Ganglion Cysts

Introduction

A tumor by definition is an abnormal nodule, lump or mass that is not a normal part of the hand and the upper extremity. The nodule may consist of skin, underyling tissue such as fat, fluid, muscle, nerve, or bone. The nodule may be benign or malignant. Upper extremity tumors usually represent a significant component of a hand surgeon’s practice. These tumors can be broadly classified into their tissue of origin, such as connective tissue, epidermal, vascular, nerve, or bone. Connective tissue tumors include ganglion cysts, giant cell tumors, fibromas, and lipomas. Epidermal tumors include warts, epidermal inclusion cysts. Vascular tumors include glomus tumors, hemangiomas, arteriovenous malformations, pyogenic granulomas. Nerve tumors include neurofibromas and schwannomas. Bone-related tumors include chondromatosis, enchondromas, and osteophytes.

Connective tissue tumors

Ganglion cysts

Ganglion cysts are the most common benign tumor in hand, accounting for about 60-70% of all nodules. On examination they are usually firm and are composed of gelatinous fluid, usually emanating from a joint, tendon, or tendon sheath. Ganglion cysts will transilluminate when a flashlight is held to it or to the surrounding skin. The patient will usually have a history of the cyst fluctuation in size and in discomfort. Approximately 10% of the patients will remember an antecedent trauma to the wrist or the finger. The most commonly location is on the dorsal wrist location, emanating from the scapho-lunate joint. The second most common location is on the volar radial forearm surface and in this location, often times the ganglion cyst lies over the radial artery. Ganglion cysts located at the DIP joint of the finger are due to a bony spur or an osteophyte. With chronicity, the DIP joint ganglion cyst can press on the germinal nail matrix, resulting in a depressed nail groove. The initial step is to make the diagnosis of a ganglion cyst is by physical exam. A radiograph is very helpful in ascertaining any osteophytes present that might be the cause of the cyst. Initial treatment consists of observation, as there is possibility, although low, of spontaneous resolution and accidental rupture due to an unexpected external force. Historically, ganglion cysts were treated by hitting the cyst with a heavy book. In the Americas and in Europe, this often times meant using the Christian Bible, and it is not unusual for a patient to come into the office stating that a friend or family made that recommendation. Should conservative monitoring not be effective, the next treatment option is to aspirate the fluid followed by an injection of a mixture of steroid and local anesthetic in attempts to sclerose the cystic lining. The rate of success is variable but generally there a 50% recurrence rate. Should it recur, surgery is the next option should the cyst remain symptomatic. Should there be an osteophyte, a localized ostectomy of the osteophyte needs to be done. The cyst should be resected along with its stalk and the joint capsule from which the cyst originated. With good surgical technique, the recurrence rate should be less than 5%. The surgery is an outpatient procedure done under intravenous sedation supplemented with local anesthesia. Healing time is minimal and the patient can return to work in one week if it is not a manually demanding job.

Giant Cell Tumors of the tendon sheath

Giant cell tumors are also known as localized nodular tenosynovitis and fibrous xanthomas. They are the second most common tumor in the hand, accounting for about 10%. They are non-tender, firm, rubbery, multilobulated, do not transilluminate, and are usually adherent to surrounding tissue. They are slow growing, and the symptoms are related to the local effects to the finger or hand such as skin irritation or digital nerve compression. They are generally more common in the fingers than in hand. The tumor is yellow/brown in color, and this can be detected upon close inspection on the skin. Given enough time and growth, giant cell tumors can be locally destructive to bone. The diagnosis is often made by clinical exam and history. An MRI can be ordered if the diagnosis is uncertain or if there is a need to determine the extent of tissue involvement if it is large. The treatment is surgical excision with meticulous technique as residual tumor can account for high recurrence rate up to 50%.

Epidermal tumors:

Warts

Warts are the most common skin lesion in the hand. Warts are caused by an infection with human papilloma virus (types 1, 2, 4, 29) and are often located in the areas of trauma, such as around the fingernail fold and the elbow. Warts can transform into squamous cell carcinoma under the right conditions such as exposure to ionizing radiation or in an immunocompromised patient. Treatment is usually by the use of topical chemicals such as squaric acid biethylester, topical salicylic acid, pulsed dye laser, or cryotherapy. Warts can also be removed surgically.

Epidermal inclusion cyst

Epidermal inclusion cyst account for 10% of all benign hand tumors. It is caused by traumatic invagination of the epidermal elements into the subcutaneous tissue. They present as round, slowly growing, non-transluminating lesion, and often times seen with a small “white-head” at the crux of the nodule. The cysts may sometimes become infected due to skin compromise and organism is usually a staphylococcus species or a streptococcus bacteria. Generally epidermal inclusion cysts are asymptomatic. When they do become symptomatic, surgical excision is usually effective as long as the cystic lining is also removed. If not, there can be a recurrence. Should the cyst be infected, surgical excision provides the best treatment option. The excision is done to remove the infected material and the wound is left open for secondary healing along with a few days of oral antibiotics.

Fibromas

Fibromas comprise about 1-3% of benign hand tumors. Clinically they are painless, slow growing, and well circumscribed. The treatment is surgical excision mostly for diagnostic purposes and to remove any mechanical functional compromise.

Vascular tumors:

Pyogenic granulomas

A pyogenic granuloma is a vascular tumor, accounting for about 1 – 2% of benign hand tumors. On examination, they are friable and easily bleed. They are always associated with a history of antecedent trauma. Following the trauma, the patient will notice at the sight of injury, a rapidly growing lesion that tends to bleed very easily and profusely with minor irritation. There can also be a superinfection due to the inability of the wound to heal over the pyogenic granuloma. If the pyogenic granuloma is small, they can be cauterized with silver nitrate. Larger lesions need surgical excision with cauterization. There is a high recurrence rate if any tissue left behind. 

Glomus Tumors

A glomus tumor is classified as a neurovascular tumor as it contains both vascular and nervous tissue. The glomus tumor originates from the glomus body, which regulates temperature and blood pressure by altering local blood flow in the finger. It is usually solitary, blue to red in color. It is most common found in the fingertips and is usually subungual. They account for 2% of benign tumors in the hand. The classically described symptoms are cold intolerance, paroxysmal pain, and pinpoint tenderness. The treatment is surgical excision with repair of the nailbed, if it is located underneath the nailplate.

Other vascular tumors

Other vascular tumors include the vascular malformations seen in isolation or in combination with syndrome such as Klippel Trenaunay Weber Syndrome.

Nerve-related tumors:

Traumatic Neuromas

Neuromas are by definition tumors of the nerve. They are benign and arise almost always from a complete or partial injury to the nerve. The neuroma is a reflection of the incomplete healing and repair of the nerve, resulting in the thickening of the nerve either at the transected end or along the length of the nerve where the injury occurred. They are very painful and often times require transposition of the nerve into a more protected location such as under a muscle or a repair to the other end of the severed nerve to try to restore nerve integrity. These two surgical options can decrease the pain and improve the symptoms.

Schwannomas

Schwannomas are the most common benign nerve tumor in the hand. They are slow growing and are composed of Schwann cells. Because this tumor does not involve the nerve fascicles and as it gets larger, it pushes and separates the fascicles away from the tumor. For this reason, schwannomas can be removed by “shelling out”. Because of its local pressure on the nerve, schwannomas may produce neurological symptoms in the distribution of the involved nerve in the form of paresthesias or numbness, or weakness if the nerve involved is a motor nerve. An MRI is usually helpful in making the diagnosis.

Neurofibromas

Neurofibroma is the second most common benign nerve tumor in the hand. It can present as a solitary nodule or with other multiple nodules, such as the case in neurofibromatosis NF1. The plexiform type of neurofibromas can transform into neurofibrosarcoma. It is estimated that this occurs about 2 to 13% of the time, and the risks are higher if the neurofibromas are larger. Because the entire nerve is involved, neurofibromas cannot be “shelled- out” during removal such as schwannomas can. The symptoms usually are pain in the distribution of nerve that is involved.

Bone-related tumors

Enchondromas

Enchondromas are benign cartilaginous growth within the medullary cavity of bones. They usually are asymptomatic with incidental discovery made on plain radiographs taken for an unrelated cause. Occasionally the enchondromas have grown to the point where the outer cortex becomes distorted and cause the finger to swell or they can weaken the cortex to the point where the finger fractures. The patient in this case presents with a fracture with only minor trauma. The diagnosis is made by plain radiographs. If the diagnosis remains uncertain, an MRI is obtained. The treatment remains surgical with resection of all cartilaginous elements. A bone graft may be needed if the residual space is significant. Should there be a fracture, most surgeons would recommend allowing the fracture to heal prior to surgery. However, simultaneous resection and fracture fixation with a small external fixator can also be done to combine the treatment of both the fracture and the resection of the enchondroma simultaneously.

Chondromatosis/osteochondroma/and other benign cartilaginous tumors

Benign proliferation of cartilaginous tissue can often times occur at the joint surface of the cartilage and the bone, resulting in a deviation of the joint. Although this occur