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Incidence, histopathologic analysis and distribution of tumours of the hand
© Simon et al.; licensee BioMed Central Ltd. 2014
Received: 4 September 2013
Accepted: 23 May 2014
Published: 28 May 2014
The aim of this large collective and meticulous study of primary bone tumours and tumourous lesions of the hand was to enhance the knowledge about findings of traumatological radiographs and improve differential diagnosis.
This retrospective study reviewed data collected from 1976 until 2006 in our Bone Tumour Registry. The following data was documented: age, sex, radiological investigations, tumour location, histopathological features including type and dignity of the tumour, and diagnosis.
The retrospective analysis yielded 631 patients with a mean age of 35.9 ± 19.2 years. The majority of primary hand tumours were found in the phalanges (69.7%) followed by 24.7% in metacarpals and 5.6% in the carpals. Only 10.6% of all cases were malignant. The major lesion type was cartilage derived at 69.1%, followed by bone cysts 11.3% and osteogenic tumours 8.7%. The dominant tissue type found in phalanges and metacarpals was of cartilage origin. Osteogenic tumours were predominant in carpal bones. Enchondroma was the most commonly detected tumour in the hand (47.1%).
All primary skeletal tumours can be found in the hand and are most often of cartilage origin followed by bone cysts and osteogenic tumours. This study furthermore raises awareness about uncommon or rare tumours and helps clinicians to establish proper differential diagnosis, as the majority of detected tumours of the hand are asymptomatic and accidental findings on radiographs.
Bone tumours are neoplasms originating in the skeletal system that are within or closely related to the bone tissue . Primary bone tumours only account for a very small part of all human neoplasms and the bones of the hand are even more seldom affected [2, 3]. The majority of tumours found in the hand are benign and of chondrogenic origin [3–5]. Almost all tumour types originating in bone can appear in the hand . There have been numerous case reports of several tumour types of the hand [7–11], however, there is still a substantial lack of knowledge with regards to frequency and demographic knowledge about tumours of the hand.
The current article presents a large collection of hand tumours and demographic analyses. The aim of this meticulous study was to enhance the knowledge of findings on traumatological radiographs and improve differential diagnosis. Therefore, a comprehensive retrospective investigation was undertaken to characterise hand tumours and identify demographic and anatomic prevalence to aid the clinician.
This retrospective study reviewed data collected from 1976 until 2006 in the Bone Tumour Registry Hamburg. The following data was documented: age, sex, radiological investigations, tumour location, histopathological features including type and dignity of the tumour, and diagnosis. The study was approved approval by the institutional ethics committee of the University Medical Center Hamburg-Eppendorf, Germany.
The tumours had been collected by our institution and from consultation cases sent to our Bone Tumour Registry. For all cases, undecalcifed specimens were embedded in methyl-methacrylate and/or embedded in paraffin wax after EDTA-decalcification. For the purposes of the present study, new fresh cut slides were prepared and stained with hematoxylin and eosin (paraffin blocks), or toluidine blue and Goldner trichrome staining methods (plastic embedded blocks). Microscopic analyses were done using a Zeiss microscope (Axiophot, Carl Zeiss, Jena, Germany) and representative microphotographs were taken using a digital camera (AxioCam MRc, Carl Zeiss, Jena, Germany) and AxioVision Rel.4.8. (Carl Zeiss, Jena, Germany).
Radiographs were collected for all cases included in this study.
All cases with osseous metastases, haematologic malignancies and inflammatory processes were excluded. The filtering process was executed and differentiation into five major tumour type categories was done as recommended by the World Health Organization (WHO) according to cell origin and one blend category was created and defined as “other” .
For the statistical analysis, we used the global chi-squared test for analysis of sampling distribution with IBM® SPSS® Statistics 19. Significance was defined as p ≤ 0.05 and/or when p ≤ 0.01.
A complete list of all tumour lesions found in the hand divided into six categories
Cartilage tumours - 69.1%
Vascular tumours - 2.2%
36.8 ± 14.7
24.5 ± 13.4
60.7 ± 19.8
24.7 ± 28.3
16.9 ± 18.2
20.5 ± 2.1
28.8 ± 19.3
34.0 ± 26.8
22.8 ± 17.0
70.0 ± 0
37.0 ± 16.1
36.0 ± 0
23.2 ± 13.9
Bone cysts - 11.3%
Fibrogenic tumours - 0.9%
Aneurysmal bone cyst
56.1 ± 16.5
17.7 ± 10.6
Simple bone cyst
32.5 ± 20.1
23.5 ± 7.0
55.5 ± 15.9
68.0 ± 0
38.0 ± 0
Osteogenic tumours - 8.7%
Other - 7.8%
35.9 ± 17.2
46.2 ± 19.9
54.3 ± 20.7
Giant cell tumour
35.5 ± 16.7
28.0 ± 19.0
13.6 ± 6.4
34.3 ± 7.6
73.0 ± 0
46.5 ± 13.4
1.0 ± 0
21.0 ± 0
There have been several reports demonstrating case-reports or collectives of specific tumour types, however, in our opinion there is a deficit in establishing a proper differential diagnosis of tumour lesions of the hand [10, 13, 14]. Therefore, this study included all types of primary tumours located in the hand. This systematic retrospective analysis of the collected data from the Bone Tumour Registry in Hamburg yielded a total of 631 cases divided into five major tissue types and one compilation of various tissue origins. Cartilage-derived tumours represented the main majority of all tumours of the hand. Furthermore, a predominance of tumours occurring in the phalanges was noted and the demographic distribution was significant aiding in establishing differential diagnoses.
A previous collection by Baumhoer and Jundt assembled chondrosarcomas, osteosarcomas and Ewing sarcomas and their main differential diagnoses . Thus, their focus was on malignant tumours. They had registered 37 malignant bone tumours of the hands in the Basel Bone Tumour Reference Center since 1972 and reported clinical symptoms and presented valuable images.
However, there were more frequent tumour lesions than the ones listed by these authors. Therefore, we included in this current collection with over 600 cases all types of tumours found in the hand. Kitagawa and colleagues acknowledged the need to assess even soft-tissue tumours of the hand as there are bone changes associated with it . They identified that many tumours are frequently associated with bone erosions. The erosions tend to increase in depth without increasing in width and often only require surgical curettage but bigger lesions require greater surgical approach.
In agreement with previous studies, benign tumours are significantly more common than malignant tumours in the hand [2, 16–18]. Furthermore, elderly patients are more likely to have a malignant lesion whereas younger individuals present with a benign tumour. Enchondroma is the most common primary tumour lesion of the hand in the present study and as documented previously [19, 20]. Enchondromas are benign but tend to have high cellularity, enlarged nuclei and double-nucleated cells making differentiation between benign tumours and malign lesions like chondrosarcomas difficult. However, proper diagnostic work up is essential to not miss any malignancies and determine accurate diagnosis followed by successful treatment. Chondrosarcomas were reported to metastasise and hence have the potential to be fatal . Treatment of enchondromas is usually customised to the patient’s symptoms and risk for a pathologic fracture. Another tumour entity, which is special, is the bizarre parosteal osteochondromatous proliferation also known as Nora’s lesion, which is usually encountered on the surfaces of bones in hands and feet [13, 22]. It has a relatively high recurrence rate between 29 to 55% [22, 23]. It usually has a characteristic clinical and histologic appearance but still may be mistaken with other benign and malignant lesions like parosteal osteosarcoma. Though Nora’s lesions present with high recurrence rates and atypical histologic appearances, no metastases or deaths were reported, but high recurrence rates are indicative of a more extensive required resection in the treatment protocol [24, 25].
The present study has several limitations. The study is retrospective and lacks clinical management, however; we believe that this was beyond the scope of our study. Additionally, the therapeutic regimens have changed considerably over the last decades. Furthermore, to have seen such an enormous collection of individuals and therefore to have personally gained differential diagnostic knowledge about tumour lesions of the hand is rather uncommon making this study tremendously valuable for the clinical practitioner. The cut-off mark for demonstrating the major tumour lesions was set at 5% covering over 80% of all lesions detected in the current study, and therefore should deliver sophisticated and at the same time not overwhelming advice for clinical practitioners.
In conclusion, all primary skeletal tumours can be found in the hand and are most often of cartilage origin followed by bone cysts and osteogenic tumours. Phalanges of the hand most frequently have tumour lesions with enchondromas being the most often detected tumour overall. Additionally, two age peaks were identified for diagnosing tumour lesions of the hand: the second and forth decade. Over the observed time period of 30 years, malignant tumours were identified in about 11% of all cases and more often in older patients than benign lesions. These statistically evaluated results represent data of paramount importance for the clinician to help differentiate between various tumour entities in unclear, accidental or challenging radiographic findings with the use of the current data sets for tumour location, patient age and gender. Additionally, this research provides awareness of uncommon and rare tumours of the hand. Therefore, this information is extremely beneficial for the clinician in order to establish correct diagnosis early and consequently initiate proper treatment processes.
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