma
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Lipomas
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Bone Tumors
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Enchondromas
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Osteoid Osteomas
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Squamous Cell Carcinoma
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Basal Cell Carcinoma
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Metastatic Tumors
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Pigmented Lesions of the Nailbed
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Melanoma
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Malignant Upper Extremity Tumors

• E. Gene Deune MD
• Assistant Professor
• Co-Director, Hand Surgery Services
• Johns Hopkins School of Medicine
• Division of Plastic Surgery
• Baltimore, MD

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Upper Extremity Malignancy

• Tumors of the skin
• Basal Cell Carcinoma
• Squamous Cell Carcinoma
• Melanoma
• Sweat Gland Carcinoma
• Metastatic Carcinoma
• Tumors of soft tissues and bone (sarcomas)

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Introduction

• Sarcomas
• Malignant tumors arising from skeletal,
  extra-skeletal connective tissues, and peripheral
  nerves.
• Tissue origin primitive mesoderm.
• More than 20 histologically distinct subtypes,
  classified based on the normal tissues they mimic.

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Sarcomas

• Arises denovo, not from preexisting benign soft
  tissue tumors
• Exception (malignant peripheral nerve sheath
  tumor in patients with neurofibroma)
• Clinical behavior (similar for all sarcomas)
• locally invasive
• metastasis by hematogenous route
• lymph node metastasis is uncommon
• Gross appearance
• Similar pale, tan-colored fish flesh

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Soft Tissue Sarcomas

• Incidence
• 6000 new cases/yr
• lt 1 annual cases of malignancies
• Location
• Lower extremity (35)
• Upper extremity (15)
• Viscera (15)
• Retroperitoneal (14)
• trunk (10)
• Other (11)

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Sarcomas

• Demographics
• Mean age 55.8 yrs
• Male Female 1.4 1
• Clinical presentation
• Painless enlarging mass
• Average size 5 cm

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Sarcomas predisposing factors

• Ionizing radiation
• Chronic Lymphedema
• Chemical Agents
• Arsenic
• Vinyl Chloride
• Chlorophenols
• Genetic Predisposition
• Neurofibromatosis
• Familial polyposis coli

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Extremity sarcomas mortality

• 5 year survival 50 - 60 for all stages
• Metastasis
• common cause of death
• most common site lung (88)
• 80 metastasis occur 2 3 years after initial
  diagnosis
• Gadd MA et al., Ann Surg, 1993

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Sarcomas Grading

• Different grading system
• 4grade system
• 3-grade system
• Recognized by American Joint Commission on Cancer
  (AJCC)
• Used at Johns Hopkins Hospital
• 2-grade system (MSKCC)

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Sarcoma TNM Staging (AJCC)

• Grade
• G1 low grade
• G2 intermediate grade
• G3 high grade
• Tumor Size
• T1 lt 5 cm
• T2 gt 5cm
• Regional Nodes
• N0 No histogolically verified LN involvement
• N1 Histologic evidence of LN involvement
• Metastasis
• M0 No distant metastasis
• M1 Distant metastasis

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Sarcoma TNM Staging (AJCC)

• Stage Groupings
• Stage IA G1, T1, N0, M0
• Stage IB G1, T2, N0, M0
• Stage IIA G2, T1, N0, M0
• Stage IIB G2, T2, N0, M0
• Stage IIIA G3, T1, N0, M0
• Stage IIIB G3, T2, N0, M0
• Stage IVA Any G, any T, N1, M0
• Stage IVB Any G, any T, N1, M1

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Sarcomas prognostic factors

• Mitosis count
• lt 3 mitosis
• 3-20 mitosis
• gt 20 mitosis
• (per 10 consecutive high power fields)
• Presence or absence of necrosis
• Tumor size

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Sarcomas types

• Fibrous tumor Fibrosarcoma
• Fibrohistiocytic tumor
• Malignant fibrous histiocytoma
• Fat tumor Liposarcoma
• Blood vessel tumor
• Lymphangiosarcoma or angiosarcoma
• Kaposis sarcoma
• Perivascular tumor
• Malignant glomus tumor
• Malignant hemangiopericytoma

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Soft tissue malignancy types

• Synovial tumor
• Synovial sarcoma
• Malignant giant cell tumor of tendon sheath
• Mesothelial tumor mesothelioma
• Smooth muscle tumor Leoimyosarcoma
• Skeletal muscle tumor Rhabdomyosarcoma
• Extraskeletal cartilaginous/osseous tumors
• Osteosarcoma
• Chondrosarcoma
• Paragangliolionic tumor
• Malignant paraganglioma

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Soft tissue malignancy types

• Neural tumor
• Malignant peripheral nerve sheath tumor
• Malignant schwannoma
• Neurofibrosarcoma
• Malignant granular cell tumor
• Clear cell sarcoma (malignant melanoma of soft
  parts)
• Primitive neuroectodermal tumors
• Neuroblastoma
• Ganglioneuroblastoma
• Neuroepithelioma (peripheral neuroectodermal
  tumor)
• Ewings sarcoma
• Miscellaneous
• Epithelioid sarcoma

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Extremity Sarcomas

• Most common in upper extremities (JHH)
• Malignant fibrous histiocytoma 48
• Synovial cell sarcoma 13
• Liposarcoma 9
• Osteosarcoma 9
• Leiomyosarcoma 4
• Epithelioid sarcoma 4

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Extremity Sarcomas

• Locations in upper extremity (JHH)
• Clavicle 5
• Shoulder 9
• Axilla 5
• Upper arm / humerus 36
• Forearm 36
• Hand 9

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Sarcomas evaluation

• Diagnosis
• biopsy (tru-cut, incisional biopsy)
• Imaging
• Radiograph of extremity
• MRI of the extremity involved
• Chest x-ray CT scan - chest
• Arteriogram (rarely)
• Source Pollock RE, Karnell LH, Menck HR,
  Winchester DP National Cancer Database Report on
  Soft Tissue Sarcomas. Cancer, v.78(10), 1996

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Treatment of limb sarcomas

• Multidisciplinary teams
• Surgical team
• Oncology Surgery (Orthopedics)
• Plastic Surgery
• Adjuvant team
• Oncologists
• Radiation Oncologists

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Treatment of limb sarcomas

• Mainstay of treatment surgical resection
• Historic limb amputation
• Current limb salvage with adjuvant therapy
• Adjuvant Therapy
• Radiation
• Preoperative and/or
• Postoperative (External Beam or Brachytherapy)
• Chemotherapy
• Preoperative and/or postoperative

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Treatment of limb sarcomas

• Limb Amputation
• Historically standard surgical treatment
• Excellent local control
• High morbidity with loss of limb with severe
  impact on the quality of life
• No added survival benefit when compared with limb
  salvage surgery combined with adjuvant therapy
  (chemotherapy and/or radiation).

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Treatment of limb sarcomas

• Long term prospective studies (N.C.I)
• Recurrence free _at_ 240 months
• Limb sparing (XRT Chemo) 80
• Amputation (w Chemo) 90
• Survival _at_ 240 months
• Limb sparing (XRT Chemo) 60
• Amputation (w Chemo) 70
• p N.S

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Treatment of limb sarcomas

• Incidence of major amputation has decreased
• 50 in 1960s vs 10 in 1990s (MSKCC)
• 29 in 1988 to 8.9 in 1993 (Pollack, RE et al,
  1996)

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Limb Sparing surgery

• Goals
• Resect tumor with wide surgical margins
• Sparing nerves, blood vessels, and bone
• Preserve limb and limb function
• Without negative impact on recurrence rate
• Without negative impact in long term survival

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Limb Salvage Literature

• Serletti JM (1998) Functional outcome after
  soft-tissue reconstruction for limb salvage
  sarcoma surgery
• Evans GR (1997) Adjuvant therapy the effects on
  microvascular lower extremity reconstruction.
• Reece GP (1997) Lower extremity salvage after
  radical resection of malignant tumors in the
  groin and lower abdominal wall
• Kumta SM (1997) Limb salvage surgery with
  microsurgical reconstruction for the treatment of
  musculoskeletal tumors involving the upper
  extremity

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Limb Salvage Literature

• Cordeiro PG (1994) The role of free tissue
  transfer following oncologic resection in the
  lower extremity.
• Usui M (1993) Microsurgical reconstruction in
  limb-slavage procedures comparison between
  primary and secondary reconstruction.
• Hidalgo DA (1993) The treatment of lower
  extremity sarcomas with wide excision,
  radiotherapy, and free-flap reconstruction.

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Algorithym reconstruction

• Wound Location
• Shoulder
• Upper arm
• Forearm
• Hand
• Wound Size
• Functional restoration needed
• Tendon transfer
• Functional muscle

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Sarcoma reconstruction Shoulder

• Pedicle flaps
• Latissimus dorsi
• recommend a fasciocutaneous island
• Free flaps
• Latissimus dorsi-contralateral
• Rectus abdominis
• Local Fasciocutaneous flaps
• Rhomboid flap
• Scapular/parascapular flap

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ShoulderMFH
2.5 years postoperative
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AxillaPleomorphic sarcomarhomboid
2.5 years postoperative
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Sarcoma reconstruction Arm/elbow

• Pedicle flap
• Latissimus
• Free flap
• Latissimus (elbow)
• Gracilis
• Rectus Abdominis
• Local flap
• Fasciocutaneous rhomboid

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Synovial Cell SarcomaPedicle Latissimus dorsi
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Elbow MFHFree Latissimus dorsi
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Arm MFHRhomboid flap
Incomplete excision
2 years postoperative
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Sarcoma reconstruction Forearm

• Pedicle
• Reversed lateral arm flap
• Free flap
• Latissimus
• Rectus Abdominis
• Gracilis
• Free fasciocutaneous (radial forearm, scapular)
• Local flap
• Fasciocutaneous rhomboid

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Undifferentiated sarcoma reversed lateral arm
flap
3 months postoperative
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Forearm MFHFree Rectus Abdominis
FDS, FDP, FPL. FCR resected
Rectus abdominis free flap tendon transfers
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3 years postoperative
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Sarcoma reconstruction Hand

• Pedicle
• Reversed radial forearm flap
• Free flap
• Muscle
• Latissimus, Rectus Abdominis, Gracilis
• Fasciocutaneous
• Radial forearm, scapular, lateral arm
• Local flap
• None

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Hand synovial cell sarcomaRectus abdominis free
flap
Free rectus abdominis
3 months postoperative
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Functional restoration

• Necessary when crucial limb functions gone
• Elbow Flexion
• Wrist flexion and extension
• Finger or thumb flexion and extension
• Types of Surgery
• Tendon transfers
• Tendon grafts
• Innervated muscle flaps
• Latissimus, pedicle
• Gracilis, free
• Nerve grafts

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Functional Restoration Surgery

• Timing of functional restoration surgery
• Immediate (at tumor resection)
• Delayed
• Frequency
• 31 Upper extremity
• 5 Lower extremity

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Malignant Fibrous Histiocystoma Right arm
Intraoperative brachial plexus dissection Plating
of humerus Reconstruction of brachial artery for
thrombosis
Pedicled innervated latissimus dorsi flap
Latissimus dorsi flap inset
Latissimus dorsi flap final inset
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Osteogenic Sarcoma of humerus Resection of
humerus biceps Placement humerus allograft 17
months postoperative
Ipsilateral gracilis free flap
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23 months postoperative
Return of elbow flexion
1 month postoperative
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Brachytherapy catheters Before tendon transfer
free Latissimus dorsi
Specimen w segment of ulna
Right forearm Epithelioid sarcoma
9 mons postoperative
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Length of Surgery

• Functional restoration 11.4 ? 2.1 hrs
• W/o functional restoration 7.8 ? 3.1 hrs

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Surgery times

• Combined Pedicle Free
• Surgery 8.3 3.4 7.5 2.9 10.6 2.1
• Resection 3.4 2.0 3.8 2.3 3.6 1.5
• Reconstruction 4.9 2.6 4.0 1.9 6.7 1.4
• (hrs) (hrs) (hrs)
• Ischemia time 1.5 0.3 hrs

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Hospital Stay (days)

• Combined Pedicle Free
• All patients 6.4 ? 3.5 5.3 ? 3.5 8.0 ? 3.2
• w/o brachytherapy 4.8 ? 2.8 4.3 ? 3.0 6.3 ? 2.2
• with brachytherapy 10.2 ? 1.7 8.3 ? 3.5 10.3 ?
  1.5
• Range 1 - 20 days

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Adjuvant Therapy

• Preoperative
• External beam radiation 6
• Chemotherapy 3
• Radiation Chemotherapy 2
• Postoperative
• Brachytherapy radiation 4
• External beam radiation 3
• External beam brachytherapy 1
• External radiation chemotherapy 1
• Chemotherapy 1
• Chemotherapy Brachytherapy 2
• Both Preoperative and Postoperative 4

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Complications

• Patients with complications 55
• Wound complications 36
• Non-wound complications 18
• Wound and non-wound cx 5
• Flap donor site moribidity 5
• Surgery for complications 18

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Wound complications

• Wound problems
• Seromas
• Wound separation
• Cellulitis
• Delayed healing
• Flap donor site morbidity
• Abdominal hernia (rectus abd)
• Rectus sheath hematoma
• Gracilis donor site hematoma

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Non wound complications

• Nerve palsies
• Ulnar nerve compression
• Brachial plexopathy (transient)
• AIN palsy
• Arm pain
• Wrist instability

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Abdominal hernia
Rectus sheath hematoma
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Postoperative Course

• Pts with reexisting metastasis 1
• Pts who developed postop metastasis 3
• One patient with 3 metastasis locations
• Location of metastasis
• Lung 3
• Bone 1
• Shoulder 1
• Brain 2
• Local recurrence 2
• Death 2
• Survival time 19.0?15.6 mo

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Postoperative Upper Limb Function

• Amputation of limb after salvage 0
• Limb with little or no function 2
• Limb with moderate function 7
• (not preoperative level)
• Full limb use without limitation 13
• Limbs with full or moderate use 20 (91)

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Conclusion

• Review of Sarcomas in upper extremity
• Limb salvage for sarcomas
• Reconstruction
• Flaps
• Functional restoration
• Postoperative results
• Surgery time
• Hospitalization
• Complications
• Limb function

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Thank-you