Chapter 77 Tumors and Tumorous Conditions of the Hand
Classification
TABLE 77-1 Classification of Benign Tumors
STAGE | TYPE |
---|---|
1 | Latent |
2 | Active |
3 | Aggressive |
Modified from Enneking WE: Musculoskeletal tumor surgery, New York, 1983, Churchill Livingstone.
TABLE 77-2 Classification of Malignant Tumors
STAGE | TYPE |
---|---|
IA | Low grade, intracompartmental |
IB | Low grade, extracompartmental |
IIA | High grade, intracompartmental |
IIB | High grade, extracompartmental |
III | Either grade with regional or distant metastasis |
Modified from Enneking WF, Spanier SS, Goodman MA: The surgical staging of musculoskeletal sarcoma, Clin Orthop Relat Res 153:106, 1980.
Treatment
TABLE 77-3 Classification of Surgical Margins
TYPE | PLANE OF DISSECTION |
---|---|
Intracapsular | Piecemeal, debulking, or curettage |
Marginal | Shell out (en bloc) through pseudocapsule or reactive zone |
Wide | Intracompartmental (en bloc) with cuff of normal tissue |
Radical | Extracompartmental (en bloc) with entire compartment |
Modified from Enneking WE: Musculoskeletal tumor surgery, New York, 1983, Churchill Livingstone.
Benign Tumors (Table 77-4)
Lipoma
Intraneural Lipofibromas
Intraneural lipofibromas are rare benign tumors that usually involve the median nerve. Patients present within the first 3 decades of life with a mass located in the palmar aspect of the hand or wrist, possibly with altered median nerve function (Fig. 77-2). Microscopically, fibroadipose tissue is seen infiltrating the epineurium, separating and compressing the fascicles. A conservative approach should be taken in treating these tumors. Incisional biopsy may be necessary for diagnosis. If extrinsic neural compression exists, surgical decompression should be performed by fasciotomy or carpal tunnel release. Intraneural excision may debulk the tumor, but this procedure is not recommended because intraneural fibrosis can increase the neural deficit. Malignant transformation is rare; however, intractable pain may result from some lesions and warrant tumor excision (Fig. 77-3). If a digital nerve is involved, en bloc excision with nerve grafting may be successful, although sensation would be altered (Fig. 77-4).
Benign Tumors of Fibrous Origin
Juvenile Aponeurotic Fibroma or Calcifying Aponeurotic Fibroma
First described by Keasbey in 1953, juvenile aponeurotic fibroma is a benign fibrous tumor typically appearing in the hands or wrists of children and young adults. It also has been called calcifying aponeurotic fibroma because in older patients calcification of the cartilaginous component may be present, a feature that distinguishes it from other benign tumors of fibrous origin. Clinically, it is a painless, solitary, and mobile mass less than 4 cm in diameter, usually involving the palm (Fig. 77-6). The tumor usually is on the volar side of the hand and is connected to peritendinous tissues and fascia. It has no gender predilection and no tendency to involve the ulnar side of the hand, as do Dupuytren nodules. Juvenile aponeurotic fibromas tend to develop close to tendons and are able to infiltrate surrounding muscle and fat. On radiographs, calcifications can be seen within the soft tissue mass. Because juvenile aponeurotic fibroma has a distinct tendency for local recurrence after marginal excision, especially in younger children (50%), a wide excision, preferably without sacrifice of function, is recommended.