SUCCESSFUL TREATMENT OF A GIANT MYXOMA OF THE RIGHT HAND
Novokuznetsk Scientific Practical Center of Medicosocial Expertise and Rehabilitation for Disabled Persons,
Novokuznetsk, Russia
Tumors and masses of soft tissues account for 6.3-12.4 % of all types of hand pathology; about half of cases are associated with connective tissue tumors and masses – 45.2 % [1]. Myxoma is related to the disease of fibroblastic pattern. This category mainly includes tumors and fibromatosis according to the signs of proliferation of fibroblastic elements [2, 3]. Owing to the insufficient state of exploration, the group of fibroblastic diseases of soft tissues presents the great diagnostic and classificatory problem resulting in some difficulties for accurate separation of tumors according to etiology and pathogenesis.
Hand tumors and masses give fairly rare limitations of hand functioning, as well as burden self-care and decrease quality of life.
The clinical case. The patient S., age of 55, was admitted to the department owing to the complaints for a mass (of the size of a tennis ball) of her right hand, limited handgrip, bad cosmetic appearance of the hand, presence of a similar mass of her left leg and multiple small masses of the extremities.
The history of the disease: the first masses of the extremities and the body appeared 15 years ago, of the right hand – 10 years ago. Over the time the size of the masses was increasing progressively, mostly, on the right hand. The main types of handgrip suffered from the significant size of the hand tumor.
The life history: the patient has not any memories about the similar disease among her relatives. She has no work experience in hazardous industry. During the last 20 years she has been caring for her disabled mother.
The local examination: there is a tumor-like mass (round shape, diameter is about 8 cm, soft tissues, elastic consistence) in the region of interdigital space of the metacarpal bones I-II of the right hand. Palpation is painless and non-mobile. The skin is of cyanotic color in the dorsal region of the hand, with some small trophic ulcers with poor purulent discharge. All types of handgrip are lacking. There is a tumor-like mass (diameter is 1.5 cm) in the carpal canal. Hypesthesia in the autonomous region of innervation of the median nerve to the right. There are multiple small knots, mainly, along the dorsal part of the forearm (Fig. 1). Electromiographic data shows distal sensory motor axonal demyelinating median nerve neuropathy to the right. No destructive changes in R-images of the right hand. There is a thickening in the cortical layer of the second metacarpal bone in the middle one-third (diaphysis). The tumor has the clear rounded borders, with some small inclusions in the depth (higher density in comparison with the main part of the mass).
Figure 1
The appearance of the tumor-like mass
The surgery was carried out: tumor resection, plastic surgery with triangle flaps according to Limberg.
The process of the surgery:
1. Skin flap marking (Fig. 2).
2. Skin flap mobilization, exposure of the tumor-like mass. The tumor pedicles are in the region of the median nerve (not beyond) – the main part of the tumor; the lesser part is in the region of the ulnar nerve (Fig. 3).
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Figure 2 Marking of skin flaps |
Figure 3 The stage of tumor incision |
3. The tumor has been resected within the bounds of the capsule (Fig. 4).
4. Plastic surgery with flaps (Fig. 5).
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Figure 4 The appearance of the incised tumor
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Figure 5 The final stage of plastics with the advanced flap |
Healing is primary. Plaster immobilization is for 3 weeks. Kinesitherapy, therapeutic exercises (according to Rozov) and removal of postsurgical contractures have been conducted after completion of the fixation.
Hand functioning restored 5 weeks after the surgery (Fig. 6). The control EMG confirmed decreasing hypesthesia in the innervation region of the median nerve. The histologic examination showed proliferative palmar fibromatosis.
Figure 6
Hand function 3 weeks after surgery
CONCLUSION
A surgeon should have knowledge and experience in hand surgery for achievement of good cosmetic effect after resection of sizable tumor-like masses with use of skin plastic procedures. Functional outcomes significantly depend on correct postsurgical kinesitherapy and rehabilitation. It is possible in big hospitals and centers including departments of hand surgery and rehabilitation units.