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Surveillance for an Indeterminate Hand Mass
MCKinney, J. D.O
St. Josephs Regional Medical Center, Department of General Surgery, Paterson, N.J.
Introduction: Here presented is the case of a 19 month old male with a hypothenar
mass who after appropriate work-up and consultation and following surgical excision and
immunohistochemistry was found to have a spindle cell tumor with myofibroblastic and
neuroectodermal elements.
Case: 19 month male presents with a palpable neoplasm of the right hypothenar
eminence. A MRI of the right hand revealed an oval heterogeneous mass in the volar
aspect in the hypothenar region of the hand. It measured 3.8 x 2.2 x 1.5 cm. It was volar
to the flexor tendons and just distal to the Guyon’s Canal. The mass was
heterogeneous, dark and bright on T2 weighted imaging and homogeneous, dark on T1
weighted imaging. There was a small projection of approximately 6mm extending
between the heads of the 4 th and 5 th metacarpals. There was very minimal
enhancement of this lesion on post-contrast imaging. The MRA revealed widely patent
radial and ulna arteries with this mass displacing the vessels. The mass demonstrated
no evidence of vascularity and no aneurysm. Complete excision of the mass and
immunohistochemical analysis revealed the lesion to be a spindle cell neoplasm with
myofibroblastic and neuroectodermal elements. The vast majority of soft tissue mass
lesions of the wrist and hand are benign. In the pediatric hand and wrist, foreign body,
ganglion cyst and vascular malformation are the most common soft tissue masses (7).
Evaluation begins with a detailed history that includes any pertinent medical
conditions. The history should also include information regarding the lesions rate of
growth, any changes in consistency or color, associated pain or neurologic symptoms, or
prior trauma to the area. Conventional radiographs should always be obtained, even for
soft tissue masses. They may show calcific densities within the lesions, such as
phleboliths in a hemangioma or changes in the cortex because of pressure from an
overlying mass (3). More specialized imaging, such as MRI, often is indicated when
doubt still exists as to the true nature of the mass. Excisional biopsies can be safely
performed for small tumors (< 2cm) and for some larger tumors (such as lipomas) that
have both the clinical and radiographic features of benign lesions. For most tumors or
when the diagnosis is in doubt, an incisional biopsy should be done before excision (3).
Discussion: For most benign lesions, surgery alone is the preferred treatment; for
malignant lesions this strategy can be accompanied by chemotherapy or radiotherapy on
an adjuvant or neoadjuvant basis, depending on the particular tumor (6). In the case of
an indeterminate lesion, as in the one presented in this case study, literature regarding
the optimal treatment and surveillance of these patients is scarce. If the lesion were to
recur, if our surveillance protocol was modeled after surveillance protocol for a lesion
with a very high recurrence rate, the lesion should be discovered during that surveillance
period. Giant-Cell Tumor of the Tendon Sheath, as described earlier in this monograph,
is the second most common tumor of the hand. It has a very high recurrence rate, in
some series as high as 44% (9, 10). The recommended follow-up period is 5 years, with
most recurrences occurring between 2-4 years later). Further studies would have to be
performed to evaluate for the optimal treatment and surveillance regimens for
indeterminate hand lesions in the pediatric population.