Evaluation and Management of Superficial Hand Masses

Initial Diagnostic Approach

The American College of Radiology recommends radiographs as the first imaging study for any suspected soft tissue mass of the hand to identify calcifications, bone involvement, or intrinsic fat 1
Radiographs can demonstrate positive findings in 62% of soft tissue masses, including calcification, bone involvement, and intrinsic fat, with a reported diagnostic yield of 27% for calcification, 22% for bone involvement, and 11% for intrinsic fat 1
Radiographs may be diagnostic for specific conditions such as phleboliths within hemangiomas or the osteocartilaginous masses of synovial chondromatosis, with a high degree of accuracy 1

Ultrasound is highly appropriate for small, superficial lesions with reported sensitivity of 94.1% and specificity of 99.7% for superficial soft tissue masses, according to the American College of Radiology 1
Ultrasound is particularly useful for differentiating solid from cystic lesions, confirming fluid content of suspected ganglion cysts, identifying fluid surrounding tendons affected by tenosynovitis, and demonstrating the relationship between a mass and adjacent neurovascular structures, with high accuracy 1

MRI without and with contrast is indicated when ultrasound findings are inconclusive, the mass is deep-seated, or there are complex anatomical considerations, with superior soft tissue characterization, according to the American College of Radiology 1
MRI is essential for preoperative planning and local staging, with high diagnostic accuracy, and is recommended by the American College of Radiology 1
CT is not typically ordered for initial evaluation of soft tissue masses but may be useful for calcified lesions to rule out myositis ossificans, with moderate diagnostic accuracy 1

Core needle biopsy is the standard approach for suspicious soft tissue masses that require histopathological diagnosis, with high diagnostic yield, according to the European Society of Medical Oncology 4
Multiple core samples should be taken under image guidance to maximize diagnostic yield, with high accuracy, and is recommended by the European Society of Medical Oncology 4
Excisional biopsy may be more practical for small subcutaneous lesions or superficial lesions less than 5 cm, with high diagnostic accuracy, and is recommended by the European Society of Medical Oncology 4

For masses with benign imaging characteristics, observation may be appropriate for asymptomatic lesions, while surgical excision is recommended for symptomatic lesions or for cosmetic concerns, with high success rates, according to the American College of Radiology 3
For masses with concerning features, referral to a specialized sarcoma center with a multidisciplinary team is mandatory, with high survival rates, and is recommended by the European Society of Medical Oncology 4
Treatment typically involves wide excision or compartmental resection, with high success rates, and is recommended by the European Society of Medical Oncology 4
Adjuvant radiation therapy may be considered for high-grade sarcomas, with moderate to high success rates, and is recommended by the European Society of Medical Oncology 4

Physical examination alone is insufficient, correctly identifying only about 85% of soft tissue tumors, with moderate diagnostic accuracy, according to the American College of Radiology 1
Radiographs have limitations and may be unrewarding when a mass is small, deep-seated, non-mineralized, or in an area with complex anatomy, with low to moderate diagnostic accuracy 1
Biopsy should be planned carefully so that the biopsy pathway can be safely removed during definitive surgery, with high success rates, and is recommended by the European Society of Medical Oncology 4