What are the evaluation and treatment options for a superficial mass on the hand?

Evaluation and Management of Superficial Hand Masses

For a superficial mass on the hand, radiographs should be the initial imaging study, followed by ultrasound which is highly accurate for superficial lesions, with subsequent management determined by imaging characteristics. 1, 2

Initial Diagnostic Approach

• Radiographs should be the first imaging study for any suspected soft tissue mass of the hand to identify calcifications, bone involvement, or intrinsic fat 1, 2
• Despite often being considered unrewarding, radiographs can demonstrate positive findings in 62% of soft tissue masses, including calcification (27%), bone involvement (22%), and intrinsic fat (11%) 1
• Radiographs may be diagnostic for specific conditions such as phleboliths within hemangiomas or the osteocartilaginous masses of synovial chondromatosis 1

Ultrasound Evaluation

• Ultrasound is highly appropriate for small, superficial lesions with reported sensitivity of 94.1% and specificity of 99.7% for superficial soft tissue masses 1, 2
• Ultrasound is particularly useful for:
  • Differentiating solid from cystic lesions 1
  • Confirming fluid content of suspected ganglion cysts 1
  • Identifying fluid surrounding tendons affected by tenosynovitis 1
  • Demonstrating the relationship between a mass and adjacent neurovascular structures 1
• For suspected lipomas, ultrasound typically shows hyperechoic, well-circumscribed masses with minimal vascularity and sometimes thin curved echogenic lines 3

Advanced Imaging

• MRI without and with contrast is indicated when:
  • Ultrasound findings are inconclusive 1, 2
  • The mass is deep-seated 1
  • There are complex anatomical considerations 1, 2
  • Malignancy is suspected based on initial imaging 1
• MRI provides superior soft tissue characterization and is essential for preoperative planning and local staging 2, 4
• CT is not typically ordered for initial evaluation of soft tissue masses but may be useful for calcified lesions to rule out myositis ossificans 1

Tissue Sampling

• Core needle biopsy is the standard approach for suspicious soft tissue masses that require histopathological diagnosis 2
• Multiple core samples should be taken under image guidance to maximize diagnostic yield 2
• Excisional biopsy may be more practical for:
  • Small subcutaneous lesions (<3 cm) that are indeterminate on imaging 1, 2
  • Superficial lesions less than 5 cm 1, 2
• Fine needle aspiration is not generally recommended unless performed at institutions with specific expertise in this procedure 1

Management Based on Imaging Findings

• For masses with benign imaging characteristics (well-defined margins, no aggressive features):
  • Observation may be appropriate for asymptomatic lesions 3
  • Surgical excision for symptomatic lesions or for cosmetic concerns 3
• For masses with concerning features (ill-defined margins, aggressive growth pattern, bone invasion):
  • Referral to a specialized sarcoma center with a multidisciplinary team is mandatory 1, 2
  • Treatment typically involves wide excision or compartmental resection 2
  • Adjuvant radiation therapy may be considered for high-grade sarcomas 2

Clinical Pitfalls to Avoid

• Physical examination alone is insufficient, correctly identifying only about 85% of soft tissue tumors 1
• Radiographs have limitations and may be unrewarding when a mass is small, deep-seated, non-mineralized, or in an area with complex anatomy 1
• Even with advanced imaging, histologic analysis may be necessary for definitive diagnosis of many soft tissue masses 5
• Biopsy should be planned carefully so that the biopsy pathway can be safely removed during definitive surgery 1