Common soft tissue masses of hand include ganglia, giant cell tumor of tendon sheath (GCTTS), lipomas, nerve sheath tumors, glomus tumors, and hemangiomas [
This prospective study was conducted over a period of 2.5 years from 1 July 2011 to 31 December 2014. The study was approved by institute ethics committee and informed written consent was obtained from all patients. A total of 35 patients presenting with soft tissue masses of the hand to the plastic surgery outpatient department were included. All patients underwent high resolution USG and contrast enhanced MRI of the hand. Patients with contraindication for MRI and those with history of previous MRI contrast reaction or renal failure and inconclusive histopathology/cytology were excluded from study.
MRI was performed on a 3-Tesla scanner (Magnetom Verio, Siemens Medical Systems) using a dedicated wrist coil. The patients were scanned in the most comfortable position (as uniform positioning in each patient was not feasible in view of the hand swelling). T1-weighted (TR/TE, 650–1070/10–20), axial, coronal, and sagittal, T2-weighted (TR/TE, 3600–4324/80–98) axial, coronal and/or sagittal and axial, coronal, and sagittal gadolinium enhanced (following intravenous injection of 0.1 mL/kg of gadopentetate dimeglumine, maximum 10 mL) T1-weighted (TR/TE, 650–950/10–20) sequences were performed. Images were reviewed by two radiologists with 10 years and 3 years of experience in musculoskeletal MRI in consensus. The same radiologist performed B-mode as well as color Doppler USG of the masses using Philips HD 11 XE and iU22 machines equipped with a 3-to-12 MHZ linear transducer Doppler settings that were optimized to “low flow,” with a medium wall filter (to minimize flash artifact) and a pulse repetition frequency of 700 Hz. The color gain was adjusted to just below the noise floor and maintained at this level throughout the scanning protocol. Each swelling was scanned in various planes. The correlation with pathological findings was performed only for MRI and ultrasonography was used as an adjunct imaging modality.
The radiologists were blinded to the clinical diagnosis/pathological findings. All patients underwent fine needle aspiration cytology (FNAC) and/or biopsy. The radiological diagnosis was then compared with cytology/histopathology.
The standard of reference was cytology/histopathology in all the patients. The efficacy of the radiological investigations was determined by comparing USG and MRI findings with the histopathological/cytological diagnosis.
The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows). All quantitative variables were estimated using measures of central location (mean and median) and measures of dispersion (standard deviation and standard error). Qualitative or categorical variables were described as frequencies and proportions (percentages).
Out of the 35 patients in the study group, there were a total of 19 (55%) females and 16 (45%) male patients. The mean age of the sample population was
All the patients (
The swellings included in this study demonstrated variable echogenicity on gray scale. The maximum number (45%) of cases was heteroechoic. Four cases included in the study were predominantly hyperechoic in echogenicity. These were later diagnosed as lipomas. Four cases were anechoic in appearance. These cases were diagnosed as ganglions. There was presence of increased color flow in 7 (20%) cases included in the study. These were either hemangioma or vascular malformations.
Majority of the cases (
Only 7 (20%) of the cases were nonenhancing. Postcontrast enhancement was seen in the rest of them. It was further divided into solid, peripheral enhancement and patchy enhancement. Most common pattern was patchy enhancement seen in 16 (45%) cases. Vascular lesions showed intense patchy progressive enhancement. The nonenhancing lesions consisted of lipomas (
A correct diagnosis was possible on MRI in 80% of the cases (
A total of 13 histologically different cases were included in the study (Table
Distribution of different types of tumors on HPE/FNAC.
Sr. number | Pathological diagnosis | Number of patients |
---|---|---|
1 | Vascular malformation | 5 (15%) |
2 | Haemangioma | 4 (11.5%) |
3 | GCTTS | 3 (8.5%) |
4 | Ganglion | 3 (8.5%) |
5 | Glomus tumor | 3 (8.5%) |
6 | Lipoma | 3 (8.5%) |
7 | Schwannoma | 2 (5.5%) |
8 | Hamartoma | 2 (5.5%) |
9 | Neurofibroma | 4 (11%) |
10 | Benign fibrous histiocytoma | 2 (5.5%) |
11 | Synovial sarcoma | 1 (2.7%) |
12 | TB | 2 (5.5%) |
13 | Nonspecific inflammation | 1 (2.7%) |
Clinical assessment of the palpable lesions of hand is of utmost importance. Imaging is used for confirmation of the clinical diagnosis and delineation of lesion extent. The most common swellings are of ganglion, synovial, and peritendinous origin [
In a study done by Capelastegui et al., MRI and case records of 134 patients presenting with swellings in the hand and wrist were reviewed [
Hemangiomas on USG show iso/hyperechoic well-defined lesions with anechoic areas in between with/without color flow [
Vascular malformations are classified into high flow and low flow [
AVM. A 22-year-old female presented with compressible swelling involving middle phalanx of right ring finger ((a), arrow). Ultrasonography shows a heterogeneously hypoechoic lesion with multiple prominent linear hypoechoic channel (arrows) and irregularity of underlying bone ((b), (c)). Doppler showed markedly increased intralesional vascularity ((d), arrow).
AVM. MRI (of the same patient as in Figure
We encountered 3 cases of ganglions in our study. Imaging is important in some cases to look for atypical findings, solid components, heterogeneous contents, and abnormal SI, in the surrounding tissues [
GCCTS are the second most common lesions of the hand and wrist. These present as slow growing, firm, nontender mass with a predilection for the radial three digits especially around the distal interphalangeal joint [
Giant cell tumor of tendon sheath. A 20-year-old female presented with swelling in right 5th finger over middle phalanx ((a), arrow). Ultrasonography and Doppler show multiple well-defined, hypoechoic, hypovascular lesions along the flexor tendons ((b)–(d), arrows).
Giant cell tumor of tendon sheath. MRI (of the same patient as in Figure
Lipoma has characteristic signal intensity on MRI. It parallels that of subcutaneous fat on all pulse sequences [
In a study by Montandon et al., imaging features in 8 cases of subungual glomus tumors were evaluated. Doppler ultrasonography was positive in five cases showing a hypoechoic nodule with internal vascularity [
Glomus tumour. A 40-year-old female patient presented with painful, tender, and noncompressible swelling involving the region of distal phalanx of right index finger ((a), arrow). Ultrasonography (b) showed a well-defined, subcentimetric, hypoechoic, hypovascular soft tissue lesion (arrow). Postcontrast MRI (c) shows a small enhancing lesion along the flexor tendon sheath (arrow). Microphotograph (d) shows vascular lumina surrounded by a solid proliferation of glomus cells with perfectly round nuclei and acidophilic cytoplasm (arrow). H&E ×200.
Neurogenic tumors (Figures
Schwannoma. A 25-year-old female patient presented with firm, noncompressible swelling over the radial aspect of the proximal interphalangeal joint of 2nd digit ((a), arrow). Ultrasonography ((b)–(d)) showed a well-defined, oval, hypoechoic, hypovascular lesion (arrow).
Schwannoma. MRI (of the same patient as in Figure
Synovial sarcoma. A 34-year-old female patient presented with noncompressible swelling involving hypothenar eminence of left hand ((a), arrow). Ultrasonography shows a hypoechoic lesion with absent color flow (b). MRI shows a large, lobulated T1W hypointense ((c), arrow) and T1WFS hyperintense ((d), arrow) lesion.
Synovial sarcoma. MRI (of the same patient as Figure
Our study population is small. There is diverse range of pathologies included in our study with insufficient number of cases of certain pathological entities in the included study population, for example, benign fibrous histiocytoma. Pathological confirmation was achieved by FNAC and not by histopathology in some cases.
Radiological investigations (USG and MRI) are important tools for the diagnosis of the soft tissue swellings of the hand. Relevant clinical history and examination play a pivotal role. Ultrasound is a widely available modality and can be diagnostic in certain entities like vascular malformations and ganglions. MRI can provide conclusive imaging findings in many pathological lesions (vascular lesions, lipomas, GCTTS, etc.) and is important for providing accurate anatomical extent. In certain lesions like glomus tumors, there is limited role of USG and patient can be directly subjected to MRI for the confirmation of the clinical diagnosis. However, pathologic confirmation of the diagnosis is important in some entities especially in absence of characteristic imaging findings.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Aditi Agarwal and Mahesh Prakash contributed equally to this paper.