Current Treatment of Malignant Hand Tumors
If you had a tumor of the hand, what would you like to know about the diagnostic process and treatment plan? In this article, a hand surgeon from the well-known and respected Sloan-Kettering Cancer Center brings us up-to-date on the topic of malignant and metastatic tumors of the hand.

The information on diagnosis, staging, and treatment modalities is important for all health care professionals because few people with finger problems would think to go to a cancer center to have it checked out.

And for the most part, the affected individuals would be right in their thinking. Malignant hand tumors are indeed rare. Most lumps, bumps, and tumors of the fingers turn out to be benign ganglions, giant cell tumors of the tendon sheath, or lipomas (fatty tumors).

By the nature of being "benign", these growths don't spread and don't cause life-threatening problems like malignant and metastatic growths. Malignant soft tissue sarcomas affecting the bone include chondrosarcoma, osteogenic sarcoma, and Ewing's sarcoma.

Any of these tumors can occur first in the bone and then metastasize elsewhere but in fact, it is much more likely that the primary (main) tumor is somewhere else and these new tumors are metastatic (spread from their original location) to the bones of the fingers.

When people develop swollen, red, painful fingers, they don't head on in to the nearest cancer clinic. Instead, they show up at their primary care physician's office or the local walk-in medical clinic. A patient history and physical exam will be performed but it's really the diagnostic testing that will supply an answer to what is going on.

First, standard X-rays are taken. Then CT scans and MRIs may be ordered. If necessary, a PET scan (PET stands for Positron Emission Tomography) of the upper body may help show tumors in the chest or other areas other than the hand/fingers. PET scans also help sort out benign from malignant tumors.

Other tests may be ordered depending on what type of tumor is present (or what the physician is suspicious of). For example, soft tissue sarcomas (a malignant tumor affecting bone or surrounding soft tissue structures) will require a sentinel lymph node biopsy.

For this test, a dye is injected into the tissue around the tumor. The dye flows through the lymph system to the lymph nodes. The surgeon removes lymph nodes near the tumor and sends them to the lab where they are examined for the presence of any dye. A positive sentinel node suggests tumor cells have reached the lymph nodes and traveled beyond (a process called metastasis).

The results of this test help physicians stage the cancer, which in turn, helps determine treatment. Staging tells us how far advanced the disease is and helps determine the prognosis. Early diagnosis and treatment is always advised and often linked with better long-term outcomes.

Treatment for malignant hand tumors consists of surgery, chemotherapy, and/or radiation therapy (also known as "radiotherapy"). The surgeon must be careful to remove the entire tumor without cutting into it. This technique is referred to as getting "clear margins".

Once the tumor is removed, it is sent to the lab where the pathologist identifies the exact type of tumor and "stages" it. The absence of clear margins requires an additional surgery to remove the rest of the tumor cells.

The process of disrupting the margins and conducting a second surgery contributes to a poorer prognosis than if clear margins are obtained the first time. But tumors don't have dotted lines around them to show the surgeon where to cut so getting clear margins isn't as easy as it sounds. The practice of performing a wide excision (cutting a large area around the tumor) is often used to avoid missing clear margins.

With hand surgery, the area is small and it could be devastating to lose a large amount of tissue and still preserve normal hand/finger function. Surgeons do everything they can to balance the need to remove tumor tissue (and enough tissue so that the tumor doesn't grow back) with the impact on local tissues. The surgeon tries to preserve tissue and avoid partial hand amputations whenever possible.

Radiotherapy may be used before surgery to shrink the size of the tumor as much as possible before operating to remove it. Not all tumors will require radiation and in some cases, radiation is given after the tumor has been removed.

Postoperative radiation is most common when the margins between the tumor and normal tissue are very narrow. Postoperative radiation is also indicated when the tumor is large and/or pressing on other vital structures.

Radiation has many negative side effects so it must be used carefully whenever it is administered. Fortunately, technology has improved a great deal in this area and special machines make it possible to deliver radiation directly to the site of the tumor without radiating the surrounding tissue at the same time.

Chemotherapy can help to reduce the risk of tumor cells growing in that area again (a process referred to as cancer recurrence. The administration of cytotoxic drugs (another name for chemotherapy) kills all fast growing cells (not just cancer cells). That means chemotherapy can also impact cancer that has metastasized or moved from the original (primary) site.

Although radiotherapy and chemotherapy help prevent local recurrence and even eliminate some metastasis, these treatments do not improve patient survival. Most of the time, the cancer cells have traveled to the hand from some other primary (first) site such as the lung, breast, or kidney. Treatment is a matter of minimizing the effects of the tumor on the hand (e.g., preventing fractures and amputations).

In conclusion, malignant tumors of the hand are rare. That's good news for anyone with cancer that can metastasize. For anyone with a painful, red, and swollen finger that looks like an infected hangnail, special care must be taken to make a proper differential diagnosis. Anyone with a past medical history of cancer of any kind but especially breast, lung, and kidney must be examined carefully before beginning any kind of local treatment.
Mark E. Puhaindran, MBBS, and Edward A. Athanasian, MD. Malignant and Metastatic Tumors of the Hand. In The Journal of Hand Surgery. November 2010. Vol. 35A. No. 11. Pp. 1895-1900.