SRPS PS - Plastic Surgery Internal

unknown. The lesions might arise de novo or might
occur secondary to a benign process. Osteosarcomas in
general tend to occur more frequently in association
with irradiated bone, Paget’s disease, fibrous dysplasia
of bone, giant cell tumor, solitary enchondroma,
multiple enchondromatosis, and multiple
osteochondromas.
Radiographically, the borders of an osteosarcoma
are indistinct, but the lesion invariably involves the
cortex and generally transgresses it. Often, a large
contiguous soft-tissue mass is present. A combination
of destructive and proliferative new bone usually is
present, showing a streaked texture and a
characteristic sunburst pattern. Histologically,
osteosarcoma has a typical spindle-shaped cell pattern.
Treatment has changed from amputation to excision
with a wide margin plus adjuvant therapy. In a study
presented by Okada et al., 320 local control was achieved
in five of six patients by using this protocol; one
patient died as a result of metastatic disease.
Chondrosarcomas—Chondrosarcomas are
uncommon in the hand, where they occasionally are
associated with osteochondromas and, to a lesser
degree, with multiple enchondromatosis, 323,324 although
the vast majority of cases include no preexisting
lesion. 325,326 Chondrosarcomas characteristically occur in
older patients (60–80 years) in the epiphyseal area of
the proximal phalanx or metacarpal. The clinical
course is slow, and metastasis is late. 327,328 The tumor
presents as a progressively painful large mass near the
metacarpophalangeal joint. Treatment of choice is
amputation or ray resection. Histological interpretation
of cartilaginous lesions of the hand is difficult, and
clinical and radiological appearance (bone expansion,
lytic areas of bone destruction, soft-tissue swelling)
often are more reliable indicators of malignancy.
Prognosis is good if metastasis has not occurred. 325,326
Soft-Tissue Sarcomas
Rosenberg and Schiller 302 have provided an excellent
review of soft-tissue sarcomas of the hand. Soft-tissue
sarcomas are an uncommon but important group of
hand tumors. They tend to occur in young patients, are
innocuous in presentation, often leading to an incorrect
diagnosis, and have protracted clinical courses. They
SRPS Volume 10, Issue 25, 2009
are prone to local recurrence, have an unusually high
incidence of lymphatic spread and regional node
metastases, and often metastasize systemically late in
their course. Deep tumors that are firm and are 5 cm or
larger should be considered to be possible sarcomas
until proven otherwise. 313 CT and MRI often are used
to define the anatomy. Standard treatment is wide
surgical excision with or without adjunctive
radiotherapy and/or chemotherapy. The prognosis
generally is poor.
Epithelioid sarcomas—Epithelioid sarcomas are the
most common soft-tissue sarcomas of the hand. 329 A
posttraumatic origin has been proposed by some. 330
Lesions are notoriously insidious and often mistaken
for a benign inflammatory condition. 331 Most lesions in
the hand arise on the palm or volar surface of the
digits. 332,333 Local recurrence is common, as is distant
metastasis. Treatment recommendations are radical
excision (often necessitating a partial amputation 313 ) and
node dissection. 334 Adjuvant therapy can be of benefit.
Malignant fibrous histiocytomas—Malignant
fibrous histiocytomas are among the more common
soft-tissue sarcomas in the adult upper extremity. 313
Lesions can be superficial or deep, single or
multinodular. They extend along tissue planes and
metastasize via the lymphatics and bloodstream. 335
Treatment primarily is surgical, with radiotherapy
added unless there has been a generous margin. The
value of chemotherapy has yet to be defined.
Alveolar rhabdomyosarcomas—Alveolar
rhabdomyosarcomas tend to involve the thenar and
hypothenar musculature. 336,337 An alveolar
rhabdomyosarcoma is a highly malignant, devastating
tumor that presents as a rapidly growing, deep mass in
the palm of a child. 313 Local recurrence is common, and
it is invariably fatal if not adequately treated. The
incidence of nodal spread and distant metastases is
high. The prognosis for alveolar rhabdomyosarcoma has
improved with multi-modality therapy but is still poor.
Synovial sarcomas—Synovial sarcomas arise in the
juxta-articular soft tissues (tendon, tendon sheath, and
bursa). 338 A synovial sarcoma presents as a slowgrowing
tumor on the volar surface of the hand, and
delay to presentation often is measured in years.
Synovial sarcoma has a poor prognosis and a high
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