What is the treatment for a hypoechoic and hyperechoic structure in the soft tissue of the hand?

Treatment of Hypoechoic and Hyperechoic Structures in the Soft Tissue of the Hand

The treatment for hypoechoic and hyperechoic structures in the soft tissue of the hand requires proper diagnosis through imaging and biopsy, followed by appropriate surgical excision with or without adjuvant radiation therapy based on the characteristics of the lesion.

Diagnostic Approach

Initial Evaluation

• Initial assessment should begin with radiographs to rule out bone involvement, detect calcifications, and identify possible foreign bodies 1
• Ultrasound is recommended as the first-line imaging study for superficial or palpable soft tissue masses, particularly useful for differentiating solid from cystic lesions 1
• MRI is the main imaging modality for soft tissue tumors and should be performed prior to definitive surgery 1

Biopsy

• Multiple core needle biopsies (using needles >16G) are the standard approach for diagnosis 1
• For superficial lesions <5 cm, an excisional biopsy may be more practical 1
• The biopsy should be performed by a trained surgeon or radiologist after interdisciplinary discussion 1
• The biopsy pathway should be planned so that it can be safely removed during definitive surgery 1

Treatment Based on Diagnosis

Benign Lesions

• For confirmed benign lesions such as ganglia (the most common soft tissue masses in the hand), complete excision is usually sufficient 2
• For lipomas and other benign soft tissue tumors, marginal excision may be acceptable as an individualized option 1

Suspected or Confirmed Sarcomas

• All patients with suspected soft tissue sarcomas should be managed by a specialist Sarcoma Multidisciplinary Team (MDT) 1
• The standard surgical procedure is wide excision with negative margins (R0) 1
• For high-grade (G2-3), deep tumors >5 cm, wide excision followed by radiation therapy is standard treatment 1
• For high-grade, deep, <5 cm lesions, surgery followed by radiation therapy is generally recommended 1
• For low-grade, superficial, >5 cm and low-grade, deep, <5 cm soft tissue sarcomas, radiation therapy may be added in selected cases 1

Radiation Therapy Parameters

• Radiation therapy should be administered postoperatively at a dose of 50-60 Gy, with fractions of 1.8-2 Gy, possibly with boosts up to 66 Gy 1
• Alternatively, radiotherapy may be carried out preoperatively, normally using a dose of 50 Gy 1
• Intraoperative radiation therapy and brachytherapy are options in selected cases 1

Special Considerations for Hand Lesions

• Plastic surgical reconstruction may be necessary for skin and/or soft tissue defects following surgery 1
• For rheumatoid-related hypoechoic thickening of tendon sheaths (tenosynovitis), surgical intervention may be required when there is risk of tendon rupture 3
• For ganglion cysts, which often present as hypoechoic structures on ultrasound, aspiration or surgical excision are the main treatment options 2, 4

Follow-up

• Re-operation must be considered in case of R1 resections (microscopic positive margins) if adequate margins can be achieved without major morbidity 1
• In case of R2 surgery (macroscopic positive margins), re-operation is mandatory, possibly with preoperative treatments if adequate margins cannot be achieved 1

Common Pitfalls to Avoid

• Misdiagnosis of pseudotumoral lesions as true neoplasms - many hypoechoic or hyperechoic structures in the hand may represent non-neoplastic conditions such as ganglion cysts, post-traumatic lesions, inflammatory lesions, or vascular anomalies 5
• Inadequate biopsy technique leading to tumor seeding or compromising subsequent definitive surgery 1
• Failure to refer patients with suspected sarcomas to specialized centers with multidisciplinary expertise 1
• Underestimating the importance of proper imaging before intervention - ultrasound and MRI provide complementary information essential for surgical planning 2